Revision THR Peri prosthetic fracture - does it need surgery?
- Thread starter alikhan42
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LimpFreeMe
junior member
Alison,
It's nice to see how much you care about your dad!
Jeff
It's nice to see how much you care about your dad!
Jeff
LimpFreeMe
junior member
I have enjoyed looking at your dad's and my x-rays. It's amazing seeing the hip before and after THR. I am a bit of a geek, so I have also enjoyed figuring out some of the software features (it says Stryker at the top.)
I saw a small semicircle missing from top of the head on my good hip. I compared it to some other x-rays and decided it might not be a defect, then found it was called the facet of the head.
I wonder if anyone would be interested in a thread similar to the hippy scar picture thread, only with x-rays?
Jeff
I saw a small semicircle missing from top of the head on my good hip. I compared it to some other x-rays and decided it might not be a defect, then found it was called the facet of the head.
I wonder if anyone would be interested in a thread similar to the hippy scar picture thread, only with x-rays?
Jeff
Josephine
NURSE DIRECTOR EMERITA
United KingdomI see what you are referring to but it's there in all the xrays and doesn't appear to be changing. These little imperfections do occur from time to time and though they might technically be classed as fractures, they're not a problem.
The signs under the lesser trochanter that you feel are fractures are just shadows of the normal irregularities of the bone. Don't forget that an xray shows several layers of bone and tissue all at once so it's a kind of 2 dimensional image of a 3 dimensional object! Easy to misinterpret.
But you are correct about the end of stem fracture, the entire fracture is clearly visible!
Screw? The only screw I see is the one in the acetabular shell.
The dark patches in the greater trochanter are perfectly normal. The trochanter is filled with a honeycomb of bone and at certain exposures, an xray will disappear them completely! As for the items that look like bone fragments, they are probably calcifications in tissues behind the hip. I don't think they are anything to do with the hip itself.
What I see here is a remodelling of the bone where indicated by the curved red line. When the prosthesis is loose and the tip can move, whether it be 'micromovement' or more, it buts against the bone and causes an indentation the shape and size of the stem tip. The bone around it looks thickened and abnormal and was probably a precursor to the fracture.
Josephine
NURSE DIRECTOR EMERITA
A common mistake! Actually, there is an accompanying facet in the acetabulum and it is these two that provide the beds for the hip ligament called the ligamentum teres. I could give you a mini lecture on the LT - it's quite an interesting little bit of anatomy!
Hi Josephine, thanks for the replies - really appreciate it especially as I have no experience whatsoever is looking at xrays!!!
I am glad that most of the other lines are not a concern - I did notice that they hadn't progressed but thought they may have had something to do with the weakening of the bone.
I failed to notice however the remodelling of the bone when the Lima stem was in place - the screw I meant by the way was the bit jutting out of the top of the stem near the greater trochanter - apparantly that was flush at time op op and was backing out over time!!! So a few more questions if you don't mind and have the time to answer them!!
(1) Have you hear of this type of prosthetic the LIMA modular Stem - I was concerned when I read on the National Joint Registry that they were used in less than 3% of total TH Revisions in 2011 and that they have no ODEP rating at all being as they only came on the market in 2010!!!!
(2) A few questions re the fracture to date on the 1/3/13 xray -
(a) what type of Fx is this - a transverse, spiral ,comminuted??? I can't decide and therefore cannot choose out of the research I have the best future treatment....
( b) is classed as a Fx of the proximal or distal femur? I thought proximal in which case its the Vancouver system that should be used to classify it ?? and would you class this is a Type 2 a - stable stem, type 2b - unstable or Type 2c - unstable and loosening. Doesn't look look a 2c but how could we tell if it was loosening apart from really during an operation to revise it?
(c) in your opinion do you feel that type of Fx should have been fixed by ORIF / replacement stem or in your experience have you ever come across anyone who has NOT had this fixed by ORIF ? and if so what is the likely success rate or complications?
(d) can you tell form the xrays the length of the Lima stem compared to the Exeter in place? I am concerned again about the gap underneath the plug where the Lima stem was - would it not have been prudent to revise it to a similar length stem rather than a shorter stem? Can't find any literature to support the shorter stem?
