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Re: Еще один перелом "около фиксатора"
Alexander Chelnokov 21 Январь 2004, 09:05
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Вчера оперировали - винты удалены через 1 прокол. Затем выполнили закрытый интрамедуллярный остеосинтез без расверливания бесканальным гвоздем 13 мм (реконструкционного для нее не нашлось). Гвоздь заперт статически - в проксимальный отломок 3 винта 6 мм, в дистальный - 1.
Учитывая варус сросшейся шейки, постарался вальгизировать проксимальный отломок, насколько гвоздь позволил. Результат в приложении. Картина перелома видна лучше, чем на начальных снимках.
Интересно, что линия перелома не выходила на отверстия от винтов, а была кзади. Комментарии?
The screws were removed through a stab wound. Then a closed insertion of an unreamed solid nail 13 mm was performed and the nail statically locked - 3 screws 6 mm in the proximal fragment and 1 in the distal.
Considering varus of the healed neck i tried to get some valgus to the proximal fragment as the nail allowed. The result attached. The fracture pattern can be seen better than in the initial films.
Any comments?
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Re: Еще один перелом "около фиксатора"
Myles Clough 21 Январь 2004, 13:35
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This looks like a good solution, technically well done and likely to succeed. I hope you will give us some follow-up in 3 months.
My question (purely to keep the discussion alive :-) is why do you use an unreamed technique? There are now several studies comparing reamed and unreamed femoral nails with increased non-union and mal-union rates in the unreamed group. A recent study from Duke showed that the amount of fat embolism during unreamed nailing was the same as during reamed nailing, measured by Trans Esophageal Echo-cardiogram. So what is the advantage of unreamed nails? In this particular case?
The following search in PubMed uses the search string (("Femoral Fractures/surgery"[MAJR:noexp] AND "Bone Nails"[MeSH]) AND unreamed[All Fields]) and yields 45 papers mostly on the subject. There are at least three different prospective randomized trials comparing reamed vs unreamed all with the same findings.
I feel even more strongly on the subject of unreamed tibials nails and deplore the current SPRINT trial. The money would be better spent comparing reamed IM fixation of the tibia to percutaneous plate fixation or ex fix. Is everyone aware that there have never been a randomized prospective trial in closed tibial fractures to show that IM nails are superior to old fashioned AO plates?! Yet we have swung almost completely in that direction. Of course, you could also say that there has never been a randomized controlled trial to show that total hip replacement is better than a Girldlestone; but I submit that the case for nailing tibias is much less secure.
Myles Clough mylesclough@shaw.ca
Orthopaedic Surgeon, Kamloops, BC, Canada
Clinical Instructor, University of British Columbia
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Re: Еще один перелом "около фиксатора"
Отправитель: Alexander Chelnokov 28 Январь 2004, 21:39
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MC> likely to succeed. I hope you will give us some follow-up in 3
MC> months.
I'll try.
MC> My question (purely to keep the discussion alive :-) is why
MC> do you use an unreamed technique?
Just because we have only solid nails, and 13 mm is a thickest available one, and due to her osteoporosis the nail passed through the canal without reaming.
MC> nailing, measured by Trans Esophageal Echo-cardiogram. So what is
MC> the advantage of unreamed nails? In this particular case?
I completely agree that for primary nailing the only advantage of unreamed technique is few saved minutes.
MC> better spent comparing reamed IM fixation of the tibia to
MC> percutaneous plate fixation or ex fix.
Do you really suppose this topic is so actual? Differencies looks so self-evident.
MC> Is everyone aware that there have never been a randomized
MC> prospective trial in closed tibial fractures to show that IM nails
MC> are superior to old fashioned AO plates?!
As i realize the rigorous study design is required for situations where advantages of one technique over another are not so evident.
MC> randomized controlled trial to show that total hip replacement is
MC> better than a Girldlestone; but I submit that the case for nailing
MC> tibias is much less secure.
Can't enough evidence be provided with retrospective studies?
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Re: Еще один перелом "около фиксатора"
Отправитель: Myles Clough 28 Январь 2004, 21:51
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Alex> Can't enough evidence be provided with retrospective studies?
>
The largest metaanalysis on this subject was published in 1999 in the Canadian Journal of Surgery. The following is the
abstract
10166. Coles, C. P. and Gross, M.,
Closed tibial shaft fractures: management and treatment complications. A review of the
prospective literature. Can.J Surg 43:256-262, 2000.
OBJECTIVE: To compare the results and complications of the various modalities for treating closed fractures of the tibial shaft described in the prospective literature.
DATA SOURCES: A MEDLINE search of the English language literature from 1966 to 1999 was conducted using the MeSH heading "tibial fractures." Studies pertaining to the management of closed tibial shaft fractures were reviewed, and their reference lists were searched for
additional articles.
