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Анте- или ретроградно?
Ортопедия и травматология Отправлено Alexander Chelnokov 26 Август 2003, 01:14
Парень 28 лет поступил с переломом 6едра уже в аппарате (см. снимок),
наложенном в Тобольске 6 недель назад. С двух строн еще переломы плюсневых костей, а с этой же стороны и дистального эпиметафиза большеберцовой кости, в гипсовых повязках до колена.Бедро намереваемся закрыто заштифтовать, но нету определенности - вводить гвоздь анте- или ретроградно (через колено)? Повязку сверху на этой голени малость подкоротили на всякий случай. Кроме как бросить монетку, чем определить выбор? Заранее спасибо.

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    Re: Анте- или ретроградно?
    Chris Wilson 26 Август 2003, 01:37
    Having used a lot of both,I definitely vote for antegrade nail.
    You don't needlessly breach a joint, there are more size choices, distal locking is easier (the "distal" screws in a long retrograde nail being in the A/P orientation) and exchange nailing and reaming are easier.
    In view of the segmental fragments a case could be made for unreamed antegrade nail, with a view to exchange nailing if there is delayed union.

    Regards
    Chris Wilson
    Orthopaedic Surgeon
    University Hospital
    Cardiff
    UK
    [ Ответить ]

    • Re: Анте- или ретроградно?
      Отправитель: Alexander Chelnokov 26 Август 2003, 02:26
      THX for your comments. The nail is to be the same anyway - a UFN-like solid one. It can be inserted both ways, can't it? i also don't like to touch an intact joint. But reduction here looks easier with retrograde insertion so i expected maybe the approach is now strongly advocated...
      :-)

      [ Ответить ]
    Re: Анте- или ретроградно?
    Enes M. Kanlic 26 Август 2003, 02:07
    You did not tell us what was the reason to have circular ExFx frame on at the first place: any problems with soft tissues, any fractures around hip (proximal femur, acetabulum, pelvis, the size of patient (access to the piriformis fossa or greater trochanter), medical condition...!?

    In general, it is risky (intramedullary infection) to have IM nail after pins transfixing the bone longer than 1-2 weeks (especially if it was any drainage around them and probably has to be after 6 weeks); it is better (not and easier; I prefer lateral decubitus) to avoid unnecessary violation of the knee joint (rare, but devastating complication of infection)...

    Retrograde mostly if: distal fcatures, bilateral femur fractures, need for additional later proximal surgeries (acetabulum), polytrauma (abdominal, thoracic, neurowork), overweight and short patient (150 kg), soft tissue damage in hip area...

    Sincerely


    Enes M. Kanlic, M.D., Ph.D.
    Associate Professor
    Ortho Department at TTUHSC
    El Paso, Texas
    [ Ответить ]

    • Re: Анте- или ретроградно?
      Отправитель: Alexander Chelnokov 26 Август 2003, 02:28
      EKTE> You did not tell us what was the reason to have circular ExFx frame on at
      EKTE> the first place: any problems with soft tissues, any fractures around hip

      I suppose closed nailing was not available there, so they preferred ex-fix rather than open plating or plaster cast.

      EKTE> In general, it is risky (intramedullary infection) to have IM nail after
      EKTE> pins transfixing the bone longer than 1-2 weeks (especially if it was any

      Our series of ex-fix to nail conversion now consist of more than 30 cases, and about 15 were acute conversion of fixators 3-11 months old with calm pin sites - no infection to date (knock-knock).

      EKTE> Retrograde mostly if: distal fcatures, bilateral femur fractures, need for

      Also ipsilateral femur+tibia. But AFAIR some colleagues in the list told about more excessive use of retrograde nails...

      [ Ответить ]
    Re: Анте- или ретроградно?
    James Carr 26 Август 2003, 02:08
    I'll vote for antegrade as well. If you get a septic complication in a retrograde nail, the knee joint is a major problem. Jim Carr
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    Re: Анте- или ретроградно?
    V.M. Iyer 26 Август 2003, 18:08
    I would certainly prefer an antegrade interlocking nail for the obvious reason. The proximal fragment will need reaming and can be done better from the pyriformis fossa than from below. From below means one has to go across the middle commin fragment, enter the prox fragment and then ream. There is n question of tossing a coin.
    I presume you will take the precautions regarding the pin tracts of Iliz fixator

    Dr V M Iyer

    Iyer Orthopaedic centre Solapur India
    [ Ответить ]

    • Re: Анте- или ретроградно?
      Отправитель: Alexander Chelnokov 27 Август 2003, 10:06
      OK, since voting was 5:0 for antegrade, the case has just been managed this way. Fixator appeared to be in malrotation about 40 degrees. Though some difficulties were met with gainig of proper length and pushing the nail beetwen parts of the comminuted fragment, the result seems satisfactory. THX!

      [ Ответить ]
      • Re: Анте- или ретроградно?
        Отправитель: V. M. Iyer 27 Август 2003, 18:25
        I would like to know if 1) the proximal fragment was reamed, 2) which nail was used solid or cannulated and the size? 3) were you not worried about the potential for infection while doing nailing straightaway on removal of the fixator, 4) why not post the postop Xray.


        Regards
        V M Iyer
        . Iyer Orthopaedic Centre,
        103,Railway lines Solapur.413001.

        [ Ответить ]
    Re: Анте- или ретроградно?
    Dr Harpal Singh Selhi 27 Август 2003, 09:25
    From my experience spare the knee whenever possible

    Prefer Antegrade nail
    [ Ответить ]

    Re: Анте- или ретроградно?
    Анатолий Лазарев 27 Август 2003, 09:40
    Перелом высокий можно и не трогать коленный сустав, да и шытья поменьше - руки не намозолишь.
    [ Ответить ]

    • Re: Анте- или ретроградно?
      Отправитель: Alexander Chelnokov 29 Август 2003, 16:49
      Насчет через колено мысль возникла из-за более хорошего сопоставления на нижнем переломе, чтобы гвоздь сразу пошел между стенками разломанной трубки. В общем, и зарубежные коллеги были единодушны со счетом 5:0 в пользу антгерадного, поэтому так и сделал.

      АЛ> да и шытья поменьше - руки не намозолишь.

      А почему при ретроградном шитья больше?

      [ Ответить ]
    Re: Анте- или ретроградно?
    M. Bryan Neal, MD 05 Сентябрь 2003, 23:02
    I favor antegrade approach.

    retrograde in obese patients or polytrauma as you can operate on other injuries in one prep without repositioning on fracture table.

    I find the biggest controversy to be the issue or immediate or delayed exchange given thin wires. What are you or did you do in terms of timing wire removal and rod insertion?

    Sincerely and respectively,



    M. Bryan Neal, MD
    Arlington Orthopedics and Hand Surgery Specialists, Ltd.
    1100 W. Central Road, Suite 304
    Arlington Heights, Illinois 60005
    [ Ответить ]

    • Re: Анте- или ретроградно?
      Отправитель: Alexander Chelnokov 06 Сентябрь 2003, 10:21
      AAC> I favor antegrade approach.

      As the case finally was done.

      AAC> injuries in one prep without repositioning on fracture table.

      We use only distractors for either.

      AAC> exchange given thin wires. What are you or did you do in terms of
      AAC> timing wire removal and rod insertion?

      In the case half-pins/wires were removed while the nail was being inserted. Now 1 week postop - no signs of infection at the moment...

      [ Ответить ]
    Re: Анте- или ретроградно?
    Fil 10 Сентябрь 2003, 16:49
    Думаю, что лучше бросить монету, так как главное то, где окажется в дальнейшем стержень.
    [ Ответить ]


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