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发表于 2011-1-7 16:27:53
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if the problem is shortening , Lengthening over nail will be a good choice : remove distal locking, apply Orthofix LRS system: 1 clamp above the fracture, 1 clamp below the fracture, and 3ed clamb below the corticotomy site which should be at jusnction middle lower 1/3 femur
that will help fracture union and limb length
for details of technique of screw removal U can see my paper published in JOT
I attached a copy of the paper
http://www.madinaortho.com/casweek/femur/fem%20plate.pdf
Dr. Khaled Emarah
Egypt
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Hi
The bone is correcting it's nonunion by braking the distal screws and compressing itself !!!.
I can see callus forming. As you said the patient is walking without aid and is asymptomatic apart from shortening.So I shouldn't treat x ray. Wait for few months and plan for femoral lengthening after removal of implants.
Other case of nonunion and shortening are best teated by a procedure which address both problems together and this is Ex fix with proximal or distal osteotomy to compress the nonunion and lengthen the bone simultaneously which save the patient other procedures.
My regards
Prof. SALEH WASLALLAH ALHARBY (FRCS)
Consultant and Professor in Orthopedics,
Arthroscopy, Sports Medicine, Limb Lengthening and Reconstruction.
Department of Orthopaedic Surgery,
King Khalid University Hospital and College of Medicine
King Saud University.
P.O.Box 87996, Riyadh 11652, Saudi Arabia.
E- mail alharbys@yahoo.com
http://faculty.ksu.edu.sa/DrSalehAlharby/default.aspx
Management is doing things right, Leadership is doing the right things.
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Dr Magdy,
Why the fracture did not unit ?
A) Because there was persistant gap at the fracture site which could not close up in 2 years
What is the cause of nail breakage ?
A) There is always a race between "bony union" and "implant break. Our aim is to make bony union faster by making all conditions favourable. Here the '"implnt break has won.
How to remove this nail ?
Remove the proximal lock and proximal part of the nail. Remove the distal locks; only the screw heads will come out, the remaining part of the sctrew can be hammered out with a Steinman pin thro the nail hole. Keep one steinman pin as a distal lock. Use any method you know to engage the distal nail. We have an extractor which engages into the nail very firmly by anticlockwise turns. Gently remove the nail after the distal lock (Steinman pin) is removed.
what is the best way to solve the problem ?
Ream again to a bigger diameter, put in a thicker nail lock below, backslap to close the gap if possible, lock above. Start weight bearing early
Cheers!!
V M Iyer
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Salam alaikum
this is first time I will make comment on case, that because I tried before from home but i cant enter inside the system. Any way
Why the fracture did not unit ?
It seems to be that the nail is not absolute stable but relative stable , thats leading to pseudoarthrosis and ending with non-united fracture.
Its might be helpfull if one revome the distal 2 scews 6 months after operation.
What is the cause of nail breakage ?
Overlaoding and it s not rare in youngs patient . Therefor operations with nail to young persons almost always are planned with removing the nail after united fracture with average 1 year postoperative.
How to remove this nail ?
Actually it will be difficult. but there are 3 ways
1. Remove the proximal part of the nail as usual., then you have to use a special pliers after remonving all srews. But its a dangreous way and can ends with crush fractues between the top of femural shaft and the old fracture.
2. Remove the proximal part of the nail as usual and all scews. Then make an another entery like retograd nail from knee joint. Then push the nail up by a hammer and a rod.
3. Remove the proximal part of the nail as usual and all scews. Then make incision on old fracture. Then cut the nail, in awys that you can catch it from both sides. Then remove it after you made it 2 parts.
what is the best way to solve the problem
Use the procedure nr. 3 and can ends with nail inside and accorde plate with cabels outsidethe bone in addition to bone marrow transplantaion after an osteotomy to non-united fracture
Muaffak Al-Ani
Orthopedic surgeon
Holbæk Hospital
Denmark
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- The fracture didnot unite as this fixation is not a rigid one where the fracture is located in the most stressfull area of the femur.
- The mail breakage occurs due to the bone void occurs at the site of non union due to : 1. fractuer gap from the start. 2. osteolysis at the fracture site.
- It is best to not remove the nail in order to not disturb the biological enviroment needed for fracture healing. I prefere leave the nail as by breakage of the distal screws it greatly corrects the gap, open at the fracture site, refresh the fracture ends as i can, put a bone graft, augment the fixation by locked surface plating.
Ashraf Ahmad Khanfour
FRCS, MD Orth
Consultant Ilizarov surgery
Dammanhour national medical institute , Egypt
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