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Re: Перелом около протеза
Alexander Chelnokov 29 Май 2004, 12:08
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Hello Tom,
Friday, May 28, 2004, 9:04:37 PM, you wrote:
TAC> Do you think the femoral component is solidly fixed or loose?
There were no signs of loosening prior the recent fracture.
TAC> I think retrograde nails through total knees give good distal fixation. I'm
TAC> not sure what kind of TK prosthesis
AFAIK it is Corin (UK).
TAC> but nearly all of the designs in the US have a big enough space
TAC> to accept a 10 mm retrograde nail between the condlyles of the
The patient is about 100 kg, so a thicker nail would be favourable...
I am not certain about whether a thicker nail can be inserted through the notch, and it seems to me cruciate ligaments are at risk.
TAC> My concern in this case would be the deformity of the old fractures might
TAC> not allow for a straight nail but might be more amenable to a locking plate;
Locking plates are still not available in our unit. And at recent EuroTrauma 2004 i've just heard a very good presentation of D.Seligson from the US about distal femoral fractures whrere he was a bit skeptical about lockig plates, demonstrated broken ones, and proposed that nails are still a way to go. And anyway it would be some kind of open reduction, muscle separation...
TAC> or particularly in Russia, XF.
Even here people are very restricted about XF for definitive fixation over endoprosthesis because of extremely high cost of pin/wire tract infection. So my primary plan is antegrade nailing with a solid nail.
If the attempt to pass through the area of union at the shaft level is failed, i switch to the retrograde approach. Which i will try to avoid by any means because the TKA was performed in another unit and in case of problems with the implant any later it is a reason to say - you see, ortho trauma guys broke our ideally implanted knee. I suppose you realize what i mean.
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Re: Перелом около протеза
Отправитель: Tom DeCoster 30 Май 2004, 20:02
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I agree with Dr. Seligson (as you mentioned) about retrograde nails being best option for distal femur fractures proximal to total knee replacement.
Although longer retrograde nails are now preferred, the shorter retrograde nails still work.
I think you are unnecessarily concerned about going through the condyles of the femoral component. The ACL is already gone in this patient (clearly no
tibial attachment) and the PCL (if still present) is not typically injured by
retrograde nail. The surgical approach is actually quite easy and much easier than antegrade femoral nailing with such shaft deformity. I don't think you will injure the knee prosthesis and even if it needed revision in the future, such revision would be facilitated by a well aligned and healed supracondylar fracture.
My suggestion you consider retrograde nail and put the largest diameter nail that you have that fits and the longest nail that you have that fits up the
deformed medullary canal. Don't perforate the cortex proximally trying to put a
long straight nail in a crooked canal; just accept whatever length you can get. If it's quite short then adjust his rehabilitation accordingly with longer use of a brace, crutches and limited weight bearing.
Good luck
TD
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