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post-nailing fracture
Ортопедия и травматология Отправлено Sandro Reverberi 17 Январь 2008, 00:31
Dear All,I should like know what is your preferred treatment for this fracture at the tip of a long Gamma nail (on a healed subtrocantheric fracture : see img).
The patient is a 81 years old lady with osteoporosis and important knee arthrosis (as you can see).
Do you remove the nail or not? can we obtain a stable ostheosynthesis with a plate without remove the nail?
Do you prefer to apply a plate or an endomedullary nail (along the old way of gamma nail) to preserve joint motion?
It is justified to apply bone cement in the bone loss ?
Best regards
Sandro Reverberi
Arcispedale S. Maria Nuova
Reggio Emilia
Italy

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    Re: post-nailing fracture
    Enes M. Kanlic 17 Январь 2008, 00:36
    Dr. Reverberi

    In my opinion:

    - It is an long, spiral, metaphyseal fracture – very good chance of healing (will not be any need for any bone cement…bone substitute – filler)

    - I would use: distal femoral locking plate with few cerclage wires in midsegment and some unicortical locked screws and cerclage wires proximal…



    Sincerely,

    Enes M. Kanlic, MD, FACS
    Professor
    [ Ответить ]

    Re: post-nailing fracture
    Wojciech Glinkowski 17 Январь 2008, 00:40
    Dear Sandro,

    I would consider retrograde femoral interlocking nail after Gamma nail removal during the same surgery.
    In my opinion the femoral bone looks osteoporotic, but no bone defect is visible to justify bone cement.
    General condition of the patient may influence on size of your surgical intervention.
    Plating with unicortical screws on osteoporotic bone will not probably stable fix this fracture. Early destabilization may occur when patient
    begins to walk and unfortunately step on her foot.

    With regards

    Wojciech Glinkowski MD, PhD

    Chair and Department of Orthopedics and Traumatology of Locomotor System
    Center of Excellence "TeleOrto"
    Medical University
    Warsaw, Poland

    [ Ответить ]

    • Re: post-nailing fracture
      Отправитель: Alexander Chelnokov 17 Январь 2008, 00:49
      Wojciech Glinkowski пишет:
      > > I would consider retrograde femoral interlocking nail after Gamma nail
      > > removal during the same surgery.


      If we have a ready entry point after the gamma removal why perforate the intact knee for another entry - why not just insert a longer antegrade
      nail? We definitely would do this. Of course retrograde nailing as well as locked plating would do the job but antegrade nailing in this case is
      least invasive among mentioned options.

      [ Ответить ]
      • Re: post-nailing fracture
        Отправитель: Enes Kanlic 17 Январь 2008, 12:19
        If I may again:

        1. Removal of the nail in elderly, frail lady is not a small procedure (timing and blood loss)

        2. It is hard to do "good fixation" of distal fracture through antegrade approach.... and probably distal incision (more than just

        for distal locking) would have to be made anyway (reduction, cerclage wires...).

        3. Retrograde nail (small diameter in large bone) does not allow for good, stable fixation (often malalignment) and early weight bearing (I have seen the locking screws and nail cutting through the distal femur into the knee joint - in osteoporotic bone, heavy persons)

        4. We could treat this fracture like there is no a nail - new locking plates allow for secure fixation.... two similar cases are attached...



        5. Immediate full weight bearing after this type of fracture is in my opinion to risky - I would suggest rather minimal.... or not at all (just transfers in wheelchair for about six weeks, until some healing happens).


