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Re: Несросшийся перелом большеберцовой кости
Alexander Chelnokov 24 Октябрь 2002, 17:41
Ilizarov technique for this kind of situation doesn't require the site exposure at all, slight distraction would suffice for healing. And a
year ago the patient would have been treated this way. But since closed nailing has been available for our unit, the choice is more
diffcult:-)
No hollow reamers and nails are still availble yet, so UTN 10 mm was used. After perQ osteotomy of the fibula i tried to open the canal, and the awl was passed to the distal fragment only after closed mobilization of the site to make some antecurvation. It resulted with some anterior translation of the distal fragment :( After impaction the nail was locked dynamically. Images attached. Comments/critics are
welcome.
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    Re: Несросшийся перелом большеберцовой кости
    Minoo Patel 24 Октябрь 2002, 17:46
    I agree. The non-union looks like a 'stiff hypertrophix non-union'. So, leave the nail in-situ. Remove the distal inter-locking screws. Apply an Ilizarov frame and initially distract and later compress. Luckily, the fibula has not united.

    Please refer to: www.aaos.org/wordhtml/anmt2002/poster/p441.htm.

    Minoo Patel MD, MS, FRACS
    Monash University &
    Melbourne Centre for Limb Reconstruction
    Melbourne Australia

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    • Re: Несросшийся перелом большеберцовой кости
      Отправитель: James Carr 24 Октябрь 2002, 17:50
      There is no doubt that the Ilizarov is a versatile tool for this problem. Much less invasive than other methods. However, it is surgeon and patient labor intensive, and requires long rx- 7.5 months in the poster (on a tough group of patients).
      In the states, it is an expensive implant. The UTN will likely work if the stability is good enough, but track record of reamed nail is better if infection is avoided. I would have performed a compression plating- simple, quick, cost effective, no immobilization, and early functional aftercare. No bonegraft. Results in published reports are good, and mirrors my experience. Patient acceptance excellent- much preferred to ex fix. Aftercare simple. So if its my leg, I'll take the more invasive initially for the later benefits. Jim Carr

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    • Re: Несросшийся перелом большеберцовой кости
      Отправитель: Alexander Chelnokov 24 Октябрь 2002, 17:52
      DMP> I agree. The non-union looks like a 'stiff hypertrophix non-union'. So,
      DMP> leave the nail in-situ. Remove the distal inter-locking screws.

      I've just placed the nail and screws into the tibia...

      DMP> Apply an Ilizarov frame and initially distract and later
      DMP> compress. Luckily, the fibula has not united.

      :-) It was osteotomized this week.

      DMP> Please refer to: www.aaos.org/wordhtml/anmt2002/poster/p441.htm

      THX for the abstract. It is very exciting that the technique is being distributed over the world. Distraction of hypertophic pseudarthroses with the Ilizarov apparatus had been studied in xUSSR in 1960-70s. About 30 years the approach is used here as "gold standard". But since closed interlocked nailing recently reached my environment it is so interesting to use the new toy :-)




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    • Re: Несросшийся перелом большеберцовой кости
      Отправитель: Bill Burman 25 Октябрь 2002, 20:08
      Re case: http://www.hwbf.org/hwb/conf/alex39/tibnu.htm

      Dr. Patel

      >initially distract and later compress

      Thank you for the interesting ex-fix distraction osteogenesis nonunion rx reference and images. There was a time when distraction secondary to ex-fix caused it to have a reputation as a "nonunion machine" and distracting a fracture over a nail was not well regarded. Maybe 2 wrongs make a right.

      Why add compression? According to Hart et al JBJS 67A:598,

      http://www.hwbf.org/hwb/conf/alex39/exfixcom.htm

      ex-fix compression has no osteogenic benefit.

      Bill Burman, MD
      HWB Foundation
      http://www.hwbf.org

      P.S. Please provide some annotation for the images 1-4:
      (http://www.hwbf.org/hwb/conf/alex39/tibnu.htm#patel). I am not sure if they are in the right order or right-side-up.

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    Re: Несросшийся перелом большеберцовой кости
    Thomas A. DeCoster 25 Октябрь 2002, 20:14
    I believe this nailed nonunion of the tibia shaft will likely go on to uneventful healing. Good job.
    I'm not clear if you opened the fracture site and used an awl or if you used an awl through the nail entry site. The latter is preferred although often difficult and sometimes impossible.

    Tom DeCoster
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    • Re: Несросшийся перелом большеберцовой кости
      Отправитель: Alexander Chelnokov 29 Октябрь 2002, 16:40
      TAD> I believe this nailed nonunion of the tibia shaft will likely go on to uneventful
      TAD> healing. Good job.

      Today the case was criticized at the week clinical report for the antecurvation deformity... Unhappily our vice-director tries to prove that such a malalignment is of great clinical importance.

      TAD> I'm not clear if you opened the fracture site and used an awl or
      TAD> if you used an awl through the nail entry site. The latter is

      Yes, nailing was closed, the canal was opened through the nail entry site.

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      • Re: Несросшийся перелом большеберцовой кости
        Отправитель: Thomas A. DeCoster 29 Октябрь 2002, 16:43
        I would expect the deformity of the case of nailed tibia shaft nonunion (slight apex posterior and slight posterior translation) to be of no definite and small theoretical clinical importance.

        TD

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