[ORT-L] Distal femur non union


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[ORT-L] Distal femur non union

j.c.goslings at amc
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Nov 26, 2007, 9:18 AM

Post #1 of 10 (949 views)
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[ORT-L] Distal femur non union	Can't Post

A question for the list members.

16 yr old boy, high energy motorcycle trauma trauma in July 2005 with:
- hip dislocation + acetabular fracture L
- distal femoral fracture L
- tibial shaft fracture L
- metatarsal fractures L

Treatment:
july 05: LISS femur, LCP plate tibia, double recon. plate post. acetabulum
oct 05: cancellous bone graft femur
aug 06: blade plate + bone graft
nov 06: revision blade plate
feb 07: retrograde nail + bone graft + BMP
may 07: dynamisation nail
sept 07: locking screw removal (max. dynamisation reached)
nov 07: persistant non-union distal femur; other fractures healed uneventfully.
All with gradual/partial weightbearing etc. Currently 50-100% weight bearing, no pain.
Soft tissues are intact. No smoking or diabetes.
CRP <2

What would you do?

Kind regards,
Carel Goslings
Trauma Unit AMC
Amsterdam, NL

Attachments:

1 - july 05.jpg (39.4 KB)

2b - july 05.jpg (138 KB)

2a - july 05.jpg (163 KB)

3a - aug 06.jpg (29.3 KB)

3b - aug 06.jpg (29.3 KB)

4 - aug 06.jpg (30.2 KB)

5 - nov 06.jpg (101 KB)

6 - nov 06.jpg (29.7 KB)

7 - feb 07.jpg (152 KB)

8a - feb 07.jpg (29.1 KB)

8b - feb 07.jpg (32.2 KB)

8c - feb 07.jpg (30.8 KB)

10a - nov 07.jpg (98.3 KB)

10b - nov 07.jpg (177 KB)

9b - sept 07.jpg (86.6 KB)

9a - sept 07.jpg (88.5 KB)

frg at myfastmail
New User

Nov 26, 2007, 11:07 AM

Post #2 of 10 (949 views)
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Re: [ORT-L] Distal femur non union [In reply to]	Can't Post

Dear Carel
This is a true atrophic pseudoartrosis (without pain).
This fracture have a two factors failure combination.
The mechanical factor failure and the biological factor failure.
The solution need a combination of treatments which give solutions for
each factor failure.
Change the intramedular nail for a lateral plate LCDCP
Decortication plus bone graft

----- Original message -----
From: "J.C. Goslings" <j.c.goslings@amc.uva.nl>
To: ORT-L@www2.aaos.org
Date: Mon, 26 Nov 2007 18:18:38 +0100
Subject: [ORT-L] Distal femur non union

A question for the list members.

16 yr old boy, high energy motorcycle trauma trauma in July 2005 with:
- hip dislocation + acetabular fracture L
- distal femoral fracture L
- tibial shaft fracture L
- metatarsal fractures L

Treatment:
july 05: LISS femur, LCP plate tibia, double recon. plate post.
acetabulum
oct 05: cancellous bone graft femur
aug 06: blade plate + bone graft
nov 06: revision blade plate
feb 07: retrograde nail + bone graft + BMP
may 07: dynamisation nail
sept 07: locking screw removal (max. dynamisation reached)
nov 07: persistant non-union distal femur; other fractures healed
uneventfully.
All with gradual/partial weightbearing etc. Currently 50-100% weight
bearing, no pain.
Soft tissues are intact. No smoking or diabetes.
CRP <2

What would you do?

Kind regards,
Carel Goslings
Trauma Unit AMC
Amsterdam, NL
---
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alex at weborto
New User

Nov 26, 2007, 11:53 AM

Post #3 of 10 (949 views)
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Re: [ORT-L] Distal femur non union [In reply to]	Can't Post

Dear Carel,

[...]

> All with gradual/partial weightbearing etc. Currently 50-100% weight
> bearing, no pain.
> Soft tissues are intact. No smoking or diabetes.
> CRP <2
>
> What would you do?

