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CASE REPORT

HSS - East River Professional Building

IOEN Vail Arthroplasty Course 2023

Goals of care for a 92 year old who uses a walker at baseline would be fastest mobilization and return to ambulation. Any weight-bearing restriction is likely going to result in higher chance of associated complications from immobility. As a result, I would have revised this to a stem I would be cer...tain was stable as opposed to hoping that there was some enough remaining ingrowth on the existing stem to handle immediate weight-bearing. I would call this a B2, and while there are some small case series that suggest ORIF for B2s in lower demand individuals is a viable solution (just like this case had a good outcome), I think there is a larger body of evidence in favor of revision leading to higher chance of success, without having to worry about union, weight-bearing restriction, etc. For me, exposure extent and operative times would be similar in either scenario (ORIF v revision) as well.

Replying to @shishkadog Looks great. And I agree completely with revising the stem for her. Should come out no problem after just 2 weeks. I'm sure that Redapt felt pretty pretty solid when you left!

Replying to @stevemchale When revising, my preference is to approach from the front to mitigate some of the dislocation risk.

I have little experience with this exact stem, which must be ingrown at the distal end for this technique to work. I have not seen fracture fragments “re-ingrow” to the prosthesis after fixation. If ORIF is to be successful, then this fracture pattern is more of an “A”, not a “B” as mentioned belo...w. What is the upside for ORIF? Less blood loss? Shorter OR time? For me, neither are necessarily true. The downsides include prolonged non-weight bearing, delayed/non-union, and component subsidence. You have avoided component subsidence, which is impressive, but can you be sure the distal tip is sufficiently ingrown without intraoperative evaluation? I agree with the surgeons who would treat this with stem revision with a Redapt long femoral stem and cable or troch plate/cable the fracture. As also mentioned below, I would pass a reamer, place a prophylactic cable just distal to the fracture and then reduce and cable the fracture around the reamer. This provides excellent fixation and allows early weight bearing.

Replying to @orthotraumamd that said, further info from the author - stemm well fixed distally - which just opens up a whole bag of worms about classification and management. if the stem is fixed distally this just turns into a mighty impressive Vancouver A - and gets fixed

PMID: 15573879 Chir Main. 2004 Oct;23(5):249-53.

[Dynamic correction of static scapholunate instability using an active tendon transfer of extensor brevi carpi radialis: preliminary report].

ABSTRACT
- We present the case of a twenty year old man who developed static scapholunate instability on the right side following a road traffic accident seven months previously. A dynamic surgical technique was devised to treat this problem using the tendon of extensor brevi carpi radialis as an active transfer. The tendon, divided at its insertion on the base of the third metacarpal, was reinserted into the distal part of the scaphoid using two anchors after shortening it by removing the distal centimetre. The tendon was rerouted via a pulley created 'de novo' at Lister's tubercle in order to centre the tendon on the same axis as the scaphoid. No other material was used for bone fixation. The wrist was immobilized in extension for six weeks. The clinical and radiological result eight months after the intervention showed excellent reduction of the scapholunate joint and a pain-free wrist with satisfactory mobility.