drjoelwilliams

AO pelvis course 2024.
Amazing experience sharing ideas and techniques last week!

2023 AO pelvis course is a wrap! Such a great educational event to teach and exchange knowledge with colleagues and friends.

Davos 2022
Grateful for the opportunity to teach and share ideas with friends and colleagues from around the world. The next generation is inspiring.

POSTERIOR WALL ACETABULAR FRACTURES: WHEN TO FIX VS FIX & REPLACE

This is a 72 year old woman that was in a car crash and sustained a posterior wall (hip socket) fracture dislocation.

Due to her age, impaction, multifragmentary fracture, femoral head dent and associated dislocation we went with combined fixation and hip replacement.

She was walking right after surgery and is doing well 2+ years postop.

The decision to fix alone vs. fix with replacement is often challenging. However, the decision to recommend replacement was fairly straightforward for her as she is a high-functioning individual with many strong risk factors for failure.

I have no regrets about the decision to recommend replacement and I’m happy with her outcome. Two critiques for this case are 1) the cup position is too vertical, 2) one of the screws is too long.

Happy nurses week to the best team on the planet. Thanks for everything you do and making work more fun.

This is not a black and white case, as evidenced by the comments on the previous post. Some said fix/preserve, some said replace....We went with fix. The outcome of this surgery will hopefully last for a significant amount of time--- longer than a hip replacement in a young, active laborer.

After a long conversation, the patient and I decided upon fixation and acute valgus intertrochanteric osteotomy.

The posterior fracture edge had eburnated with a 1cm defect when the anterior portion was reduced. I placed a bicortical piece of auto-ICBG in the defect and compressed with lag screws. The osteotomy was 20 degrees and a partial wedge.
He is now 7 months postop, healing and not showing signs of AVN.

There isn’t a chapter in a book or high level data to guide decision making for this situation.

Know your options (or phone a friend) and take the patient specific details into account.

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1. Pros/cons for replacement: This is the most predictable and fastest option for recovery, but the long term fate of a THA in a 35yo (especially in the context of his societal/insurance problems that brought him to this situation) are concerning. Revision rates in most publications for young THA are unacceptably high. Each time he undergoes a revision THA, the longevity decreases and complication rates increase.

2. Pros/cons for fixation/preservation: High risk and high reward. If it works, it could be a great long term solution for him. The downside is a higher risk of early failure (nonunion, AVN). For a young healthy guy that has a viable head with intact cartilage, I didn't want to jump straight to replacement. If this option doesn't work, replacement is still an option.

This is a 35-year-old patient who is a manual laborer. He presented to our hospital over three weeks out from this injury. He went to a number of other facilities but was denied treatment due to lack of insurance (yes, in chicago, in 2021 🤦‍♂️).

His injury resulted from a ground level fall and had difficulty walking after the incident. He denies antecedent pain, personal/family history of metabolic/endocrine disorders. He would like to remain as active as possible.

What would you do if this patient showed up in your emergency room? I realize many people would jump straight to a replacement but what are the other options and do they make sense for this young healthy patient?

⚠️Hip transplant from a cadaver

This patient is a 26 year old woman with bilateral hip osteonecrosis who underwent a bone/cartilage ‘transplant’  and a labral reconstruction.

Osteonecrosis (avascular necrosis or AVN) is a devastating condition that often causes hip arthritis in young people.  If caught before the arthritis process starts, hip preservation is an option.

Before the procedure, she had a diagnostic hip arthroscopy and core decompression by to be sure she was a good candidate for the transplant procedure.

X-rays at the end.

Meet Annalise Warnock:

Annalise (.13) is an active 19 year old who has had PAOs done on both (!!) hips.

When I met Annalise she had pain on her right side and with some tests it became apparent she had hip dysplasia. Over a year later she returned with pain on the left side and a second PAO was done.

These photos are her riding horses and playing/coaching beach volleyball between her Right and Left hip surgeries.

So good to see Annalise doing well in clinic this week. Her post op xrays are also included.

Looking forward to more updates of Annalise back to doing what she loves in the near future!

This is one of the cases presented from Fracture Night in America last week.

70 year old man that was brought to the ER with right hip pain after a ground level fall. He has a large pannus and had a previous inguinal hernia repair on the same side as the fracture. The rods in his femurs are from a car accident years ago. He is now 2+ years postop and doing well.

For the nerds 🤓:

Diagnosis: associated both column acetabular fracture with dome impaction

Approach: stoppa + lateral window with ASIS osteotomy

Reduction: 1. distal femoral traction 2. anterior column 3. dome impaction through fracture with osteotome 4. posterior column

Tune into Fracture Night in America tonight @8:30p (CST). We’ll be discussing a Pelvis and Acetabulum case.

Register here: https://ota.org/education/interactivecaseconferences

New study alert!

The periacetabular osteotomy (PAO) is the most common operation world wide for hip dysplasia. Asia is the only continent that uses an alternate technique— the rotational acetabular osteotomy (RAO or ERAO) instead of PAO. Click link to read about how they compare.

https://academic.oup.com/jhps/advance-article/doi/10.1093/jhps/hnab009/6129366?login=true

A periacetabular osteotomy (PAO) is an operation for patients with symptomatic hip dysplasia.

The hip socket (acetabulum) is cut from the rest of the pelvis and re-oriented to a better position.

In properly selected patients it is a powerful tool to postpone or eliminate the need for hip replacement surgery.