(3) Dad's now walking about the house on two crutches partially weight bearing - not toe touching - I presume that this is ok as he is not experiencing any pain at all. I would have thought he should have a protected brace on at the very least???
(4) Personally I think that the consultant does not want to operate again so soon after the last one or is worried about the potential of a future op causing more Fxs and is hoping that the Fx will heal enough to allow dad to walk with one stick - I am however a little concerned about his future especially regarding the possible knee replacement which is needed!!! Do you feel ( and I will not hold you to anything) that we should go for a second opinion outside the region?
Once again sorry about the long post - we have another appointment on May2nd and I want to be prepared!!!
I am glad that most of the other lines are not a concern - I did notice that they hadn't progressed but thought they may have had something to do with the weakening of the bone.
I failed to notice however the remodelling of the bone when the Lima stem was in place - the screw I meant by the way was the bit jutting out of the top of the stem near the greater trochanter - apparantly that was flush at time op op and was backing out over time!!! So a few more questions if you don't mind and have the time to answer them!!
(1) Have you hear of this type of prosthetic the LIMA modular Stem - I was concerned when I read on the National Joint Registry that they were used in less than 3% of total TH Revisions in 2011 and that they have no ODEP rating at all being as they only came on the market in 2010!!!!
(2) A few questions re the fracture to date on the 1/3/13 xray -
(a) what type of Fx is this - a transverse, spiral ,comminuted??? I can't decide and therefore cannot choose out of the research I have the best future treatment....
( b) is classed as a Fx of the proximal or distal femur? I thought proximal in which case its the Vancouver system that should be used to classify it ?? and would you class this is a Type 2 a - stable stem, type 2b - unstable or Type 2c - unstable and loosening. Doesn't look look a 2c but how could we tell if it was loosening apart from really during an operation to revise it?
(c) in your opinion do you feel that type of Fx should have been fixed by ORIF / replacement stem or in your experience have you ever come across anyone who has NOT had this fixed by ORIF ? and if so what is the likely success rate or complications?
(d) can you tell form the xrays the length of the Lima stem compared to the Exeter in place? I am concerned again about the gap underneath the plug where the Lima stem was - would it not have been prudent to revise it to a similar length stem rather than a shorter stem? Can't find any literature to support the shorter stem?
(3) Dad's now walking about the house on two crutches partially weight bearing - not toe touching - I presume that this is ok as he is not experiencing any pain at all. I would have thought he should have a protected brace on at the very least???
(4) Personally I think that the consultant does not want to operate again so soon after the last one or is worried about the potential of a future op causing more Fxs and is hoping that the Fx will heal enough to allow dad to walk with one stick - I am however a little concerned about his future especially regarding the possible knee replacement which is needed!!! Do you feel ( and I will not hold you to anything) that we should go for a second opinion outside the region?
Once again sorry about the long post - we have another appointment on May2nd and I want to be prepared!!!
Josephine
NURSE DIRECTOR EMERITA
I've heard of but no experience with it, meaning I've never worked with a surgeon who used it. But I retired from surgery nursing back in 2006.
Why do you feel you should be choosing the kind of treatment? That's the surgeon's job. That's why he does years and years of training and practice and why you are paying him the big bucks - for his "skill and expertise". These kinds of decisions are not for non-medical folk.
But if you want the specifics:
- technically it's a mid-shaft peri-prosthetic fracture and because there are more than two fragments it would be referred to as a comminuted fracture
- classifications are mute since they deal in generalities. All fractures are totally unique and it takes skill and expertise to decide which classification they fall into. Also views of the leg from at least two different aspects.
- classifications are really for the purposes of research and would not be the guideline surgeons use to decide treatment. Often the actual choice of appropriate treatment cannot be decided until one opens up the area and eyeballs it
- ORIF is just an acronym meaning open reduction and internal fixation. It is not a descriptive term implying one kind of approach or another.
Josephine - apologies for the last post - the bit about future treatment options came out all wrong! What I meant was that I like to know as much as I can about something prior to making any decisions... My dad however is very different... Of course its the surgeons decision in the end but at least we can , if we are informed, ask the right questions!!
We are also 'up north' like you but in Teesside.
We are also 'up north' like you but in Teesside.
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