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Re: Несращение шейки бедра
Clifford B. Jones, M.D. 02 Декабрь 2002, 19:04
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This is a good example of sub optimal placement of the neck screws. Young patients with neck/shaft combo fxs have a high Pauwells' angle. This is counteracted by open reduction and internal fixation in order to reduce caudal portion of fem neck. The screws are angled differently by placing them perpendicular to the fem neck fx line (typical AO technique) or horizontal to the floor. The screws here are similar to elderly fem neck fx types. Therefore, no biomechanical advantage exists and the nonunion is produced.
You need to perform a valgus osteotomy with 130 osteotomy plate. This will improve the relative Pauwells' angle and improve the union rate. Problem is the probable nonunion or partial union to the shaft. The osteotomy plate is
only made with 6 holes which will not allow for bypassing the shaft problem.
You will probably require an open plating and bone grafting. Try to angle your distal ost and prox shaft screws so that they overlap and theoretically decrease the stress riser created with the double plates.
Cliff Jones
Grand Rapids MI
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Re: Несращение шейки бедра
Carlo Bellabarba 02 Декабрь 2002, 19:07
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I agree with your assessment re: the neck, and think that ORIF of the femoral shaft is a good option. However, why not address the shaft
component with a retrograde nail? You could perform the osteotomy in the usual way, secure the side plate to the proximal shaft initially with unicortical screws, complete the retrograde nailing procedure, then re-secure the side plate with bicortical screws directed around the nail.
This would eliminate your concerns regarding the stress riser, and might be more practical then ORIF in this obese patient. I haven't done this with proximal femoral osteotomies per se but I've done it for shaft fractures with certain associated femoral neck or intertrochanteric fx patterns treated with a retrograde nail and DHS.
One potential problem with recommending treatment options for the femoral neck nonunion is that we have no idea what the femoral neck alignment looks like on the lateral view
Carlo
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Re: Несращение шейки бедра
Отправитель: Alexander Chelnokov 03 Декабрь 2002, 08:24
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CB> unicortical screws, complete the retrograde nailing procedure, then
CB> re-secure the side plate with bicortical screws directed around the nail.
This is very close to my view.
CB> One potential problem with recommending treatment options for the femoral
CB> neck nonunion is that we have no idea what the femoral neck alignment looks
This view was obtained in abduction + ext. rotation.
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Re: Несращение шейки бедра
Alexander Chelnokov 03 Декабрь 2002, 08:38
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IMHO the problem here was the neck malreduction.
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