Absorbable Rods in Salter's Osteotomy

Absorbable Rods in Salter's Osteotomy - ‫ممم مممم...

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Unformatted text preview: ‫ممم مممم مممممم مممممم‬ Absorbable Rods in Salter’s Absorbable Osteotomy Osteotomy Prof. Mamoun Kremli , FRCS Prof. Consultant Pediatric Orthopedics College of Medicine & King Khaled University Hospital Riyadh, Saudi Arabia Absorbable Rods in Salter’s Osteotomy Salter’s Osteotomy First published: JBJS 1961, 43B: 518­39 Redirectional acetabuloplasty Easy to perform The commonest performed acetabuloplasty Two K­wires are used to fix the graft and stabilize the osteotomy Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 2 Absorbable Rods in Salter’s Osteotomy Salter’s Osteotomy Indicated for acetabualr dysplasia Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 3 Absorbable Rods in Salter’s Osteotomy Salter’s Osteotomy Problems of K­wires Protrusion Infection Migration Second surgery Anesthesia, scar, bed, socio­economic Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 4 Absorbable Rods in Salter’s Osteotomy Salter’s Osteotomy Replace K­wires with absorbable rods? Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 5 Absorbable Rods in Salter’s Osteotomy Materials Available SR­PGA: Self reinforced polyglycolic acid SR­PLLA Self reinforced poly­levo lactic acid Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 6 Absorbable Rods in Salter’s Osteotomy Materials Available Material Type Size SR­PGA Rods Diam . 1.1 – 4.5 mm Length 10 – 70 mm SR­PLLA Rods PDS Rods Diam. 1.3 / 2 mm Length 40 mm Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 7 Absorbable Rods in Salter’s Osteotomy Materials Strength Material Initial Bending Strength Steel 310 – 690 (depends on geometry) SR­PGA 410 SR­PLLA 300 Cancellous bon 210 Cortical bone 120 PDS 60 Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 8 Absorbable Rods in Salter’s Osteotomy Rate of Degradation Material Loss of Strength Complete Resorption SR­PGA 1 month PDS 2 months SR­PLLA < 12 months 6 months 8 months 3­6 years Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 9 Absorbable Rods in Salter’s Osteotomy Loss of Strength Bending Strength Steel SR­PGA Pan Arab Orthopedic Conference 31.10 – 3.11 Sheering Strength SR­PLLA Prof. M Kremli, King Saud Univ , Riyadh 10 Absorbable Rods in Salter’s Osteotomy Absorbable Rods in Ped. Fractures Pediatric Elbow Fractures Hope et al (JBJS 1991) Makela et al (Clin. Orthop. 1992) Bostman et al (J. ped. Orthop. 1993) Supracondylar fractures Bostman et al (J Ped Orthop 1993) Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 11 Absorbable Rods in Salter’s Osteotomy Absorbable Rods in Ped. Fractures Pediatric Ankle Fractures (Rovinsky 1998, Bostman 1993 , Svensson 1994 ) Osteochondral Fractures of The Knee Svensson et al , J Ped Orthop 1994 150 displaced physeal and non­physeal fractures (1987 – 1999 ) E Makela et al ­ Symposium Feb 16­17 2000 Finn­Medi Auditorium. Tampere Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 12 Absorbable Rods in Salter’s Osteotomy Condylar Fractures Lateral condyle in an 8 year old Lucent pin tracks Preoperative immediate 6 months 12 months Hope et al , JBJS 73B(6) ,1991 Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 13 Absorbable Rods in Salter’s Osteotomy Absorbable Rods in Acetabuloplasty Report of 28 dysplastic hips. SR­PLLA screws. Nakamura et al, Act Orthop Scan, 1993 Rotational Acetabular Osteotomy : 41 pt. (age 12 ­ 55 y ) SR­PLLA screws. Pan Arab Orthopedic Conference 31.10 – 3.11 Nakamura et al, Int Orthop, 1999 Prof. M Kremli, King Saud Univ , Riyadh 14 Absorbable Rods in Salter’s Osteotomy .Absorbable Rods in Salter’s Osteot M Kremli: J Ped Orthop B 11 No 2, 2002 Started in 1998 Salter’s Osteotomy : 18 hips. SR­PGA Rods 1.5 mm. Follow up 13 ­ 34 months (mean 25m). Results: 15 healed well : no complications. 