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Re: Перелом бедра выше пластинки
Myles Clough 11 Март 2002, 00:41
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Many surgeons including the AO group would argue that plates do indeed produce a stress riser at the end of the plate where the stiffer bone
reinforced by the plate joins the more flexible bone. For this reason removal of the plate has been advocated even when it is assymptomatic.
I personally cannot bring myself to do this. Cases such as yours seem to be rare. More to the point it is extremely rare to see fractures of the femur below hip fracture plates. Surely these old folk would be very vulnerable to a "plate induced" fracture if the stress riser is an important contributing factor. I have seen many contralateral fractures, where the other hip is
fractured some years after the index injury. And I have seen periprosthetic fractures so people do fall and injure the index hip. But fracture at the
distal end of a DHS (Dynamic Hip Screw) I have never seen. I would be interested to hear if this is contrary to other peoples' experience.
Incidentally the incidence of re-fracture after removal of internal fixation is reportedly quite high (5%) so it is not clear to me what the indications for this procedure in assyptomatic patients might be. A high proportion of my patients with supracondylar plates do have symptoms.
Myles Clough mylesclough@shaw.ca
Orthopaedic Surgeon, Kamloops, BC, Canada
Clinical Instructor, University of British Columbia
President, Internet Society of Orthopaedic Surgery and Trauma
http://www.isost.com
Editor, OWL (Orthopaedic Web Links) http://owl.orthogate.com
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Re: Перелом бедра выше пластинки
Ajit Phadke 11 Март 2002, 01:00
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Till now in 16 years i have treated 3 cases of fractures beginning at the lower end of a DHS/Jewett nail, but all these were young patients. Older patients usually reduce their activity levels after a fracture neck femur,
especially in India, and so probably do not get fractures at the end of plates(this is only my opinion). Funnily enough, I have also treated five fractures beginning at the upper end of condylar plates and two at the proximal ends of radial plates but none in the humerus.
As literature and the general view of other orthopaedic surgeons around favours removal of implants, I always advise patients to get their plates removed SOON after fracture healing, more so because trying to remove plates after three- four years is always difficult and often impossible. I have had the misfortune of fracturing a patients ulna while trying to remove a plate put in four years earlier. Luckily for me the fracture healed in a cast.
I am not so convinced about removing Intramedullary nails as these rarely cause any problems.
Dr. Ajit Phadke
Consultant
Phadke Hospital
Tilakwadi, Yavatmal
India 445001
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Re: Перелом бедра выше пластинки
M. S. Dhillon 12 Март 2002, 18:32
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Myles
Yours is a point well taken. Almost all the orthopods will feel that the removal surgery, involving a significant incision, and protected weight bearing for some time is cumbersome and time consuming.
But the following points still do remain. AO philosophy dicatates that we remove implants, as they have experimentally demonstrated that there is stress shielding/ stress risers etc; so we remove them. I think your thoughts should awaken some folks to the fact that there is no study which actually proves the fact that plates left inside the lower limb contribute to subsequent fractures! We should have some statistics on this. Unfortunately most plates are removed, and
hence we have no long term comparison studies, with removed or unremoved implants.
However another point, which is also valid does exist. If a refracture occurs with the plate in situ, the fracture usually starts almost at the end of the plate. This makes the subsequent fixation a cumbersome job, and the options slected sometimes maybe less than optimal. In this case, would it not be better to have no implant, when a second fracture occurs?
I think this maybe important also. On the other hand, how many patients get involved in significant trauma in the same limb!
These points are for discussion only, and your point is well taken, and definitely appreciated by me.
Dr M S Dhillon
Addl Professor, Orthop
1090/2 Sector 39-B, Chandigarh
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