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Re: Несращение бедра
послал Thomas A. DeCoster 11 Апрель 2002, 08:54
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I concur with the suggestion for retrograde nail and lysis of adhesions.
Peri-articular nonunions typically involve joint stiffness and if you don't mobilize the joint your new fixation is at great risk because the long lever arm and the stiff joint puts lots of stress on the nonunion. Thus your
comment about "improved knee flexion".
Although "quadricepsplasty" is the term most orthopedists think of when faced with a stiff knee it is not usually actually shortening of the quadriceps but rather scar formation that includes (in order of importance IMHO): capsular contracture, scar between the anterior distal femur and quad, intra-articular adhesions, quadriceps tendon fibrosis, quadriceps shortening. Rather than cutting and lengthening quad tendon as primary focus (with some loss of strength etc) a focus on releasing and stretching scar/adhesions/contractures is more effective at obtaining and maintaining motion. You could consider a lateral parapatellar approach for nail insertion and obtaining knee flexion(releases) and getting the reamer guide across the nonunion.
Re-establishing a medullary canal requires breaking through the sealing callus at the fragment ends. Sometimes easy sometimes hard. Ball tipped guide occasionally works, Kuntscher long thin spade tipped guide for more difficult
cases and for the other 50% Smith & Nephew makes a "pseudarthrosis chisel" 6 mm diameter very sharp tip with a heavy handle for hammering; long enough for tibia or retrograde femur here. Alternative for difficult cases is to open the fracture and drill out the medullary canal but you really have to mobilize the ends which is much more extensive than a fresh fracture situation. The amount of angulatory deformity in this case would be amenable to acute
correction. You might have to remove the broken screw part to ream the medullary canal. Check for indolent infection.
Retrograde nailing allows: 1) better distal fixation than antegrade nailing in this case 2)concomitant release of scar allowing knee flexion 3)easier intramedullary passage than antegrade (whether open or closed).
TD
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