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Periprosthetic fx dislocation after THR
Ортопедия и травматология Отправлено Michael Markushevich 12 Октябрь 2007, 22:42
Patient 77 yaers old man falled two day after elective THR operation.
Was done noncemented THR,Direct Lateral Approuch .During posedure wasn't any complication.Now we have Vancouver AL fracture (to be more prosize between A to B1).What your sudgests?

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    Re: Periprosthetic fx dislocation after THR
    Marco Berlusconi 13 Октябрь 2007, 15:42
    Dear Sirs, in my opinion the actual problem isn't the AL fracture but the
    hip dislocation.
    The AL fracture can be well reduced and fixed with 2 cerclage wires and it is stable and heals, but why was there a dislocation? I see in fact an +
    7mm neck so it means that the implant wasn't so stable at the end of surgery.
    So I'll reduce and fix the fracture than looking to stability eventually change the implant to prevent further dislocations Best regards
    Marco Berlusconi
    Trauma Unit
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    Re: Periprosthetic fx dislocation after THR
    mohan desai 13 Октябрь 2007, 20:36
    I suppose this one is a fully porous coated stem?AML ? solution stem.
    If it's so then AL type # should be bothering since it's not compromising the stability of the stem . The cause of dislocation is probably multifactorial.
    Decreased head to neck ratio due to the long head with a skirt probably causing impingement.
    Old age with ?weak abductors.
    One needs to checkout the alignment of the cup.
    I would just reduce the hip at the moment under anaesthesia. check the range & stability.I would give the pt. hinged brace for a period of 3 mths or so.
    For First time dislocators without any component malalignment ,closed reduction is successful in ~ 2/3 rd of the cases.
    If this has gross component malalignment then, I would rectify(surgically) that & change the head to large diameter.
    dr. mohan desai,mumbai
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    Re: Periprosthetic fx dislocation after THR
    Rashid Tikhilov 13 Октябрь 2007, 21:07
    Dear Michael Markushevich,
    My opinion is: open reduction, estimation of stem stability and if stem would be found well fixed, fixation of greate trochanter and proximal part of the femur. If stem is not stable - change it, with the same procedure with fractures. I think that fixation of the greate trochanter is very
    important for joint stability.
    Best regards,
    Rashid Tikhilov
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    Re: Periprosthetic fx dislocation after THR
    Chris Wilson 14 Октябрь 2007, 00:12
    This what a hip colleague of mine thinks

    Chris Wilson
    University Hospital

    Good case - Problems are :

    1. Dislocation - as it was through Lat approach abductor repair will also have failed
    2. Fracture - In terms of classification doesn't fit neatly into Vancouver Classification because both lesser & greater trochanters are fractured - therefore is AL & AG.
    Medial fracture line extends into diaphysis and would therefore be more accurately defined as a B fracture. The stem looks like a Zimmer proximally coated FMT therefore as it is only 2 days post-op & given the morphology of the fracture probably best described as a B2 fracture around loose stem.

    Treatment - Revision surgery to include -

    1. Stem revision to stem which allowed distal fixation - ie fully coated porous or tapered distal fixation stem.
    2. Reduction of medial calcar fragment & greater
    trochanter probably best achieved with rochanteric cable plate system
    3. Regarding instability - offset was obviously an issue in primary surgery given long neck skirted head. Therefore I would advise careful intra-operative assessment of socket position and abductor damage. If component position poor then revisie socket if not increase head size to 36mm
    (which will also lateralise liner helping offset) or if abductor damage significant consider constrained liner (the Trilogy socket that is in place will allow for both these options).

    Cheers - Steve
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    Re: Periprosthetic fx dislocation after THR
    Michael Markushevich 15 Октябрь 2007, 00:53
    In the first I'd like to thank all collegues for fast and professional reaction to my case.Among I am also like to clarify, that joint was very stable at the end of surgery and another joint, which was operated few years ago has same offset of proximal femur.The patient was falled during confiuse state,so this is pure traumatic case.
    Exactly ,I used Zimmer proximally coated stem.And
    I am agree with Mr.Chris Wilson that Vancouver
    classification isn't appropriate to this case.
    Sure I will go to revision procedure with use distal fixation. I am going to use Corin long stem with distal locking.If during surgery be made clear that socket position isn't accetable I am ready to change component,increased head to 36mm and to use constrained liner.
    Thank you very much.
    Michael Markushevich.

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    Re: Periprosthetic fx dislocation after THR
    pepp 16 Октябрь 2007, 20:59
    Этого Израильского коллегу знаю лично. Когда-то работали в одной больнице в Израиле.
    Ну что можно сказать, для начала, в той больнице где он работает сейчас, думаю, с честью выйдут из данной ситуации. Отделение очень сильное.
    Насчет протеза, мы видим нон цементный протез с усадкой после перелома. Его надо вытаскивать, восстанавливать перелом и делать теперь уже цементный стем. Все в общем -то довольно банально.
    Не согласен с тем, что написал Маркушевич, что он будет делать длинный стем. При нормальном циркляже и укреплении малого вертела, думаю, обычный протез, посаженный на цемент вполне подойдет, без наступания на ногу в течение 6 недель.
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    Re: Periprosthetic fx dislocation after THR
    Michael Markushevich 18 Октябрь 2007, 02:29
    Good evening!In the morning operation was done.
    Procedure was much more difficult that my sense.
    Socket is acceptable position so wasn't change.Fracture proximal femur - three part I mean G.T & L.T. After removal femoral prosthesis was done reduction of L.T & Calca. Reaming and insert new prosthesis with distal locking by 3 screws,reduction G.T.and fixation by 4 cyrclages.
    Connection head and reduction femur.In the end surgery got stable joint.
    Here x-ray after operation.

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