DGoetz at ghs
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Jun 26, 2008, 9:25 AM
Post #13 of 14
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There are no single "right" answers for many complex problems. Let me
make a point for a third alternative.
As someone who does trauma and also the total joint replacements for
failed hip and acetabular reconstructions at our institution, I am not
so optimistic that a few years of pain free mobility will be available
to this patient with fracture fixation.
First, a simple repair EVEN if successful will leave a young person's
hip short and more importantly, with inadequate offset [being that
considerable fracture impaction will be necessary to obtain enough bone
contact to keep the joint fluid out of the fracture site]. The hip is
likely to be painful even if united and wear will be accelerated. With
today's total joint replacement technology, saving someone from a joint
replacement for 3-5 years is probably of little long term value unless
the patient's health and/or social situation is likely to be
significantly better in the future.
A healed fracture and osteotomy should restore offset and give a hip
sparing procedure a chance of longer survivorship. However, this
introduces another change in hip anatomy, increases risk of infection or
bacteria contamination of retained hardware thereby further compromising
the potential results of a tha.
Your joint reconstruction partner may be much happier with the normal
anatomy that currently exists in this hip. Consider running the x-rays,
history, patient expectations, etc., by him now for his input.
Dave Goetz
Greenville SC
________________________________
From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On
Behalf Of George Thomas
Sent: Thursday, June 26, 2008 7:45 AM
To: ORT-L@www2.aaos.org
Subject: Re: [ORT-L] old hip fx
In a 22 year old, even if the MR image showed an avascular head, I would
still try to get this fracture united. The patient will have at least a
few years of pain free mobility and an arthroplasty can be postponed.
The surgical technique I would use would be a valgus osteotomy. The
implant to fix it would be a double angled blade plate from the AO
(Synthes).
Sincerely,
On Thu, Jun 26, 2008 at 10:42 AM, Chip Routt <mlroutt@u.washington.edu>
wrote:
Is there a lateral hip image?
Why the MRI?
Chip
> thanks to everyone for their input. there is an MRI, and I will
resend.
> dan
>
>
> --- On Wed, 6/25/08, Jeff Brooks <jjbrooksmd@gmail.com> wrote:
>
>> From: Jeff Brooks <jjbrooksmd@gmail.com>
>> Subject: Re: [ORT-L] old hip fx
>> To: ORT-L@www2.aaos.org
>> Date: Wednesday, June 25, 2008, 5:04 PM
>> what about the influence of vascularity of the femoral head
>> (which we
>> don't know, do we?), and its influence on feasiblity of
>> ORIF? is
>> there an mri attachment that got blocked by my email
>> program?
>>
>> chip, is that what you meant by the "fancy
>> mri"(perhaps im a little
>> slow on the uptake). no mri has been shown, correct?
>>
>> jeff
>>
>>
>>
>> On Jun 25, 2008, at 1:35 PM, Anglen, Jeffrey O wrote:
>>
>>> I vote for ORIF, but am unaware of any evidence that
>> fibular strut
>>> graft would improve results. When you say
>> "either vascularized or
>>> a strut" it implies that those two techniques are
>> equivalent, when
>>> in fact they are very different options both in
>> theory, in the
>>> goals and certainly in the required resources. I
>> think a non-
>>> vascularized strut will just hold the fracture
>> distracted without
>>> adding either stability or healing potential.
>> Vascularized graft
>>> at least has the theoretic advantage of bringing in
>> new blood
>>> supply, if the vessel stays patent, etc. - but
>> requires
>>> microvascular skills that I don't have, and I
>> don't know of any
>>> good big series that definitively shows improved
>> outcomes -(not to
>>> say one doesn't exist)
>>>
>>> I would fix it with open reduction and three
>> cancellous screws
>>> (with washers and compression), accepting that the
>> neck will be
>>> short, and have a low threshold for IT osteotomy at
>> the first sign
>>> of screw loosening or varus displacement.
>>>
>>> Jeff Anglen
>>> ________________________________
>>> From: ORT-L-owner@www2.aaos.org
>> [ORT-L-owner@www2.aaos.org] On
>>> Behalf Of emal wardak [emalpgi@gmail.com]
>>> Sent: Wednesday, June 25, 2008 12:01 PM
>>> To: ORT-L@www2.aaos.org
>>> Subject: Re: [ORT-L] old hip fx
>>>
>>> dear
>>>
>>> for sure ORIF with fibular graft,,, no second thought
>>> go for it
>>> On Wed, Jun 25, 2008 at 6:10 AM, dan schlatterer
>>>
>> <danschlatterer@yahoo.com<mailto:danschlatterer@yahoo.com>>
>> wrote:
>>> hello,
>>> attached are images of a healthy 26 yo female, 2
>> months post
>>> partum. in february she started using crutches for
>> "sciatic" pain.
>>> today is first visit with ortho. would anyone attempt
>> ORIF? thank
>>> you for your input.
