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Re: Перелом "около пластинки"
Tom DeCoster 05 Январь 2004, 15:19
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All good and cogent arguments for antegrade nailing.
Regarding knee motion:
Knee motion is slower to return after retrograde nailing as you mention, but does come back after a few months just like or better than other knee operations (e.g., ACL reconstruction). Hip motion (that you didn't mention) returns to normal faster and more completely with retrograde nailing than antegrade.
Hence the concept of "entry site problems are probably equivalent."
Regarding distal fixation. I think the retrograde nail has better distal fixation because it is typically placed under direct control more distally in the distal fragment with potential for nail in the subchondral bone. The distal screws (3 or more) can be placed obliquely in several planes with nail mounted guides giving better purchase on the distal fragment than the typical co-linear transverse screws (often 2 or maybe 3). The clustered oblique screws seem better at resisting toggling of the voluminous distal fragment around the nail better than the co-linear screws, (which were designed for and work great for rotation and length control of mid-diaphyseal fractures).
But that is theory and you can achieve many of the desired effects with antegrade technique by driving the nail very distally as in the case shown and using a nail with very distal locking screws, as you mentioned and illustrated.
That's what makes this case an interesting discussion.
TD
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Re: Перелом "около пластинки"
Alexander Chelnokov 05 Январь 2004, 23:19
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TAC> does come back after a few months just like or better than other knee
TAC> operations (e.g., ACL reconstruction).
It would be interesting to compare long-term follow up of both techniques.
TAC> Hip motion (that you didn't mention) returns to normal faster
TAC> and more completely with retrograde nailing than antegrade.
Really i didn't check limits of abduction/rotation. But it seems that fnctionally significant range of hip motions is not strongly affected.
TAC> Hence the concept of "entry site problems are probably equivalent."
Yes, i agree in general - cases of abductor weakness show that there is no ideal here.
TAC> fixation because it is typically placed under direct control
Pls add some more details about the direct control.
TAC> screws (3 or more) can be placed obliquely in several planes with nail mounted
Not available here yet. Though tibial nails can be used as retrograde femoral - it has 45 degrees holes except trasverse.
TAC> better than the co-linear screws, (which were designed for and work great for
TAC> rotation and length control of mid-diaphyseal fractures).
Why the holes are not threaded? It would provide greatest angular stability.
TAC> using a nail with very distal locking screws, as you mentioned and illustrated.
TAC> That's what makes this case an interesting discussion.
THX for your as usual very interesting comments.
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Re: Перелом "около пластинки"
Отправитель: Tom DeCoster 06 Январь 2004, 11:43
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1. Knee motion after antegrade and retrograde nailing of femur shaft fractures has been reviewed and generally suggests knee motion is slower to return after retrograde nailing but at 3 months motion is generally full and equal with the 2 techniques.
2. For distal femur fractures the typical comparison has been between retrograde nails and plates and the motion is similar with the two techniques, although some loss of motion is typical.
3. I agree with Dr. Carr's description of the subchondral purchase of retrograde nails.
4. Threaded distal locking holes in retrograde nails seems like a good idea but is not yet available, to my knowledge. Locking plates are gaining great popularity over the past year and do provide for a construct with outstanding stability.
5. Direct control to me means the relative small distal fragment can be moved with the partially inserted nail used as a joystick in contrast to the "indirect" reduction achievable by trying to align the distal fracture with an antegrade nail. Other percutaneous manipulation/reduction maneuvers are occasionally required. Rarely would extending the incision to visualize the fracture surfaces of an extra-articular distal femur fracture be required.
6. "Generations" are used colloquially in many medical musings. I would say first generation nails were Kuntscher type without locking. Second generation were lockable nails. A variety of products have referred to themselves as third generation (titanium, sleeved systems, retrograde, active compression nails and the like) but none have really been a quantam improvement and I doubt there is any consensus on what, if anything, constitutes a third generation nail as of 2004.
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