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Re: LISS?
послал Alexander Chelnokov 14 Ноябрь 2004, 00:42
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KEMMD> unfortunately, nails are not reliable in many hands.
KEMMD> Attached are few examples from our Hospital:
Axial malalignment and hardware cut-out in poor bone stock is a common problem for any fixation technique. Except Ilizarov-based - "with external fixator we control the situation, without - the situation controls us" :-)
KEMMD> A. Difficult reductions, even in retrograde nailing (my preference, easier
KEMMD> control of "small" distal fragment) and it is much, much harder to do it
KEMMD> anterograde
Depends on reduction techniques. Though i know some virtuosos who applied ex-fix without any preliminary traction and reached perfect reduction, it is not a reproducible technology. So using of reduction aids is necessary - in our case it is still the Ilizarov.
KEMMD> (Alex, do you have one good case in your collection of
KEMMD> anterograde nailing in very distal fractures - as you have
I presented a series of ~25 such cases at EuroTrauma'2004. Many cases were discussed here. I attach am example. Look also recent cases at http://www.hwbf.org/hwb/conf/alex58/scfx.htm,
http://www.hwbf.org/hwb/conf/alex63/alex63.htm
KEMMD> Malpositioning is much too common (recurvatum, varus - valgus).
Did you mark valgus malalignment in that case with LISS you posted Nov 9? Aplication of external distractor can help to avoid the pitfalls but some further development of the technology is necessary to shorten the learning curve.
KEMMD> B. Fixation loosening: distal cutting of the nail, non-unions do happen
KEMMD> (cases attached).
The nail can be unlocked in the proximal fragment to prevent it.
Though severe osteoporosis needs special measures - bone substitute insertion into the bone itself and screw holes looks very promising. Western colleagues must be more happy with Norian SRS
available.
KEMMD> Locking Plating has more distal screws than any nail,
In the nails we use now the distal screw is about 3 mm from the nail tip. Many vendors AFAIK in their modern implants moved holes more close to the ends of nails.
KEMMD> fixed angles and
KEMMD> provides much better fixation, especially in osteoporotic bone.
There are some experimental studies on that subject which demonstrated no big differencies:
-Biomechanical Evaluation of the Less Invasive Stabilization System (LISS), Angled Blade Plate, and Retrograde Intramedullary Nail for the Fixation of Distal Femur Fractures: An Osteoporotic Cadaveric Model Michael Zlowodzki et al., OTA Annual Meeting, 2002.
-Comparison of the LISS and a Retrograde Inserted Supracondylar Intramedullary Nail for Fixation of a Periprosthetic Distal Femur Fracture Proximal to a Total Knee Arthroplasty
M. R. Bong et al., 2002г. OTA Annual Meeting, 2002
And a recent clinical report:
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Clin Orthop. 2004 Sep(426):252-7.
Femur-LISS and distal femoral nail for fixation of distal femoral fractures: are there differences in outcome and complications?
Markmiller M, Konrad G, Sudkamp N.
Department Orthopadie und Traumatologie, Klinik fur Traumatologie, Universitatsklinikum, Freiburg, Germany. Markmill@ch11.ukl.uni-freiburg.de
We evaluated the functional and radiologic outcomes after stabilization of distal femoral fractures using the distal femoral nail and a less invasive stabilization system to determine if the new implants are superior to other implants (especially the condylar blade plate) regarding the rates of axial deviation, nonunion, and infection and if one of these new implants (Less Invasive Stabilization System, or distal femoral nail) is superior to the other.
Two groups, each with 16 patients, were documented prospectively and the results were compared. To record the findings objectively, the Lysholm-Gillquist score was used. A conversion procedure was done in two patients in the plate group and one patient of the nail group. At the 1-year followup mobility of the knee was on average 110 degrees in the plate group and 103 degrees in the nail group. The Lysholm-Gillquist score did not show any significant differences between the groups. There were clinically relevant varus or outer rotation deviations in
three patients in the plate group and two patients in the nail group. The two minimally invasive implants used were good in terms of technique and outcome for treatment of distal femoral fractures and did not differ significantly for epidemiology, fracture type, conversion procedures, infection rate, malalignments, and subjective and objective findings at the 1-year followup.
They were also superior to the condylar plate in terms of infection and axial malalignments.
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