        Sincerely,


        Enes M. Kanlic, MD, FACS
        Professor


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        • Re: post-nailing fracture
          Отправитель: Wojciech Glinkowski 18 Январь 2008, 01:37
          Dear all,

          Interesting discussion, Thx.
          Play with osteoporotic bone is always the challenge.
          Images sent by Professor Kanlic look nice, very good job. Excellent achorage in distal fragment. However, unicortical screwing or bicortical
          makes a difference, also for locked screws. Proximal fragment unicortical fixation may present stability not easlily predictable. Certainly its stability for wheelchair should be sufficient. Full weight bearing can not be mentioned for this case. If minimal bearing is allowed full weight
          single step may happen in elderly.
          Gamma nail exchange may probably fit the criteria of optimal and minimal invasivness, indeed. Removal could be relatively fast due to large intramedullary diameter seen on X-ray.
          I do agree that distal locking of the nail in distal femur remains critical.

          Best regards

          Wojciech Glinkowski

          [ Ответить ]
          • Re: post-nailing fracture
            Отправитель: Marco Berlusconi 18 Январь 2008, 01:38
            Our experience with locking plates in osteoporoticbone and weight bearing is that there's no difference with a nail. the old patient start walking with crutches and 20kg weight bearing as the general conditions are good as for the nail. In this case 13 holes LISS with at least 8 cortex proximally
            best regards

            [ Ответить ]
      • Re: post-nailing fracture
        Отправитель: Marco Berlusconi 18 Январь 2008, 01:41
        As you know the strain theory of Perren says that a narrow line of fracture should have absolute stability especially in this porotic bone. So the
        option of a longer nail with 2 screws in will not give an absolute stability; it should go if it was a multiragmentary pattern of fracture.
        best regards
        marco berlusconi

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    Re: post-nailing fracture
    Marco Berlusconi 17 Январь 2008, 00:44
    Dear Sir, in my opinion it's better to take off the gamma nail, anatomically reduce the spiral with 2 lag screws, and fix the shaft fracture with a LISS-LCP 13 holes. No bone graft. Immediate mobilization and weight bearing.
    Best regards
    Marco Berlusconi
    Trauma Unit
    Milan
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    Re: post-nailing fracture
    Adonin Sergiy 17 Январь 2008, 10:47
    I completely agree with Dr Wojciech Glinkowski. I would also do a retrograde nailingfor this patient.

    unfortunately , I don't have any expirience with minimally invasive femoral locking plating and can't judje this technique. Anterograde nailing in this particular case will be definately inferior to retrograde one in terms of quality of distal bone purchase, central positioning of the implant in the medullary canal and, thereby, fracture reduction
    [ Ответить ]

    Re: post-nailing fracture
    Dino Aguilar 17 Январь 2008, 11:09
    Remove gamma nail, proceed for a supracondylar nail.


    Regards.


    Dino Aguilar
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    Re: post-nailing fracture
    Wojciech Glinkowski 17 Январь 2008, 12:36
    Dear all,

    Interesting discussion, Thx.
    Play with osteoporotic bone is always the challenge.
    Images sent by Professor Kanlic look nice, very good job. Excellent achorage in distal fragment. However, unicortical screwing or bicortical makes a difference, also for locked screws. Proximal fragment unicortical fixation may present stability not easlily predictable. Certainly its
    stability for wheelchair should be sufficient. Full weight bearing can not be mentioned for this case. If minimal bearing is allowed full weight
    single step may happen in elderly.
    Gamma nail exchange may probably fit the criteria of optimal and minimal invasivness, indeed. Removal could be relatively fast due to large
    intramedullary diameter seen on X-ray.
    I do agree that distal locking of the nail in distal femur remains critical.

    Best regards

    Wojciech Glinkowski

    [ Ответить ]

    Re: post-nailing fracture
    Michael Markushevich 18 Январь 2008, 18:36
    Good day dears colleguaes! In this case I'd like to use distal femoral lock plate with locking across nail through two holes of nail and number monocortical screws on proximal fragment. This technique demand some skill but be posible.
    Good luck! Best regards Michael.

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    Re: post-nailing fracture
    олег 17 Февраль 2008, 02:46
    можна дати дистракцыю та зкомпресувати в кiльцi iлiзарова + лiжковий режим
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