These are the preop, intraop and postop images from a 15 year old high-schooler with 2 years of debilitating hip pain that was treated with a PAO.

The preop acetabular index (Tonnis angle) was 12.6 degrees and is now 0. Red lines on image 5 show anteverted acetabulum.

Uncommon injury and solution:

This 51 year old contractor had a hip resurfacing 1 year before this injury. He fell through a ceiling while renovating a house and sustained this femur fracture.

This is a reverse oblique intertrochanteric femur fracture with a nondisplaced extension into the trochanter.

Without the resurfacing, a medullary hip screw is typically used for this injury.

A nail would have been possible but I was concerned about 1. difficulty placing the lag screw near the prosthesis 2. displacing the nondisplaced fracture line and 3. messing with his young healthy abductors unnecessarily so I went with a different solution.

He healed uneventfully and I removed his plate one year post op.

Thoughts?
What would you have done?

*Nail, SHS, specialty femur plate, revision arthroplasty are all considerations.

PART 2/2:

The hinge was busted.

A high tibial osteotomy is a great option for patients with arthrosis from a malalignment.

His varus alignment was appropriately corrected during the first operation, but it did not heal (as and pointed out) because there was a fracture of the lateral hinge. If recognized intraop, a lateral plate should be applied to re-establish the hinge.

His 6 month imaging and symptoms were consistent with a nonunion. In addition to getting his tibia to heal, it’s also important to maintain proper alignment.

Image 1/2: starting alignment measured in the OR with a bovie cord

Image 3: hardware and bone graft removal and restoring neutral axis

Image 4: bicortical structural autograft iliac crest (and cancellous autograft)

Image 5: application of lateral plate and compression with a pull screw + clamp

Image 6: assessment of alignment after correction

Images 7-9: final result with neutral mechanical axis

Intraoperative assessment of alignment is tough! The bovie cord (or guide wire) techniques aren’t fool proof. Any changes in the limb position (rotation and flexion/extension) can change your assessment.

As has pointed out numerous times, get a portable flat plate if you’re unsure.

What other techniques are people using for assessing intraop alignment?

TWO PART POST:

This is a 54 year old man referred to me 6 months after a failed high tibial osteotomy.  His knee was still extremely painful and needed crutches to walk.  He is otherwise healthy.

A high tibial osteotomy is an excellent joint-preserving procedure for medial knee arthritis in properly selected patients.  Usually patients are on the road to recovery in 2-3 months.

Why didn’t he heal?

Jaiseana is back in action 4 months after car accident. She had an ischial T-shaped acetabulum (hip socket) fracture and complete ipsilateral sacral fracture.

Images 2-4: injury images

Image 5: intraoperative image with bend in guide wire to precisely position screw

Image 6-8: current images

Image 9: reference for bent guide wire technique

The fixation for her anterior column was tricky due to the tiny bone corridors. Understanding the techniques in the reference attached helps! Additionally, her sacral dysmorphism limited the posterior ring fixation options.

Thank you to everyone who made a COVID-19 vaccine possible.

Madden is 8 weeks out from her hip preservation surgery and ready to ditch the crutches!

She had hip pain and instability from excessive femoral antetorsion.

Scroll for postop xray

Madden is 8 weeks out from her hip preservation surgery and getting ready to ditch the crutches! Just in time for the big game Monday.

She had a rotational correction of her femoral torsion for hip instability and pain.

Scroll to see the post-op xrays.

This patient is a 64 year old active woman who came to me with a hip fracture after a bad fall.

Images 1-3: Initial xrays of intertrochanteric femur (hip) fracture.

Images 4-6: Intraoperative images showing a pointed reduction clamp and temporary wires to maintain the reduction

Images 7-8: Final xrays showing fixation with a plates and screws (DHHS and TSP)

Images 9-10: Final healed xray and a happy patient.

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For the orthopods and trainees— the alternate option for this patient was a nail. I chose the plate/screw option for several reasons:

1. It is challenging to maintain an acceptable reduction for many (A1/2s) intertrochanteric femur fractures when the fracture exists through the tip of the greater trochanter. The nail acts like a wedge and often results in varus and/or translation.

2. This is a young(er), active patient who uses her hips and legs— a lot! The plate/screw option preserves her abductor tendon. Whereas, the entry start for the nail is right through the abductor tendon. Often this results in persistent, debilitating pain and there is not a good solution.

3. If this fracture did not heal correctly and needed a salvage procedure, such as a hip replacement, the integrity of the abductors is critical.

Last PAO of 2020!

This is our hard working team of Rush residents, nurses, implant reps, and xray techs operating on New Year’s Eve. (Missing my rockstar PA .)

Looking forward to kicking off 2021 with a full week of hip surgeries on the books .

This patient had a hip fracture that did not heal correctly (femoral neck nonunion) and avoided a total hip replacement at a young age.

Image 1: 42 year old woman referred for management of a displaced femoral neck nonunion.  She is very active without pre-existing hip problems. Our discussion included hip preservation vs. hip replacement options. Although replacement is a great option for elderly/arthritic patients, preservation is a much better choice for many patients. 

Image 2: We both agreed that a hip preservation procedure was the best option for her. I planned an operation called a valgus intertrochanteric osteotomy.  

Image 3/4: Intraoperative x-rays

Image 5: At the 6 month postop visit she was walking pain free and back to normal life

happy new year! looking forward 2021

drjoelwilliams updated their phone number.