Tough case. Severe injury, many surgeries...
I'd prefer to be less agressive to periosteal blood supply slowly
reviving after all those plates.
Looks like shortening is not significant yet. So my choice would be
closed re-nailing with a larger nail. Some time ago an option of dynamic
locking in comression by special end cap was discussed in the list -
IMHO it is suitable for this case. The nail will play role of shaft
endoprosthesis for some years that must be enough for restoration of
cortical blood supply. Good luck!

___
Best regards,
Alexander N. Chelnokov
Ural Scientific Research Institute
of Traumatology and Orthopaedics
7, Bankovsky str. Ekaterinburg 620014 Russia
---
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shitalparikh at hotmail
New User

Nov 26, 2007, 1:15 PM

Post #4 of 10 (949 views)
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RE: [ORT-L] Distal femur non union [In reply to]	Can't Post

An Ilizarov apparatus is useful for such nonunions. it is more elastic than the other implants giving it a compressive effect with full weight bearing. A corticotomy above and a few cm of bone transport will help 2 fold - compression across fracture site and resotration of blood supply by neovascularization. the construct can be 3 rings. two above the fracture and one below, and the corticotomy between 1st and 2nd rings.
best wishes

Shital Parikh, MD 2769352165> Date: Tue, 27 Nov 2007 00:53:01 +0500> From: alex@weborto.net> To: ORT-L@www2.aaos.org> Subject: Re: [ORT-L] Distal femur non union> > Dear Carel,> > > [...]> > > All with gradual/partial weightbearing etc. Currently 50-100% weight > > bearing, no pain.> > Soft tissues are intact. No smoking or diabetes.> > CRP <2> > > > What would you do?> > > Tough case. Severe injury, many surgeries...> I'd prefer to be less agressive to periosteal blood supply slowly > reviving after all those plates.> Looks like shortening is not significant yet. So my choice would be > closed re-nailing with a larger nail. Some time ago an option of dynamic > locking in comression by special end cap was discussed in the list - > IMHO it is suitable for this case. The nail will play role of shaft > endoprosthesis for some years that must be enough for restoration of > cortical blood supply. Good luck!> > ___> Best regards,> Alexander N. Chelnokov> Ural Scientific Research Institute> of Traumatology and Orthopaedics> 7, Bankovsky str. Ekaterinburg 620014 Russia> ---> [This E-mail scanned for viruses by Declude Virus]>
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jjbrooksmd at gmail
New User

Nov 26, 2007, 3:33 PM

Post #5 of 10 (949 views)
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Re: [ORT-L] Distal femur non union [In reply to]	Can't Post

Mark Brinker's group published a very thought-provoking article in a
recent (<6 mos) J.O.T. that showed significant metabolic
abnormalities in patients with nonunions that "should have" otherwise
healed, as this "should have". (they had specific criteria for
inclusion in the 'should have' group). I forget the exact
distribution of abnormalities but they included most frequently
Vitamin D deficiency, abnormalities of calcium and parathyroid
function, and some other metabolic problems.

Bottom line in my opinion: be sure this young healthy kid is
thoroughly worked up metabolically before any more surgery.

Jeff

PS - I can send the .pdf of that article if you want to see it.

On Nov 26, 2007, at 4:15 PM, shital parikh wrote:

> An Ilizarov apparatus is useful for such nonunions. it is more
> elastic than the other implants giving it a compressive effect with
> full weight bearing. A corticotomy above and a few cm of bone
> transport will help 2 fold - compression across fracture site and
> resotration of blood supply by neovascularization. the construct
> can be 3 rings. two above the fracture and one below, and the
> corticotomy between 1st and 2nd rings.
> best wishes
>
>
> Shital Parikh, MD
> 2769352165
>
>
> > Date: Tue, 27 Nov 2007 00:53:01 +0500
> > From: alex@weborto.net
> > To: ORT-L@www2.aaos.org
> > Subject: Re: [ORT-L] Distal femur non union
> >
> > Dear Carel,
> >
> >
> > [...]
> >
> > > All with gradual/partial weightbearing etc. Currently 50-100%
> weight
> > > bearing, no pain.
> > > Soft tissues are intact. No smoking or diabetes.
> > > CRP <2
> > >
> > > What would you do?
> >
> >
> > Tough case. Severe injury, many surgeries...
> > I'd prefer to be less agressive to periosteal blood supply slowly
> > reviving after all those plates.
> > Looks like shortening is not significant yet. So my choice would be
> > closed re-nailing with a larger nail. Some time ago an option of
> dynamic
> > locking in comression by special end cap was discussed in the list -
> > IMHO it is suitable for this case. The nail will play role of shaft
> > endoprosthesis for some years that must be enough for restoration of
> > cortical blood supply. Good luck!
> >
> > ___
> > Best regards,
> > Alexander N. Chelnokov
> > Ural Scientific Research Institute
> > of Traumatology and Orthopaedics
> > 7, Bankovsky str. Ekaterinburg 620014 Russia
> > ---
> > [This E-mail scanned for viruses by Declude Virus]
> >
>
>
> Live the life in style with MSN Lifestyle. Check out! Try it now!

