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Re: Перелом стержня
послал Adam Starr 23 Июнь 2002, 23:06
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Hi Alex,
This is one of those cases where the answer I'd use here in the USA is probably not the answer you'll be able to apply where you are.
I would do my best to remove the broken nail and screws through the original, antegrade incision. I'd try to spare the knee joint, if at all possible. It is hard to retrieve broken nails, especially when the broken piece is so far distal, but it is not impossible.
There are several articles in the literature with tips on how it can be done. If you are going to continue using nails (and I think you should, since they work well) you'll have to get used to taking broken ones out every now and then.
Once I got the old hardware out, I would plate the fracture and bone graft it. A blade plate would be the strongest device to use. But, I think I would choose a LISS plate, or a locking condylar plate. These plates have threaded screw holes that lock into threads on the screw heads. Once the screw is seated, you have, in effect, a mini-blade plate at each screw.
You can read a bit about it here:http://www.aodialogue.org/Dialogue/1_01/PDF%20Folder/LCP.pdf
Far as I know, nobody has published anything about the use of the LISS or other locking plates in the treatment of a large
series of femoral nonunions. But, there are lots of surgeons here and in Europe using the locking plate systems like crazy,
so I'm sure someone will have a series soon.
There was a great article recently in JOT (Bellabarba et al., 16:287-296) about the treatment of supracondylar nonunions
using indirect reduction and plating.
In that article, the authors reported the use of 95' blade plates, condylar buttress plates and a few locking condylar plates. They stressed the importance of doing as little dissection as possible, to avoid devitalizing the bone. Bone
grafting was used in atrophic nonunions, if I remember correctly.
I think the locking plates make sense, because the usual method of failure for the old style plates is for the screws to loosen, toggle, and pull out, or to break at the screw neck. That doesn't seem to be a problem with the locking screw technology.
The problem with the LISS is that you have to get the reduction BEFORE you place the plate on the bone (at least Synthes says you do). Since this fracture is not that old, you might still be able to reduce it.
The other downside to the LISS in the treatment of nonunions is that the plate doesn't allow for compression. It may be that if you got good stability without devitalizing the periosteum, the fracture would go ahead and heal, without
compression at the fracture site. I'm not sure. Probably one of the surgeons doing lots of LISS plates, or locking plates, will tell us in the future.
I don't know if locking plate technology is available to you. If so, great. If not, then I think the most reliable way to get union would be to use a blade plate and bone graft. Presumably, blade plates are available to you.
I'm sure there are retrograde nail enthusiasts who'll recommend retrograde nailing. I think a plate will allow you to restore anatomy better, give you better fixation, and allow compression across the fracture better than a nail will.
Especially a narrow, unreamed nail.
Good luck with it.
Adam Starr
Dallas, Texas
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