Instructional course lectures
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We have each experienced a significant learning phase for surgical treatment of these fractures. However, problems of articular reduction remain significant, particularly for complex fractures. It is our opinion that a certain degree of centralization of acetabulum fracture treatment--especially for the associated types--can lead to an improved standard of care overall.
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Arthrodesis remains the procedure of choice for salvage of an infected total knee arthroplasty in patients with relatively minor preprosthetic arthroplasty disability. Patients with very severe preprosthetic disability resulting from multiarticular disease or other systemic disease may be treated best by a resection arthroplasty. Systemic sepsis can be eliminated in almost all patients, and drainage can be eliminated in most. ⋯ The advantages of a two-stage arthrodesis are that it is an elective procedure, performed in a limb free of sepsis. The patient has been psychologically prepared for the arthrodesis, and the two-stage procedure has a high probability of success. Neither the underlying diagnosis, nor the infecting organism, nor the type of infected prosthesis is a reliable predictor of success or failure of either a resection arthroplasty or a second-stage arthrodesis.
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Primary fixation of displaced subcapital fractures offers a low morbidity and low mortality approach to a very common problem. The vast majority of patients receiving this form of treatment will not require further surgery. When contrasted with the problems of primary arthroplasty which included a higher morbidity and higher mortality, a higher infection rate, and the possibility of prosthetic loosening, prosthetic dislocation, acetabular wear to subsequent pain, and protrusio, the choice seems very clear. ⋯ In patients greater than 60 years of age we would advocate the following: Anatomic or slight valgus reduction of the fracture; Sound secure fixation; Impaction of the fracture; Weight bearing as tolerated. If these principles are followed, the results of a policy of femoral head preservation in displaced subcapital fractures will be very acceptable for both the patient and surgeon alike. In our opinion, prosthetic replacement equals salvage surgery, and it should be delegated to that role.