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Re: ANKLE FRACTURE
Enes M. Kanlic 13 Сентябрь 2004, 00:39
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Alex,
As I mentioned before (down), in Dr. Salvi's case, I am for temporary fixation, sparing even the talus (not to get wire as possible vehicle for contamination) and than early fusion.
Fixing the fibula, will provide some stability to the ankle and through the incision relatively far from the major zone of injury (antero-medial), and if we do want to restore the anatomy (if feasible), that is the first step - as T. Rüedi told us a long time ago.
Your (or Dr. Lazarev) case is nice but a quite different. The stability is obviously provided by very well placed nail, and "soft and bent" wire does provide just some weak reinforcement to the construct - I would prefer the plate if tissues are good, or "real" nail, like Rush - non locked,
percutaneous large cannulated screw, or even locked (Biomet SST fibular nail)... (examples some other time, I have work to do...)
There are different ways to skin the cat, but I guess, we agreed that is good to fix the fibula in distal nailed tibia fractures, aren't we!?
Enes M. Kanlic, MD, PhD
Associate Professor
Department of Orthopaedics
TTUHSC in El Paso, Texas
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Re: ANKLE FRACTURE
Alexander Chelnokov 13 Сентябрь 2004, 01:56
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KEMMD> fixation, sparing even the talus (not to get wire as possible vehicle for
KEMMD> contamination)
If the foot is fixed by a wire in the metatarsus, any motions are excluded, and risk of contamination anywhere around the ankle is
extremely low.
KEMMD> and than early fusion.
I have no experience of so early fusion in such comminuted case. So many avascular fragments... The talus would contact with nothing, and a graft will "hang in the air". I would still try closed reconstruction of the distal tibia at least to provide more host for the fusion and postpone it for few months.
If plan to do something early - maybe perform shaft corticotomy and bone transport to the talus? I bet it would take less time than wait for the fusion after open surgery in 2-3 weeks.
Or maybe perform a closed tibia-talar nailing as is? Then control the healing and add grafts from time to time.
Or maybe combine these? Corticotomy, transport of the peice of the tube down to the talus, then small incision for talar cartilage removal, and after docking perform conversion to nailing.
KEMMD> Fixing the fibula, will provide some stability to the ankle and through the
KEMMD> incision relatively far from the major zone of injury (antero-medial), and
What instability of the ankle we are talking about if the tibia and the foot are fixed by the fixator? No forces are applied to the fibula in the environment.
KEMMD> provide just some weak reinforcement to the construct
I didn't perform stress tests, at least it prevents fibula against secondary displacement. Stressed 2 mm double wire is not so weak.
I used it only in two fibular cases recently. Colleagues from Moscow use the wires mostly for proximal humerus and even femoral neck.
KEMMD> - I would prefer the plate if tissues are good, or "real"
KEMMD> nail, like Rush - non locked, percutaneous large cannulated
KEMMD> screw, or even locked (Biomet SST fibular nail)... (examples
I realize what you mean. I also have seen a very attractive small nail which is locked by multiple wires - if it is available, it is great. But when the tibia is stablized by a nail or external fixator the stressed wire looks quite enough as a supplement for such a small bone.
KEMMD> There are different ways to skin the cat, but I guess, we
KEMMD> agreed that is good to fix the fibula in distal nailed tibia
KEMMD> fractures, aren't we!?
If the tibia is broken at the distal level, and fibula - at the midshaft, no need to touch it. To my mind fixation of the fibula is necessary for low fibular/malleolar fractures, when the ankle mortise is or near to be involved. For stabilization of the tibia it plays no role. Just take a large nail and use all locking options for the distal fragment.
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