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Re: Locked nailing femur
послал V. M. Iyer 02 Декабрь 2004, 20:18
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Dear all,
Thanks to Marco, Alex, Simon, Sunil, Satish, Bhayendra, Abhay, Yasir and Sanjay for your responses. I would like to clear my doubts regarding things mentioned by you all.
It is agreed by almost all that this is a hypertrophic nonunion.
It has been proved beyond any doubt by experience and literature that hypertrophic nonunion does not need bone grafting but only stabilisation. That is because the reason for NU in this case is instability. This stabilisation can done by 1) rigid plate fixation , 2) ring fixator, by itself or with distraction. (GSK et al), or 3) by thick nail properly locked above and below. I have not done bone grafting for such a nonunion in the last 25 years and have not regretted. So bone grafting, as an additional safeguard measure, is not essential except to protect yourself at the consumer court. (Marco, Bhayendra, Sunil, Abhay, Yasir and Sanjay) The second point is : Is there sufficient amount of angulation and overriding that the the fracture needs to be realigned? If the answer is yes, then only the question of doing it by distraction (Alex) or by opening disengaging the fracture and realigning (Abhay, Yasir and Sanjay)
The third point is: Between the plate and nail it has been established that the nail, as an intramedullary implant, is load sharing as against the load bearing plate. In diapyseal fractures, almost everyone will use a nail There may still be some surgeons who are very sure of success withplate fixations. I have seen enough broken plates even when done as per thhe book, my own as well as of others. Just because nailing has failed once in this case, it is not prudent to use a plate now.
Dr Yasir >> We all seem tempted to nail the femoral fractures and forget that they could as well be teated the ''old fashion'' ; i.e. why not then open the fracture site , refashion the # ends, put a descent bone graft and then fix
the # by an LCDCP
1) I was thinking that the old fashion was the nail. 2) Then what is this "descent" bone graft?
Satish, 1) Why static locking? Is it to keep the # more stable ? Using one proximal dynamic hole keeps the fracture equally stable and allows the fracture to heal faster.- My individual opinion. 2) What is this isoelastic titanium nail? How does it help more than a usual strong nail. My ignorance.
Dr Simon >> To my knowledge, you do not have to debride or ream in those cases if angular
Dr Simon >> deformity of the medullary canal allows nail passage. If you are able to compress the
Dr Simon >> fracture, this should have a high rate of union.
If the deformity forces you to ream, you might have to consider doing so under direct vision to avoid eccentric reaming and possible cortical perforation.
Do you mean, just removing the earlier implant and passing another nail of the same size and lock? 2)
Here despite the so called angular deformity, the medullary canal will allow the passage of another
nail. 3) How do we compress the fracture as mentioned by you? I do it by locking distally and doing a couple of guarded back slappig. Here it will not work because the fracture is 14 mths old. 4) Eccentric reaming can be avoided by using Poller screws. ( I use thick K wires). 5)Reaming in such cases is said to throw out the reamed particles at the fracture site acting as bone grafts. (Literature and hearsay)
I am surprised that no one has replied stating Ilizarov fixator and distraction.(Alex excluded). That is probably because this can be treated successfully with other methods.
Probably G S K and Mangal are quietly watching what is happening before responding.
Finally: Removal of the broken implant. What special instrument does the AO implant removal set have?
Is it the long rod with a strong hook at the bottom, to thread thro or outside the nail and hook the nailat tip and pull out or is there any other instrument?
Alex has mentiond his own indigenous method. Alex, I have done almost similar technique to remove a stuck distal part of the nail. Passed a smooth guide wire thro the distal nail, pushed it down to come
out thro the femur distally and out thro the skin, used that point of exit to enter another nail from
distally and hammer the stuck nail out proximally. I thought it may be difficult to introduce "a guide pin inserted from the knee through the stab wound" To negotiate the guide wire from below into the distal end of the hollow nail !!! One has got to be really precise.
My final plan is as follows:
Remove the implant. (taking all sort of precautions and preparations). The fracture will not disengage or disimpact. Introduce a beaded guide wire. While entering the distal fragment, I will try to guide it more laterally (and not in the same earlier track) by using one or two Poller screws (pins) to be in the center of the medullary cavity, ream up to 12mm or more if possible, introduce an Indian ss nail (of which I am confident) size 1 mm less than what I have reamed, and lock with one proximal and 2 distal bolts. This nail if it has entered properly the way it was meant to be some correction of the angulation would have taken place. Weight bearing as soon as the patient can. Wish me all luck.
V M Iyer
. Iyer Orthopaedic Centre,
103,Railway lines Solapur India
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