Does size matter

The size of the incision or the implant does nothing to the longeivity or function of the implants. It is the technique, quality of bearing, fixation and alignment which is paramount. The approach whether anterior or posterior if done well does not matter. Why are we stuck on the size? yes, it could be a marketing tool. These fads fade away  and what matters most is the function and longievity. Smaller Proximal loading stems might have a role in preserving proximal bone. Till date No hip other than resurfacing maitain bone in gruen zone 1 and 6. With the metal on metal controversies surface replacement is used in select cases only.

Wounds heal side to side and possibly better rehab and multimodal analgesis will help to get the patient up quickly.

migrating stem

65 year old lady 10 years post primary THR.

Well fixed cup with no major wear.

Migrated stem with varus remodelling of proximal femur

Plan- ETO for correcting the femoral deformity while revison. cup was also revised . unfortunately only 22 mm heads were available in india then in 2000.

type 3 valgus knee

76 year old lady with 60 degree valgus with no medial end point
Only A rotating hinge TKR is possible in heras she has an incompetent MCL.

Risks include a foot drop postop when you correct the deformity.

I used the Link Devise succesfully in her. She is 3 years postop with no major problems

protrusio acetabuli in RA

This is 36 year old Doctor with RA on long term steroids. Presented with pain in hip as well as knee.

Why do we wait to complicate reconstruction?

Problems

1. Severe Osteoporosis

2.Huge cavitatory acetabulum with deficient medial and anterior wall

Young patient

Any comments on Options for acetabular reconstruction.

 We used a Cone prosthesis and a wagner uncemented cage with ceramic on poly bearing.

 A peripheral fitting cup was an option but due to the osteopenia, we opted for  a cage which came in 2 sizes. I understand Zimmer has withdrawn both these products from Sulzer.

Dislocation in in bipolar of 3 weeks duration

76 year old female presented with dislocated bipolar of 3 weeks duration. she is asa gr 3, memory loss and is a household ambulator. The dislocation occured while sitting on the toilet

The lesser trochanter appears more prominent

Possible causes in general for dislocation

Inadequate Offset

abnormal version and impingement

Options

1. Closed reduction and abductor bracing

2.if found unstable at closed reduction the options

The cup has been medialised slightly and a capture cup inserted. Tripolar cup was not available at present. the problems include cup loosening and  disimpaction of the head neck junction

Trochlear dysplasia in an 18 year old boy

18 year old engineering student presented with recurrent patellar dislocation and pain.

O/E

positive apprehension test. tuber sulcus angle of 10 degrees

xray- crossing sign and trochlear bump present

MRI showed a convex trochlea

Trochleoplasty was done to reshape the trochlea
After removing subchondral bone from the trochlea from proximal to disatal direction and collapsing the cartilage to ereshape the trochlea.

the final ic at 6 weeks during Chondron implantation for the patella

medial patellar facet chondral defect

grade 4 medial patella r defect 3 cm circumference in a 19 year old male student. Normal TT:TG diatance. MPFL intact. No history of injury.

cartilage mapping at 6 months. this was done in 2010 has good function till date 10 years followup.

ceramic on metal cleared by FDA

It was anounced that FDA approved ceramic on metal bearing by depuy for use recently. We have been using this bearing couple over the last 2 years with no untoward problems( 11 cases with 2 year follow up). Ever since J. fishers article in j of biomechanics(2004) suggesting decrease in metal debris as well as decrease chances of liner fracture, this was an option to look forward to.

Does this reduced metal debris cause problems

will this evolve to other new bearing Viz; ceramic on oxinium bearings.

anterior column fracture with posterior hemitransverse in an 82 year old male

anterior column is displaced with an essentilly undispalced hemitransverse fracture as described by letournel.

would you fix it or treat him conservatively

or fix and repalce it ?

He was advised PTH for severe porosis 2 years before> it was deferred by the patient due to percieved immediate cost.

This patient was advised antiresorptive therapy 2 years ago. He refused and paid the price. We fixed the posterior column and used a ganz cage to cement a cup.. the trochanrteric flip was used to improve exposure. A single screw was used to stabilse the anterior column thru the cage . He was mobilised on day 3 PWB. Awaiting for the six week review.

recurrant dislocation of patella.

16 year old girl with 3 episodes of patellar dislocation.

Apprehension test positive for lateral patellar subluxation

No clinical torsional abnormality.

normal xrays

MRI- show laterally subluxed patella mild trochlear hypoplasia. No chondral damage

CT Scan- 14 degree anteversion

TT_TG distnce 23 mm

Plan- MPFL reconstruction with tibial tubercle transfer(fulkerson)

thr in dysplastic hip post pprp

32 year old financially challenged girl with painful hip. She has a foot drop . grade 4+ hip abductors and flexors

problems1. dyspalstic acetabulum

coxa calga

narrow osteoporotic femoral canal.

TKR in a valgus knee with malunited shaft of femur

68 year old gentleman whose xrays below where sent to me for opinion.

Option 1. Ideal case for CAS

option 2. If CAS is not available what next? comments pleaase

poly wear 6 years post thr

this is my own patient done 6 years ago with metal on poly( CLS with sportono cup). 2 week history of thigh pain.
ESR, CRP and cbc are normal. Bone scan shown minimal uptake in the proximal femur( gruen 1 and 5).

Impending fracture post thr

68 year old sister with an aseptic loosening. How can one advise to continue walking innthis case? Are we waiting for the inevitable fracture of femur and posterior column.

Isn't it better to revise early once loosening occurs.

THR in non unon fracture acetabulum

Case sent by C . mahajan

67 year old with 2 year old malunited acetabular fracture planned for thr

problems.

1. Is the fracture united - if not in situ posterior column plating single or double.

2. Cavitatory defect with posteriosuperior migration. peripheral reaming to widen the acetabular mouth to fix a peropheral fitting cup and particulate grafting of the cavity. The union to could be assesd from the floor.

Implants. - keep larger cups as well as pinnacle revision cup back up in case.

Gages may not be needed.

Dr mahajan felt that the acetabulum was united and did an uncemented cup without screws. He was confident of the stabiilty. I would have been comfotable with screw at least 2 of them as well as posterior plates if there was any doubtof column union. I need to get his permission to upload the post op pics

jacob