case based discussion during Covid19!

1. Gashaye T.
7th Case discussion

2. Q19.
 The patient is a 45-
year-old builder who
sustained this injury
whilst at work.
 He has no other
injuries.

3. Questions
 Describe what you can see
in these radiographs.
 AP X ray of pelvis
 Left femur neck fracture
 Garden Type IV
 Seems had commutation

4. What would be your management
plan for treatment of this fracture?
 Internal fixation with
cannulated screw
 Percutaneous or
Open
 Cannulated screw
fixation
 3partially threaded screw
in an inverted triangle
confinguration
 4screw in diamond
configuration

5. Others
 DHS/cephalomedilary
nail
 Basicervical #
 Additional screw above
sliding hip screw to
prevent rotation

6. Could you describe the blood supply
to the femoral head?
 The blood supply has three
sources:
 The medial circumflex
femoral artery (MCFA) is the
most important supply; it is a
branch of the profunda
femoris artery.
 The lateral circumflex femoral
artery (LCFA) supplies the
inferior portion; it is a branch
of the profunda femoris.
 The artery of the ligamentum
teres is a minor blood supply

7.  When consenting this patient for surgery what
particular risks would you warn him about?
 If we are going to do it percutaneous being open
reduction
 Subsequent development of non union and AVN
 REVISION SURGERY THR MAY NEED

8.  Can you quote the incidence of these complications
and any literature to back this up?

9. Title: Operative treatment of femoral neck fractures in patients
between the ages of fifteen and fifty years.
 Study Design: Retrospective Review
 83 femoral neck fractures in 82 patients between the ages of 15 and 50 years who were treated by ORIF at the Mayo Clinic
between 1975 and 2000.
 73 fractures were followed to union, until conversion to total hip arthroplasty (THA), or for a minimum of 2 years.
 Average follow-up: 6.6 years (3 months to 23 years).
 Fracture pattern
 51 displaced
 22 nondisplaced
 Evaluated effect of various factors on outcome
 Fracture displacement
 Reduction quality
 Capsular decompression
 Results
 53 fractures (73%) healed with no evidence of osteonecrosis.
 17 fractures (23%) developed osteonecrosis
 Osteonecrosis developed in 14/51 (27%) displaced fractures
 Osteonecrosis developed in 3/22 (14%) nondisplaced fractures
 There was a strong trend for displaced fractures to demonstrate a higher rate of osteonecrosis development, but the difference
was not significant (P = .17)
• 6 fractures (8%) developed nonunion
 4 nonunions later healed following a second procedure
 Nonunion developed in 5/51 (10%) displaced fractures
 Nonunion developed in 1/22 (4.5%) nondisplaced fractures
 Influence of reduction accuracy on outcome
 11/46 (24%) cases with good-to-excellent reduction developed osteonecrosis
 3/5 (60%) cases with fair-to-poor reduction developed osteonecrosis (2 of these also developed a nonunion)
 2/46 (4%) cases with good-to-excellent reduction developed nonunion
 3/5 (60%) cases with fair-to-poor reduction developed osteonecrosis
 Only 1/5 cases with fair to poor reduction healed without complication

10.  Influence of capsulotomy on outcome
 No statistical effect of capsulotomy on development of osteonecrosis (P = .50)
 14 displaced fractures underwent open reduction, with direct visualization and therefore had a
capsulotomy performed
 4 displaced fractures treated successfully by closed reduction were treated with a capsulotomy
 3 nondisplaced fractures were treated with a capsulotomy, and 1 with aspiration
 4/22 (18%) cases that underwent capsulotomy/decompression developed osteonecrosis
 13/51 (25%) cases without capsulotomy developed osteonecrosis
• At the time of final follow-up, 13 fractures (18%) had undergone conversion to THA
 11 due to osteonecrosis
 1 due to nonunion
 1 due to osteonecrosis and nonunion
 Average time from injury to THA was 7.3 years (3 months to 15 years)
 Conclusions
 The 10-year hip survival rate following femoral neck fracture in young patients treated by
ORIF was 85%.
 Osteonecrosis was the main reason for conversion to THA.
 Not all patients with osteonecrosis required further surgery.
 Initial fracture displacement and quality of reduction influenced the outcome.

