[Treatment of united fractures of the leg bones].
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A new method for the intramedullary fixation of trochanteric fractures with prebent, 4.5-mm, round, semielastic nails has theoretical advantages over use of nail-plate devices. Use of the method in 25 patients suggest that it is mechanically sound, relatively easy to learn, and easier for the patient to tolerate. Operating room time is reduced and blood replacement was not necessary. No infections were encountered, and all patients who were ambulatory preoperatively remained ambulatory postoperatively.
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We present a difficult case of hypertrophic nonunion associated with a large cavity in the lower third of the femur. The cavity had been created by a windshield-wiper effect after failure of fixation with a Schneider intramedullary rod in a patient weighing 450 pounds. Treatment consisted of exchanging the Schneider nail with a larger-diame-ter interlocking nail and using the intramedullary fibular allograft to fill the cavity. The fracture healed 4 months after the procedure. At 5-year follow-up, the patient had no complaint, and plain radiographs showed obliteration of the large cavity in the distal femur. Intramedullary fibular graft technique can be used as an adjunct to use of an intramedullary nail when the distal femur contains a large cavity or when the intramedullary rod does not provide adequate fixation stability.
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To analyse retrospectively the results of thirty-eight fractures of the tibial and fibular treated with reamedintramedullary interlocking nail from May 1997 to June 2000. The patients were followed for an average of 14.6(range: 6-32) months. The mean age was 32.8(range: 18-64) years, the sex distribution was 29 males and 9 females. 26 fractures were closed (One case was failure of plate and screws) and 12 were opened: 6 were graded I, 4 were II, 2 IIIa, according to Gustilo's classification. A solid union was achieved in all patients within a period of 6 months. There were no deep infections except one case of superficial infection. Cases of deformity or peroneal nerve injury were no noticed. It is believed that reamed intramedullary interlocking nail allows a stable and safety fixation in open or closed tibial and fibular fractures.
The medical records and radiographs of 63 patients, who were admitted between 1989-1997, with a combined femur fracture, were reviewed. Associated injuries were present in 38 (60%) patients. The combined fractures were classified into four major types depending on their anatomical position: type I, femoral shaft fracture combined with hip neck fracture; type II, femoral shaft fracture combined with a trochanteric fracture; type III, femoral shaft fracture combined with a distal femur fracture; and type IV, femoral shaft fracture combined with a proximal or distal femur fracture. The fractures were treated with locked intramedullary nailing and additional free cancellous 6.5-mm screws as needed. Fifty-six fractures healed without further operations. Of the remaining 6 fractures, 2 were material failures, 1 malunion with 3-cm shortening and external rotation of the femoral diaphysis, 2 early infections of the surgical wound, and 1 pseudarthrosis of the femoral shaft. All fractures were healed between 16 and 32 weeks (average: 20 weeks).
At 12 preparations of the upper extremities of still-born fetuses has been studied microcirculatory channel of long bones of a hand. Clinical confirmation of the experimental results is based on the analysis of data obtained in process of treatment of 54 children with instable fractures of phalanges and metacarpal bones. An arterial channel of long bones of a hand is formed by the branches of finger arteries and vessels of the surrounding tissues. Epiphysis, metaphysis and growth cartilage have common circulatory system. The types of phalanx epiphysiolysis determine the terms of the open reposition realization. Comparison of morphological data and clinical observations demonstrated that the optimal methods of fixation of instable fractures of long bones of a hand are as follows: diafixation by means of wires, intramedullary osteosynthesis and perosseous compressive-distractive osteosynthesis.
Twenty cases of osteomyelitis, following intramedullary nailing of tibial shaft fractures, were managed with a prospective treatment protocol, comprising intramedullary reaming debridement, antibiotic-bead depot, external skeletal fixation, microvascular muscle flap and early cancellous bone grafting. The follow-up period ranged from 25 to 48 months (average, 34.3 months). Pseudomonas aeruginosa (37.5%) and Staphylococcus aureus (20.8%) were the organisms most commonly involved. There were eight united and 12 ununited fractures after reaming debridement surgery. Nineteen infections were initially arrested by one debridement. One infection was arrested by two Sequential debridements. All 12 ununited fractures were stabilized by Hoffmann unilateral external fixation until the fracture healed. The time spent in external fixation ranged from three to seven months (average, 5.2 months). Early cancellous bone grafting was successfully accomplished for nine ununited fractures with major debridement bone loss. The average union time of the nine fractures with bone grafting was 6.5 months (range, from six to eight months). We believe that this treatment protocol gives a predictable and rapid recovery. The complications were infection recurrence in two cases at the old tibial shaft fracture sites, minor Hoffmann pin tract infection in two cases and stiffness in two ankles and one knee.
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Sixteen patients with ununited fractures of the femoral shaft were treated by the fluted intramedullary rod. Five cases were considered delayed unions and eleven nonunions. Fourteen fractures were managed by an open technique and two by a closed technique. Three of four cases treated open without a bone graft failed to unite after the initial nailing. These three fractures subsequently united following bone grafting. Two were renailed with a larger rod. Eventually, all 14 fractures united. The fluted rod appears to be an effective device for treating a variety of ununited fractures of the femur. Bone grafting in association with an open technique is advisable and is especially recommended when interposed connective tissue and bone have had to be excised from the fracture site.
UNLABELLED: Fracture of the distal radius is a common injury and treatment varies depending on the fracture, patient factors, and surgeon preference. Internal fixation has grown in popularity because it affords increased stability and early motion of the extremity. The desire to provide stable fracture support while minimizing soft tissue dissection and complications has led to the development of new intramedullary implants. These implants use distal screw divergence for subchondral support, fixed-angle screws locked to the implant, and minimally invasive technique to allow early patient rehabilitation. Early results of these intramedullary devices are promising but require longer followup. LEVEL OF EVIDENCE: Level IV (expert opinion).