3 slipped : 1 pt. too old ( 9 y ). 2 pt. misplaced rods. Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 15 Absorbable Rods in Salter’s Osteotomy Results M Kremli: J Ped Orthop B 11 No 2, 2002 AGE 22 ­ 108 m ( 36 m ) 10 10 9 8 7 6 5 4 4 3 2 2 2 1 0 0-24 25-36 Pan Arab Orthopedic Conference 31.10 – 3.11 37-48 >48 Prof. M Kremli, King Saud Univ , Riyadh 16 Absorbable Rods in Salter’s Osteotomy Results M Kremli: J Ped Orthop B 11 No 2, 2002 Bilateral : 9 patients 7 patients: k­wire on one side and absorbable rod on the other side. Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 17 Absorbable Rods in Salter’s Osteotomy Results M Kremli: J Ped Orthop B 11 No 2, 2002 Type of Surgery Salter’s only Salter’s and Open reduction Salter’s and Open and Femoral Pan Arab Orthopedic Conference 31.10 – 3.11 6 8 4 Prof. M Kremli, King Saud Univ , Riyadh 18 Absorbable Rods in Salter’s Osteotomy Procedure M Kremli: J Ped Orthop B 11 No 2, 2002 Position of wires/rods Both Medial to Acetabulum Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 19 Absorbable Rods in Salter’s Osteotomy Procedure M Kremli: J Ped Orthop B 11 No 2, 2002 Measure length of wire Cut rod to length Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 20 Absorbable Rods in Salter’s Osteotomy Procedure M Kremli: J Ped Orthop B 11 No 2, 2002 Introduce rods one at a time SR-PGA Rod Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 21 Absorbable Rods in Salter’s Osteotomy Procedure M Kremli: J Ped Orthop B 11 No 2, 2002 Introduce rods one at a time Rods in place Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 22 Absorbable Rods in Salter’s Osteotomy Procedure M Kremli: J Ped Orthop B 11 No 2, 2002 Pins/ Rods same diameter as K­wires. Cut with electro­cautery wire loop or oscill. saw NOT with bolt cutters / scissors. Gentle insertion of pins/ rods. Do not soak in saline or water.. Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 23 Absorbable Rods in Salter’s Osteotomy Procedure M Kremli: J Ped Orthop B 11 No 2, 2002 Preop Intraop Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 24 Absorbable Rods in Salter’s Osteotomy Procedure M Kremli: J Ped Orthop B 11 No 2, 2002 6 m 12 m Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 25 Absorbable Rods in Salter’s Osteotomy Procedure M Kremli: J Ped Orthop B 11 No 2, 2002 Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 26 Absorbable Rods in Salter’s Osteotomy Complications M Kremli: J Ped Orthop B 11 No 2, 2002 Wound infection : none Inflammatory reaction : none Femoral fracture : Displaced graft : Pan Arab Orthopedic Conference 31.10 – 3.11 1 3 Prof. M Kremli, King Saud Univ , Riyadh 27 Absorbable Rods in Salter’s Osteotomy Complications M Kremli: J Ped Orthop B 11 No 2, 2002 Failures (Displaced Graft and Osteotomy) WHY ? Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 28 Absorbable Rods in Salter’s Osteotomy Displaced Graft: Case I M Kremli: J Ped Orthop B 11 No 2, 2002 Age 26 m ­ L CDH Only Salter’s ­ post previous open reduction. Position of rods : 1st : medial, but totally exposed outside bone graft. 