11. Q20. not clear question
 This is a photograph
of two types of
femoral stem used in
a total hip
replacement
 Can be cementless
and cemented or
 Modular and non
modular design
respectively.

12. Questions
What are they called?
 Exeter stem design
and charnley stem
design or
 taper slip / force
closed and shape
closed/composite
beam

15. What are the characteristic features
of both the stems?
 Both are cemented stem
 Exeter stem
 tapered mediolaterally flat anterioposterior
 Need over broaching
 Cement mantling -2 to 4mm
 Charnley stem design
 Thick and round minimally tappered distally
 Taper three dimensional
 Close shape
 Does not need over brouching
 Can be flanged or have collar
 Cement mantling 1mm

16.  Mounting evidence suggests that failure of cemented
stems is initiated at the prosthesis-cement interface
with debonding and subsequent cement fracture.
 Various types of surface macrotexturing can improve
the bond at this interface.
 The practice of precoating the stem with polymethyl
methacrylate (PMMA) has been associated with a
higher than normal failure rate with some stem
designs and has largely been abandoned.
 Noncircular shapes, such as a rounded rectangle or
an ellipse, and surface irregularities, such as grooves
or a longitudinal slot, also improve the rotational
stability of the stem within the cement mantle

17.  There is concern that even with surface modifications the
stem may not remain bonded to the cement.
 If debonding does occur, a stem with a roughened or
textured surface generates more debris with motion than a
stem with a smooth, polished surface.
 Higher rates of loosening and bone resorption were found
with the use of an Exeter stem with a matter surface than
with an identical stem with a polished surface
 Similar findings have been reported when comparing the
original polished Charnley stem with its subsequent
mattefinish modification. For this reason, interest has been
renewed in the use of polished stems for cemented
applications.
 Ling recommended a design that is collarless, polished,
and tapered in two planes to allow a small amount of
subsidence and to maintain compressive stresses within
the cement mantle.

21. Which material are they composed of
and why?
 A femoral stem most
commonly composed of
 titanium
 ceramic
 cobalt chromium
(CoCr)or stainless-steel
alloy with insertion in
interference fit or with
PMMA as means of
fixation connected to a
modular femoral head
of Co Cr alloy or
ceramic
 Cobalt chromium
advantage
 Stronger than titanium
 cobalt disadvantage
 More bone resorbtion
proximally
 Toxic to body
 Titanium advantage
 Elastic modulus near to
bone
 Better bone ingrowth
 Better tolerated at
cellular level
 Titanium disadvantage
 Increased risk of
fracture
 Notch sensitivity

22. Why?
 material composition need to be
 resist cyclic loading in a demanding environment
 well tolerated by the body /inert
 needs to be corrosion resistant
 have adequate material strength
 inexpensive to manufacture
 available in large quantities

23. What is the engineering principle behind the success of
each of these stems? Please describe with an
illustration.
 The good long-term outcomes for the flat-back Charnley
and the polished Exeter stems can be attributed to the
taper slip principle
 Taper-slip principle
 depends on shortening or subsidence in order to obtain and
maintain a tight fit
 the taper should be polished and that the cement should allow
some subsidence.
 The system is then held together by the resultants from
axial forces and the greater the load, the tighter is the fit of
the taper
 When there is subsidence, radial compressive forces are
created in the adjacent cement, and transferred to bone as
hoop stress

24. Cont.
 The polished double
tapered Exeter stem
creates radial
compressive loading
as the predominant
force, unlike a non-
polished surface non
tapered stem, which
creates greater shear
force as stem
migrates distally

25. What are their long-term clinical
results?
 The long term survival of hip implants depends on
how well the implant becomes fixed from the
outset of the procedure.
 Two methods are now routinely used to attain
initial implant fixation:
 cementing the implant in the bone using
polymethylmethacryV late(PMMA)
 press fitting the implant into the prepared bone site
with subsequent bone ingrowth into the implant
porosity

26. Long term Out come
 Overall, long-term results of Type 1 /exeter stems
are excellent.
 proven to be reliable in both young and old
patients, and for multiple pathologies
 high incidence of early per prosthetic fracture than
other may act as a wedge, splitting the femur
following a fall.
 Aseptic loosening 0.6%
 Overall long-term results of Type 2 /Charnley
stems are excellent and variable with generation
and design
 exhibiting higher revision rates compared to others
at the 10 to 15-year follow up
 6% rate of aseptic loosening

