[Ortho] Перипротезный перелом дистального отдела бедра

[Alexander Chelnokov]

Clin Orthop Relat Res. 2016 Jun;474(6):1498-505. doi: 
10.1007/s11999-016-4709-3. Epub 2016 Jan 21.
Addition of a Medial Locking Plate to an In Situ Lateral Locking Plate 
Results in Healing of Distal Femoral Nonunions.
Holzman MA1, Hanus BD2, Munz JW1, O'Connor DP3, Brinker MR1,4.
Author information
Abstract
BACKGROUND:
Nonunion of the distal femur after lateral plating is associated with 
axial malalignment, chronic pain, loss of ambulatory function, and 
decreased knee ROM. The addition of a medial locking plate with 
autogenous bone grafting can provide greater stability to allow bone 
healing and may be used to achieve union in these challenging cases.

QUESTIONS/PURPOSES:
We wished to determine (1) the proportion of patients who achieve 
radiographic signs of osseous union for distal femoral nonunions with an 
in situ lateral plate after treatment with addition of a medial locking 
plate and autogenous bone grafting, and (2) the frequency and types of 
complications associated with this treatment.

METHODS:
Between 2007 and 2013, we treated 22 patients for 23 distal femoral 
nonunions, defined as an unhealed fracture with no radiographic signs of 
osseous union at a mean of 16 months (SD, 13 months) after injury. 
During that time, we used a treatment algorithm consisting of treatment 
in one or two stages. The single-stage procedure performed in 16 aseptic 
nonunions with a stable lateral plate involved addition of a medial 
locking plate and autogenous bone graft. A two-stage treatment performed 
in seven nonunions with lateral plate failure involved placement of a 
new lateral locking plate followed by addition of a medial locking plate 
with autogenous bone graft at least 2 months after the first procedure. 
Of the 22 patients treated, 20 had a median followup of 18 months (SD, 
6-94 months). We defined osseous union by bridging bone on three of four 
cortices with absence of a radiolucent line or more than 25% 
cross-sectional area of bridging bone via CT.

RESULTS:
Twenty of the 21 nonunions attained radiographic signs of osseous union 
by 12 months. Six of the 20 patients experienced complications: one 
patient had a persistent nonunion; four patients underwent removal of 
symptomatic hardware; and one patient experienced skin breakdown at the 
bone graft harvest site.

CONCLUSIONS:
A very high proportion of patients achieve union when using medial 
locking plates to treat distal femoral nonunions after lateral plating 
of the original injury. Addition of bone graft, staged reconstruction, 
and revision of the initial lateral plate is indicated when the nonunion 
is associated with fatigue failure of the initial lateral plate.

LEVEL OF EVIDENCE:
Level IV, therapeutic study.
https://www.ncbi.nlm.nih.gov/pubmed/26797911
Alexander Chelnokov