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Re: Non-Union
Nikolaj Wolfson 01 Апрель 2005, 20:10
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Dear friends:Evgueny, Alexander Mitrofanov, and rest of the Forum:
I owe you an answer, and due to your active participation in the pre-op discussion of the case, I do
have a plan. It is not final, since tomorrow my patient is going for MRI, and this will give me more
info about condition ot her tibia, so I can have better idea to what degree to be aggressive with the
intervention on the site of non-union and tibial fragment. Obviously, it will be just one more piece
of information in this decision making process, and you may argue its necessity, but, I think it will
help me, and hopefully, and mainly, the patient.
So:
1. Approach: will go from the lateral side and excise part of the fibula, which, if not removed,
might be on a way and prevent compression at the site of non-union. I will, likely be able to have
some idea about the ends of the bone fragments of non-union, at that time, and will decide to pen it
up from the medial side or not, at hat time.
2. Frame:
1. Proximal ring 1: level I ( Solomin)
2. Tibial osteotomy: just below tibial tubercle. I believe this will give the entire lower leg,
better mechanical and biological environment ( nothing to do with the time saving issue),
3. Ring #2: ( or may be even two rings) for the tibial fragment below osteotomy ( Level IV, or III
and IV, if two rings).
4. Ring at level VIII, distal tibial fragment, with 2-3 wires. The fragment is small( short), and
while this ring will be connected to the more distal foot part of the frame, with wires going through
the Calcaneous and metatarsals, and may be on more wire for the Talus, I am concerned, that wires in
this distal tibial fragment might be a problem from the potential infection point of view, both within
this fragment as well as ankle joint itself.
So, this way, I hope it would be possible to achieve immediate stability and compression at the
non-union site, while staring proximal tibial osteotomy distraction about 10 days after osteotomy, and
subsequently, may be ( big ?)even distraction at the level of non-union .
Number of concerns:
1. Obviously flare up of infection,
2. Stiffness of the ankle joint,( if non-union will demonstrate evidence of healing, I obviously
will remove the foot part,but it is likely going to take some time).
Surgery is booked for Tuesday.
Nikolaj Wolfson
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