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Re: Any thoughts?
послал Bill Obremskey 27 Ноябрь 2004, 12:11
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Anyone else (not in a tryptophanic stupor) have words of wisdom for my friend?
Tough case. It should have healed, I think it was the right implant.
Was it in varus to start? Too much stripping w/ the reduction?; or poor protoplasm and cancer. On the lateral it looks like the piriformis starting point was reamed w/ starting point too posterior and aiming too ant. and med. This is a common problem w/ this fx and the proximal piece ends up
flexed, ER and in varus. This may have contributed to failure, but this deformity will be the same challenge on the revision. Do you have
initial post op xrays.
Questions are:
Does she and family know that she can die due to blood loss w/ this operation.
Will she use Erythro.?
If she wants to procede (I think it is necessary) options are:
1) Minimalistic - leave IMN or remove proximal implant and provide some stability with 4.5 mm locked submuscular plate and bone graft w/PICBG or INFUSE (rhBMP) to decrease EBL. This may give enough stability to allow her to mobilize some with minimal blood loss and risk of loss of life. I think would have significant risk to fail, but could be done to temporize while Hct improves and then procede to #2
2) Remove implant and replace w/ blade plate (greater blood loss) or TFN.
With either I think it is critical to correct the deformity. In this case due to blood loss I would lean to using an IMN. I would have originally preferred a standard IMN w/ proximal locking w/ a spiral blade, but w/ GT starting point already reamed I would replace TFN and correct deformity and bone graft. I think main advantage of IMN is to decreased EBL. A blade plate will improve control of proximal fragment, but requires taking down the vastus, which can significantly increase
EBL.
Technique- I would do this in the lateral position with the leg draped free on a bean bag. I think it helps with the reduction of proximal piece and allows you to get PICBG if necessary. You need a good assistant on the leg.
Remove proximal pieces, use hook or through fx site remove distal implant.
I think you will need to improve reduction to get distal implant out.
Put 5 mm schanz pin in proximal piece in same orientation you would place a blade plate, but start more posterior in GT so IMN will pass.
Place deep into head to maintain control. Take down the nonunion. Use the schanz pin and clamps acrosss the nonunion to maintain reduction.
Replace IMN and keep reduced until locked.
If you use a blade plate, I would do w/ distal femoral traction on fx table.
Remove implant as above, place BP in proximal fragment and use the implant to reduce to shaft. Then bone graft.
Good luck and call me if you have any Q's
Bill
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