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Jun 26, 2008, 10:36 AM
Post #14 of 14
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Of course, the important goal isn't really about making the joint reconstruction surgeons happy. We won't know anything significant about the outcomes of "today's total joint replacement technology" for a couple decades, so it is difficult to know what is best. I think we are overly optimistic about every new twist in joint replacement, and underplay the significance of problems after operations which are essentially irreversible, as is THR. We've all seen patients with chronic recurrent dislocations, prosthetic infections, a few revisions down the road, who would be happy as a pig in slop with a healed neck that is a little short.
In my experience, if you show the Xrays to a total joint surgeon, she'll think the patient needs a total joint, so that's sort of predictable.
If the fixation doesn't work, you still have multiple bail out options.
JOA
________________________________
From: ORT-L-owner@www2.aaos.org [ORT-L-owner@www2.aaos.org] On Behalf Of David Goetz, MD [DGoetz@ghs.org]
Sent: Thursday, June 26, 2008 12:25 PM
To: ORT-L@www2.aaos.org
Subject: RE: [ORT-L] old hip fx
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<mailto: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<mailto:jjbrooksmd@gmail.com>> wrote:
>
>> From: Jeff Brooks <jjbrooksmd@gmail.com<mailto:jjbrooksmd@gmail.com>>
>> Subject: Re: [ORT-L] old hip fx
>> To: ORT-L@www2.aaos.org<mailto: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<mailto:ORT-L-owner@www2.aaos.org>
>> [ORT-L-owner@www2.aaos.org<mailto:ORT-L-owner@www2.aaos.org>] On
>>> Behalf Of emal wardak [emalpgi@gmail.com<mailto:emalpgi@gmail.com>]
>>> Sent: Wednesday, June 25, 2008 12:01 PM
>>> To: ORT-L@www2.aaos.org<mailto: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><mailto: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><mailto:mqsd25@aol.com<mailto:mqsd25@aol.com>>
>>> <mqsd25@aol.com<mailto:mqsd25@aol.com><mailto:mqsd25@aol.com<mailto:mqsd25@aol.com>>>
>> wrote:
>>>
>>>> From: mqsd25@aol.com<mailto:mqsd25@aol.com><mailto:mqsd25@aol.com<mailto:mqsd25@aol.com>>
>>
>>>>
>> <mqsd25@aol.com<mailto:mqsd25@aol.com><mailto: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><mailto: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><mailto:nswolfso@usc.edu<mailto:nswolfso@usc.edu>>>
>>>> To:
>> ORT-L@www2.aaos.org<mailto:ORT-L@www2.aaos.org><mailto:ORT-L@www2.aaos.org<mailto:ORT-L@www2.aaos.org>>
>>>> CC:
>> orthopod@googlegroups.com<mailto:orthopod@googlegroups.com><mailto: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><mailto: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
--
---
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--
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<http://www.issuesinmedicalethics.org>
www.ijme.in<http://www.ijme.in>
---
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