2nd : supero­medial RE IL U A Graft broken intra­operatively. LF A IC AN H EC M Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 29 Absorbable Rods in Salter’s Osteotomy Displaced Graft: Case II M Kremli: J Ped Orthop B 11 No 2, 2002 Age 34m ­ R CDH. Salter’s post closed reduction. Psition of rods : both supero­medial Pan Arab Orthopedic Conference 31.10 – 3.11 E UR IL FA L ICA N HA C ME Prof. M Kremli, King Saud Univ , Riyadh 30 Absorbable Rods in Salter’s Osteotomy Displaced Graft: Case III M Kremli: J Ped Orthop B 11 No 2, 2002 Age 9 y ­ R CDH ­ Short R LL. Open reduction and salter’s and femoral shortening. Position of rods: Both medial Pan Arab Orthopedic Conference 31.10 – 3.11 E UR IL FA L ICA N HA C ME Prof. M Kremli, King Saud Univ , Riyadh 31 Absorbable Rods in Salter’s Osteotomy Precautions M Kremli: J Ped Orthop B 11 No 2, 2002 Rods should be positioned medial to the acetabulum. The medial cortex should not be seperated ! Stronger rods or metal k­wires should be used for patients above 5 y of age. Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 32 Absorbable Rods in Salter’s Osteotomy Precautions M Kremli: J Ped Orthop B 11 No 2, 2002 Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 33 Absorbable Rods in Salter’s Osteotomy Follow­up & Ongoing Procedure M Kremli - 2007 14 patients added to previous series using PGA rods ( total 32 ). SR­PLLA rods ongoing since 2002. • 38 hips Salter’s. • 12 hips modified Pemberton’s . ? Screws for some acetabuloplasties. Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 34 Absorbable Rods in Salter’s Osteotomy Follow­up & Ongoing Procedure M Kremli - 2007 Three PLLA displaced All had only ONE rod medial to acetabulum. Initial strength of PLLA less than PGA Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 35 Absorbable Rods in Salter’s Osteotomy Follow­up & Ongoing Procedure M Kremli - 2007 Three PLLA displaced All had only ONE rod medial to acetabulum. Initial strength of PLLA less than PGA m eco m R datio en L h PL t : Bo n Pan Arab Orthopedic Conference 31.10 – 3.11 A o ds sh ro c e pla uld b lly edia ed m Prof. M Kremli, King Saud Univ , Riyadh 36 Absorbable Rods in Salter’s Osteotomy Possible Complications Foreign Body Reaction Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 37 Absorbable Rods in Salter’s Osteotomy Possible Complications Foreign Body Reaction Less in children : Less if kept deep­seated away from skin smaller amount, high metabolic rate. In Salter’s, rods very deep­seated Treatment : NSAID, rest, aspiration, drainage. Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 38 Absorbable Rods in Salter’s Osteotomy Possible Complications Osteolytic Reaction More with SR­PGA rods. Self­limiting. Disappears within one year. No treatment needed. ? clinical significance. Histologically : F.B. reaction. Recommended follow up to 2 years. Bostman et al, JBJS(B)1991 Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 39 Absorbable Rods in Salter’s Osteotomy Possible Complications Osteolytic Reaction Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 40 Absorbable Rods in Salter’s Osteotomy Possible Complications Osteolytic Reaction 6 m 12 m Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 41 Absorbable Rods in Salter’s Osteotomy Conclusions SR­PLLA bioabsorbable rods are safe to use in Salter’s osteotomy. Advantages on K­wires: No need for another surgery Prevent complications related to K­wires Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 42 Absorbable Rods in Salter’s Osteotomy Conclusions Mechanical stability is important Both rods should be medial to acetabulum Salter’s osteotomy should be closed medially Rods should be totally embedded in bone Not recommended above 5 years of age Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 43 Absorbable Rods in Salter’s Osteotomy Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 44 Absorbable Rods in Salter’s Osteotomy Pan Arab Orthopedic Conference 31.10 – 3.11 Prof. M Kremli, King Saud Univ , Riyadh 45 ...
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