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Re: Locked nailing femur
послал V. M. Iyer 04 Декабрь 2004, 21:21
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Dear All,
This mail may also be a little long. Because orthogate list and indiaorth list both will be reading this. Some may be accessing only one.
Thanks for further inputs.
Casrtro >> Now I can suggest removing the nail, Ilizarov frame application, with
Casrtro >> distraction, then compression, healing well be achieved after 12 weeks.
We have an expert with us who replies as follows
Mangal >> Multiple reasons for putting ilizarov/ex fix at the bottom of the list. Fracture
Mangal >> is fairly proximal. I would need to use an arch to hold the proximal fragments. Any
Mangal >> compression or distraction using an arch is a less than ideally stable situation in my
Mangal >> opinion. Fracture is very oblique. Axial compression will not work well in this situation.
Mangal >> would need transverse compression via olives, which is not a good idea at this level.
If I just had to do an ilizarov for this patient (hypothetically nothing else available for example), I would probably do a minimal opening up, create a transverse ostetomy thru the middle of the oblique fracture line,shift the fragments slightly medio-laterally in relation to each other, to get an axially stable internal construct, bone graft the area, and use the fixator in a 'holding mode'
Satish >> the obliquity of the fracture precludes one from leaving it unlocked,unless you
Satish >> have an extremely well fitting nail.
VMI- No question of leaving it unlocked
sure one could lock it in the dynamic mode but i am afraid, the nail suggested by me does not permit it.
VMI- Many other nails have one thirdly, as i had written for bijayendra's query, a titanium implant would go reasonably close to the young's modulus of bone and it is proven that that aids in healing. too rigid an implant either provides stress sheilding or fails early. books on biomechanics would have details with figures and calculations etc VMI- It should never be a too rigid implant. Locked nails heal faster because of axial compression while wt bearing, which will not happen if the nail is a very tight fit. Even the so called static locking does permit some axial motion because the screw holes and the screws are not tight fit
Yasir >> There might well be some soft tissue interposition, and definitly jsome fibrous tissue
VMI- There will only be fibrous tissue and no other soft tissue. This fibrous tissue has got great potential. Ilizarov has shown bone forming by distracting it gradually.
Stabilisation by a plate can also turn it to bone"anatomic reduction" of the # and it was shown to give better results (Schatzker).
VMI- If you see Ilizarov's results as seen in his book you will never find any anatomic reduction. I do not say that we do not want anatomic reduction, but I say that stability is more important for better healing
Ajit >>Also, there is insufficient callus to suggest a hypertrophic nonunion after 14 mths. As
Ajit >>mentioned by you the first surgeon has already opened the fracture site and probably
Ajit >>devitalised/ stripped the femur of its perisoteum. Adding bone grafts will surely help.
VMI- OK It is not hypertrophic but normotrophic nonunion. Mangal has already said so. Though the first surgeon has devitalised the femur, that was 14 mths ago. By the way, the second surgery (may be the same surgeon) 5 months ago may also have done some harm. Anyway there is no need to do bone grafting if everything is done closed.
The next mail concerns the nail removal. Regards
V M Iyer
. Iyer Orthopaedic Centre,
103,Railway lines Solapur India
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