STUDY SELECTION: An analysis of the relevant prospective, randomized controlled trials was performed. Studies including confounding data on open fractures or fractures in children were excluded. The 13 remaining studies were reviewed.
DATA EXTRACTION: Raw data were extracted and pooled for each method of treatment.
DATA SYNTHESIS: The 13 studies described 895 tibial shaft fractures treated by application of a plaster cast, fixation with plate and screws, and reamed or unreamed intramedullary nailing. Although definitions varied, the combined incidence of delayed and nonunion was lower with operative treatment (2.6% with plate fixation, 8.0% with reamed nailing and 16.7% with unreamed nailing) than with closed treatment (17.2%). The incidence of malunion was similarly lower with operative treatment (0% with plate fixation, 3.2% with reamed nailing and 11.8% with unreamed nailing) than with closed treatment (31.7%). Superficial infection was most common with plate fixation (9.0%) compared with 2.9% for reamed nailing, 0.5% for unreamed nailing and 0% for closed treatment. The incidence of osteomyelitis was similar for all groups. Rates of reoperation ranged from 4.7% to 23.1%. CONCLUSIONS: All forms of treatment for tibial shaft fractures are associated with complications. A knowledge of the incidence of each complication facilitates the consent process. To fully resolve the controversy as to the best method of treatment, a large, randomized, controlled trial is required. This review more precisely predicts the expected incidence of complications, allowing the numbers of required patients to be more accurately determined for future randomized controlled studies
Highlights are
- delayed, non-union and malunion lower with plates
- superficial infection more common with plates
- deep infection the same for all treatment groups.
So, no! I don't think the advantages of one technique over another are self-evident; except that unreamed tibial nails seem to be the worst option. I do emphatically think the subject needs to be subjected to rigorous scientific investigation. Since that study closed in 1999 we have begun to use periarticular plates which can be inserted in a closed fashion with just a small opening at top and bottom leaving the blood supply of the fracture fragments undisturbed. On the other hand, perhaps we have become more skilled at doing closed IM rod fixation and so have less malunions.
See additional Tibial Fracture websites C.M.Court-Brown's 1998 review The management of femoral and tibial diaphyseal fractures AO Publishing Bibliography on treatment of the Tibial Shaft fracture Royal College of Surgeons of Edinburgh summary on Tibial Shaft fractures
Socioeconomic Burden of Traumatic Tibial Fractures: Nonunion or Delayed Union (Medscape)
Tibial Fractures Bibliography with abstracts from George Washington University
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
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Re: Еще один перелом "около фиксатора"
V. M. Iyer 21 Январь 2004, 19:03
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Dear Alexander,
Very well done. This nail that You have used is something new to me. This has different holes proximally than the routine nail. After getting such a good reduction,(which I had not anticipated) if there were more holes beyond the screws that you have put then screws could be introduced thro the nail across the # site too.
V M Iyer
. Iyer Orthopaedic Centre,
103,Railway lines Solapur India.
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Re: Еще один перелом "около фиксатора"
Отправитель: Alexander Chelnokov 28 Январь 2004, 13:30
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VMI> Very well done.
THX.
VMI> This nail that You have used is something new to me. This
VMI> has different holes proximally than the routine nail.
Only one more proximally to the oval hole.
VMI> if there were more holes beyond the screws that you have put
VMI> then screws could be introduced thro the nail across the # site too.
Sorry, do you mean holes in AP direction? Or where?
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Re: Еще один перелом "около фиксатора"
Отправитель: Alexander Chelnokov 28 Январь 2004, 21:45
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VMI> Very well done.
THX.
VMI> This nail that You have used is something new to me. This
VMI> has different holes proximally than the routine nail.
Only one more proximally to the oval hole.
VMI> if there were more holes beyond the screws that you have put
VMI> then screws could be introduced thro the nail across the # site too.
Sorry, do you mean holes in AP direction? Or where?
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Re: Еще один перелом "около фиксатора"
Dr. Daga 21 Январь 2004, 19:07
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there are solid and clover leaf nails all over the world.Then why it is that you have only solid nails which atre more prone to breakage.
with regds,
Dr.K.P.daga
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Re: Еще один перелом "около фиксатора"
Отправитель: Alexander Chelnokov 28 Январь 2004, 13:29
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Because of AO/Mathys/Synthes activity here, many local vendors offer only rather cheap copies of UFN/UTN. Hollow nails available at the local market are from abroad so more expensive.
Another reason is higher infection risk with hollow nails after secondary nailing after ex-fix.
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Re: Еще один перелом "около фиксатора"
Михаил Абрахманов 28 Январь 2004, 10:19
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Хорошо.
Best regards,
Михаил
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Re: Еще один перелом "около фиксатора"
Tom DeCoster 28 Январь 2004, 13:31
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I would expect that would do well. I'm not sure you can "make" that fracture go into "valgus" to compensate for the neck but it looks quite good.
TD
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