27. Q21.
 10-year-old girl
presented to the
outpatients clinic with a
progressively worsening
deformity of her wrist
joint.
 There was no history of
trauma or of recent
infection.
 These are her clinical
photographs

28.  Describe the clinical photographs.
 Prominent distal dorsal ulna
 Mild deformity… volar displaced wrist or hand fall
forwardly

29.  What is the diagnosis?
 Madlung deformity
 Female
 Adolescent
 Spontaneous deformity

30. and what are the classical clinical findings in
these patients?
 absence or underdevelopment of ulnar and volar
portion of growth plate of the radius
 articular surface directed ulnar ward and volar ward
 uninvolved radial and dorsal portions of the physis
continue to grow
 faster growing, newly formed bone bends toward area
of slower growth, causing the articular surface of distal
radius to slant in palmar and ulnar direction

31. Cont.
 ulna is unaffected and remains in its usual dorsal
position
 Clinical feature
 Wrist deformity- prominent dorsal ulna
 pain from radioulnar subluxation or radiolunate
impingement (insidious onset )
 Worse at activity
 usually becomes less severe at maturity
 wrist motion
 extension and supination, is limited

32. These are the radiographs of another
patient with the same condition
 Describe the radiographs
 AP and lat x ray of wrist
 Ap view
 Posetive ulnar variance
 Significant
 ulnar tilt
 Lunate subsidence
 Lat view
 Palmar carpal displacement

34. McCarron et al
 4 radiographic parameters for early MD
 Ulnar tilt >330
 Lunate subsidence > 4mm
 Lunate fossa angle > 400
 Palmar carpal displacement > 20mm

35.  Controversy
 Symptoms are mild & the condition is often self
limiting
 Symptoms are significant and prolonged in to
adulthood
 Deformity and cosmetic issue

36.  Conservative
• If mild or intermittent pain in skeletally mature patient
• She is young progressive deformity expected
• Need follow-up in the mean time surgery

37. surgery
 Goals for surgical
 primarily of pain relief and correction of the
cosmetic deformity.
 A secondary goal is to increase range of motion
 decision is based on the following four factors:
 Patient's age and the growth remaining in the distal
radius
 Severity of the deformity
 Severity of the symptoms
 Clinical and radiographic findings

38.  Three broad categories
 Procedures that correct primary deformity of
radius
 Change the growth or anatomy of the physis
 Change the bony anatomy of metaphysis
 Salvage procedures
 Procedures that attempt to decrease pain and
increase ROM by making compensatory change
to ulna
 Procedures that address both

39.  Darrach procedure – ulnar resection arthroplasty

40.  Sauve Kapandji procedure
 DRUJ arthrodesis + distal ulna osteotomy creating
pseudoarthrosis

41. Combine radial and ulnar osteotomies
 Dorsolateral closing wedge osteotomy of radius
 Ulnar osteotomy +/- DRUJ arthrodesis

42.  Ligamentous release
and dome osteotomy
 Apex distal or
proximal Dome
 Dome in both
directions
 Radial to ulnar and
volar to dorsal
 Rotation reorients
lunate facet in three
dimension
 From anterior ulnar
stance to dorsal ulnar
position

43.  Distal – radial and dorsal translation
 Proximal – volar and ulnar
 Pins or plate fixation
 Ronguer to limit cortical prominence of proximal
fragment

44. Others
 Physiolysis with release of Vickers ligament
 wrist pain or decreased range of motion
 efficacy of prophylactic release of Vickers ligament
in mild deformity in skeletally immature patients
unknown
 DRUJ arthroplasty and arthrodesis
 highly controversial
 painful DRUJ instability and limited
supination/pronation
 significant deformity may require staged procedures

45. Reference
 Campbell's operative orthopedics
 orthobullet
 Rapid_reference_review_in_orthopedic_trauma_pivot
al_papers_revealed
 Current concepts and outcomes in cemented femoral
stem design and cementation techniques: the
argument for a new classification system
 Exeter total hip system
 FEMORAL STEM FIXATION An engineering
interpretation of the long-term outcome of Charnley
and Exeter stems
 Madelung Deformity Andrew C. Ghatan, MD Douglas
P. Hanel, MD

46.  Thank you!