>>> dan schlatterer
>>>
>>>
>>> --- On Tue, 6/17/08,
>> mqsd25@aol.com<mailto:mqsd25@aol.com>
>>> <mqsd25@aol.com<mailto:mqsd25@aol.com>>
>> wrote:
>>>
>>>> From: mqsd25@aol.com<mailto:mqsd25@aol.com>
>>
>>>>
>> <mqsd25@aol.com<mailto:mqsd25@aol.com>>
>>>> Subject: Re: [ORT-L] Tibia and ankle fracture
>>>> To:
>> ORT-L@www2.aaos.org<mailto:ORT-L@www2.aaos.org>
>>>> Date: Tuesday, June 17, 2008, 5:19 AM
>>>> After close view of the X rays and CT slices, I
>> would
>>>> suggest to fix this fracture with LCP distal
>> tibial plate,
>>>> and that will need fixing the Fibula with 3rd
>> tubulat plate
>>>> to give stability and eas of reduction. I will
>> ignore the
>>>> small posterior fragment.
>>>> Elastic fixation , early NWB mobilisation and
>> satrt wt.
>>>> bearing at 6 to 8 weeks.
>>>> Nailing is an option but may split open the
>> fracture down
>>>> to articular surface, may be ok in expereinced
>> hands.
>>>>
>>>> ?I have similair??cases? and did well post op with
>> LCP
>>>> distal plates, but fracture must be reduced well,
>> if these
>>>> is gap fracture will? end up with delayed union.
>>>>
>>>> MR Mohammad Maqsood
>>>> consultant orthopaedic surgeon
>>>> Lincoln county Hospital
>>>> Lincoln
>>>>
>>>>
>>>> -----Original Message-----
>>>> From: Nikolaj Wolfson
>> <nswolfso@usc.edu<mailto:nswolfso@usc.edu>>
>>>> To:
>> ORT-L@www2.aaos.org<mailto:ORT-L@www2.aaos.org>
>>>> CC:
>> orthopod@googlegroups.com<mailto:orthopod@googlegroups.com>
>>>> Sent: Mon, 16 Jun 2008 23:46
>>>> Subject: [ORT-L] Tibia and ankle fracture
>>>>
>>>>
>>>>
>>>>
>>>> Dear colleuges:
>>>>
>>>> I would appriciate your opinion about surgical (
>> ORIF)
>>>> approach of the
>>>> treatment of 36 yo otherwise healthy person with
>> closed
>>>> tibia and ankle
>>>> fractures ( good soft tissues) and no other
>> associated
>>>> injuries.
>>>>
>>>> Thanks
>>>>
>>>> Nik
>>>>
>>>>
>>>>
>>>> Nikolaj Wolfson, MD, FRCSC
>>>> Assistant Professor of Orthopaedic Surgery
>>>> Department of Orthopaedic Surgery
>>>> Keck School of Medicine
>>>> University of Southern California
>>>> nswolfso@usc.edu<mailto:nswolfso@usc.edu>
>>>> (323) 226-7346 phone
>>>> http://www.usc.edu/medicine/orthopaedic_surgery
>>>>
>>>> The information contained in this document and any
>>>> attachment is privileged and
>>>> confidential under state law, including Evidence
>> Code
>>>> section 1157 relating to
>>>> medical professional peer review documents and
>> Government
>>>> Code Section 6254
>>>> relating to personnel records.
>>>>
>>>>
>>>> This message, including any attachments, contains
>>>> confidential information
>>>> intended for a specific individual and purpose.
>> If you are
>>>> not the intended
>>>> recipient, you should delete this message. Any
>> disclosure,
>>>> copying, or
>>>> distribution of this message, or the taking of any
>> action
>>>> based on it, is
>>>> strictly prohibited.
>>>>
>>>>
>>>>
>>>>
>> _____________________________________________________________________
>>
>>>> ___
>>>> AOL's new homepage has launched. Take a tour
>> at
>>>> http://info.aol.co.uk/homepage/ now.
>>>
>>>
>>>
>>>
>>>
>>>
>>> --
>>> May Almighty bless us all
>>>
>>> Dr Emal Wardak
>>> MBBS "SMS, Jaipur"
>>> MS "Ortho" PGI Chd, India
>>> Member of NZIOA,IAA "India"
>>> AADO "Hong Kong", SICOT
>>> Orthopaedic Surgeon
>>> Kabul
>>> 0093-707034241
>>> http://www.jaxtr.com/emalpgi
>>> ---
>>> [This E-mail scanned for viruses by Declude Virus]
>>>
>>
>> ---
>> [This E-mail scanned for viruses by Declude Virus]
>
>
>
M.L. Chip Routt, Jr.,M.D.
Professor-Orthopedic Surgery
Harborview Medical Center
325 Ninth Avenue
Box 359798
Seattle, WA 98104-2499
phone 206-731-3658
FAX 206-731-3227
--
---
[This E-mail scanned for viruses by Declude Virus]
--
George Thomas,
Chief Orthopaedic Surgeon,
St. Isabel's Hospital,
Mylapore,Chennai 600004,
India.
Phone +91-44-24991081/82/83
Editor, Indian Journal of Medical Ethics,
www.issuesinmedicalethics.org
www.ijme.in
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