george.s.thomas at gmail
New User

Nov 26, 2007, 5:58 PM

Post #6 of 10 (944 views)
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Re: [ORT-L] Distal femur non union [In reply to]	Can't Post

It should have healed with the locking plate, provided the plate was
introduced using a minimal invasive technique. However, once that plate had
failed, the subsequent attempts at plate osteosynthesis ignored the medial
buttress required, and by the time the nails were used there is already a
gap.
At this point my choice would be a thin wire fixator (Ilizarov), proximal
corticotomy and compression at the fracture site.

On Nov 27, 2007 5:03 AM, Jeff Brooks <jjbrooksmd@gmail.com> wrote:

> Mark Brinker's group published a very thought-provoking article in a
> recent (<6 mos) J.O.T. that showed significant metabolic abnormalities in
> patients with nonunions that "should have" otherwise healed, as this "should
> have". (they had specific criteria for inclusion in the 'should have'
> group). I forget the exact distribution of abnormalities but they included
> most frequently Vitamin D deficiency, abnormalities of calcium and
> parathyroid function, and some other metabolic problems.
> Bottom line in my opinion: be sure this young healthy kid is thoroughly
> worked up metabolically before any more surgery.
>
> Jeff
>
> PS - I can send the .pdf of that article if you want to see it.
>
>
> On Nov 26, 2007, at 4:15 PM, shital parikh wrote:
>
> An Ilizarov apparatus is useful for such nonunions. it is more elastic
> than the other implants giving it a compressive effect with full weight
> bearing. A corticotomy above and a few cm of bone transport will help 2 fold
> - compression across fracture site and resotration of blood supply by
> neovascularization. the construct can be 3 rings. two above the fracture and
> one below, and the corticotomy between 1st and 2nd rings.
> best wishes
>
>
> Shital Parikh, MD
> 2769352165
>
>
> > Date: Tue, 27 Nov 2007 00:53:01 +0500
> > From: alex@weborto.net
> > To: ORT-L@www2.aaos.org
> > Subject: Re: [ORT-L] Distal femur non union
> >
> > Dear Carel,
> >
> >
> > [...]
> >
> > > All with gradual/partial weightbearing etc. Currently 50-100% weight
> > > bearing, no pain.
> > > Soft tissues are intact. No smoking or diabetes.
> > > CRP <2
> > >
> > > What would you do?
> >
> >
> > Tough case. Severe injury, many surgeries...
> > I'd prefer to be less agressive to periosteal blood supply slowly
> > reviving after all those plates.
> > Looks like shortening is not significant yet. So my choice would be
> > closed re-nailing with a larger nail. Some time ago an option of dynamic
>
> > locking in comression by special end cap was discussed in the list -
> > IMHO it is suitable for this case. The nail will play role of shaft
> > endoprosthesis for some years that must be enough for restoration of
> > cortical blood supply. Good luck!
> >
> > ___
> > Best regards,
> > Alexander N. Chelnokov
> > Ural Scientific Research Institute
> > of Traumatology and Orthopaedics
> > 7, Bankovsky str. Ekaterinburg 620014 Russia
> > ---
> > [This E-mail scanned for viruses by Declude Virus]
> >
>
>
> ------------------------------
> Live the life in style with MSN Lifestyle. Check out! Try it now!<http://content.msn.co.in/Lifestyle/Default>
>
>
>

