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Re: prox screw failure
послал Tom DeCoster 30 Ноябрь 2004, 00:48
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I have seen distal broken screws prevent nail extraction and fracture the femoral shaft on attempted removal. I was consulted intra-operatively on a case where the nail was partly removed and radiographs demonstrated the residual medial part of a broken distal screw had cut through about 10 inches of medial cortex (incredible and I wouldn't have thought it possible if I hadn't seen it with my own eyes). I use that radiograph to illustrate the point that implant removal is fraught with trouble.
Such a response in your case could produce a femoral neck fracture or other severe injury to the femoral head and neck. Therefore I suggest caution.
I have taken the connecting rod from the C series Hoffman external fixator (4 mm diameter stainless steel) and beveled the ends (one flat and the other with a slight hollow or concavity). I use that to tap the residual medial part of the broken screw immediately after removal of the lateral portion and the screw. In the distal femur the medial piece can be extracted by another incision or left. In the only case of proximal femur broken screw I left the screw in the medial thigh and is has stayed there for at least 3 years as the nonunion united. I keep the connecting rod for sterilization on cases with broken screws. For smaller screws (3.5 mm tibial) use the mini Hoffman connecting rod. You could use anything that works as a tamp but it's best if it is strong, straight, cylindrical, slightly less diameter than the screw, reasonable working length and has a flat end. Sorry.
If you try to extract the rod and it only comes a little then you lose the alignment of the lateral part of the screw to the nail and it makes it difficult to drive the medial part of the screw out. The threads may get caught on the inside of the nail.
I have never had any luck with trying to overdrill the screw through the nail. I don't think there is room. You can over-drill the tip from the medial side if it is sticking out of the cortex and you do a medial exposure. I've done that distally but never proximally.
Bonne chance.
TD
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