--
George Thomas,
Orthopaedic Surgeon,
Chennai, India
Editor, Indian Journal of Medical Ethics,
www.issuesinmedicalethics.org
www.ijme.in

wdburman at frontiernet
New User

Nov 26, 2007, 9:24 PM

Post #7 of 10 (944 views)
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Re: [ORT-L] Distal femur non union [In reply to]	Can't Post

>>significant metabolic abnormalities in patients with nonunions

Interesting, but does this 16 y o patient (who apparently healed all
his other fxs) meet the criteria for metabolic/endocrine screening
suggested in the Brinker article "Metabolic and Endocrine
Abnormalities in Patients with Nonunions: Have We Been Missing the
Boat?" See
http://www.hwbf.org/ota/am/ota07/otapa/OTA070315.htm

Also see exchange nailing comments of Bob Winquist and Mike Chapman
from OTA BFC
http://www.hwbf.org/ota/bfc/chapm/ft012.html

and if that doesn't work, another Brinker article to consider -
"Ilizarov compression over a nail for aseptic femoral nonunions that
have failed exchange nailing: a report of five cases." JOT 2003
Nov-Dec;17(10):668-76.
http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=pubmed&dopt=AbstractPlus&list_uids=14600565&query_hl=2

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

-----------------------------

>Mark Brinker's group published a very thought-provoking article in a
>recent (<6 mos) J.O.T. that showed significant metabolic
>abnormalities in patients with nonunions that "should have"
>otherwise healed, as this "should have". (they had specific criteria
>for inclusion in the 'should have' group). I forget the exact
>distribution of abnormalities but they included most frequently
>Vitamin D deficiency, abnormalities of calcium and parathyroid
>function, and some other metabolic problems.
>
>Bottom line in my opinion: be sure this young healthy kid is
>thoroughly worked up metabolically before any more surgery.
>
>Jeff
>
>PS - I can send the .pdf of that article if you want to see it.

A question for the list members.

16 yr old boy, high energy motorcycle trauma trauma in July 2005 with:
- hip dislocation + acetabular fracture L
- distal femoral fracture L
- tibial shaft fracture L
- metatarsal fractures L

Treatment:
july 05: LISS femur, LCP plate tibia, double recon. plate post. acetabulum
oct 05: cancellous bone graft femur
aug 06: blade plate + bone graft
nov 06: revision blade plate
feb 07: retrograde nail + bone graft + BMP
may 07: dynamisation nail
sept 07: locking screw removal (max. dynamisation reached)
nov 07: persistant non-union distal femur; other fractures healed uneventfully.
All with gradual/partial weightbearing etc. Currently 50-100% weight
bearing, no pain.
Soft tissues are intact. No smoking or diabetes.
CRP <2

What would you do?

Kind regards,
Carel Goslings
Trauma Unit AMC
Amsterdam, NL
---
[This E-mail scanned for viruses by Declude Virus]

bray at renoortho
New User

Nov 26, 2007, 9:39 PM

Post #8 of 10 (944 views)
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RE: [ORT-L] Distal femur non union [In reply to]	Can't Post

Be sure he is not infected- even though the ESR is low, I have had
non-unions that have turned out aspirate positive when I couldn't get them
to heal. Remember the unusual organisms and check to be sure the lab can
adequately run the cultures for them. Although I am not an "Ilizarovian" it
appears the non-union interface is void of biological activity adequate
enough to heal the fracture- Dean Cole has written about resection of the
dead bone, compressing the interface and then lengthening the bone away from
the fracture site to regain leg length, although he described this in the
tibia, I think this would be my next thought for this unfortunate young man.
Good Luck, TBray

-----Original Message-----
From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On Behalf
Of Bill Burman
Sent: Monday, November 26, 2007 9:24 PM
To: ORT-L@www2.aaos.org
Subject: Re: [ORT-L] Distal femur non union

>>significant metabolic abnormalities in patients with nonunions

Interesting, but does this 16 y o patient (who apparently healed all
his other fxs) meet the criteria for metabolic/endocrine screening
suggested in the Brinker article "Metabolic and Endocrine
Abnormalities in Patients with Nonunions: Have We Been Missing the
Boat?" See
http://www.hwbf.org/ota/am/ota07/otapa/OTA070315.htm

Also see exchange nailing comments of Bob Winquist and Mike Chapman
from OTA BFC
http://www.hwbf.org/ota/bfc/chapm/ft012.html

and if that doesn't work, another Brinker article to consider -
"Ilizarov compression over a nail for aseptic femoral nonunions that
have failed exchange nailing: a report of five cases." JOT 2003
Nov-Dec;17(10):668-76.
http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=pubmed&dopt=Abstrac
tPlus&list_uids=14600565&query_hl=2

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

-----------------------------

>Mark Brinker's group published a very thought-provoking article in a
>recent (<6 mos) J.O.T. that showed significant metabolic
>abnormalities in patients with nonunions that "should have"
>otherwise healed, as this "should have". (they had specific criteria
>for inclusion in the 'should have' group). I forget the exact
>distribution of abnormalities but they included most frequently
>Vitamin D deficiency, abnormalities of calcium and parathyroid
>function, and some other metabolic problems.
>
>Bottom line in my opinion: be sure this young healthy kid is
>thoroughly worked up metabolically before any more surgery.
>
>Jeff
>
>PS - I can send the .pdf of that article if you want to see it.

A question for the list members.

16 yr old boy, high energy motorcycle trauma trauma in July 2005 with:
- hip dislocation + acetabular fracture L
- distal femoral fracture L
- tibial shaft fracture L
- metatarsal fractures L

Treatment:
july 05: LISS femur, LCP plate tibia, double recon. plate post. acetabulum
oct 05: cancellous bone graft femur
aug 06: blade plate + bone graft
nov 06: revision blade plate
feb 07: retrograde nail + bone graft + BMP
may 07: dynamisation nail
sept 07: locking screw removal (max. dynamisation reached)
nov 07: persistant non-union distal femur; other fractures healed
uneventfully.
All with gradual/partial weightbearing etc. Currently 50-100% weight
bearing, no pain.
Soft tissues are intact. No smoking or diabetes.
CRP <2

What would you do?

Kind regards,
Carel Goslings
Trauma Unit AMC
Amsterdam, NL
---
[This E-mail scanned for viruses by Declude Virus]

---
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jjbrooksmd at gmail
New User

Nov 27, 2007, 4:21 AM

Post #9 of 10 (943 views)
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Re: [ORT-L] Distal femur non union [In reply to]	Can't Post

found the pdf. interesting and thought-provoking reading.

On Nov 27, 2007, at 12:24 AM, Bill Burman wrote:

>>> significant metabolic abnormalities in patients with nonunions
>
> Interesting, but does this 16 y o patient (who apparently healed
> all his other fxs) meet the criteria for metabolic/endocrine
> screening suggested in the Brinker article "Metabolic and Endocrine
> Abnormalities in Patients with Nonunions: Have We Been Missing the
> Boat?" See
> http://www.hwbf.org/ota/am/ota07/otapa/OTA070315.htm
>
> Also see exchange nailing comments of Bob Winquist and Mike Chapman
> from OTA BFC
> http://www.hwbf.org/ota/bfc/chapm/ft012.html
>
> and if that doesn't work, another Brinker article to consider -
> "Ilizarov compression over a nail for aseptic femoral nonunions
> that have failed exchange nailing: a report of five cases." JOT
> 2003 Nov-Dec;17(10):668-76.
> http://www.ncbi.nlm.nih.gov/sites/entrez?
> cmd=Retrieve&db=pubmed&dopt=AbstractPlus&list_uids=14600565&query_hl=2
>
> Bill Burman, MD
> HWB Foundation
> http://www.hwbf.org
>
> -----------------------------
>
>> Mark Brinker's group published a very thought-provoking article in
>> a recent (<6 mos) J.O.T. that showed significant metabolic
>> abnormalities in patients with nonunions that "should have"
>> otherwise healed, as this "should have". (they had specific
>> criteria for inclusion in the 'should have' group). I forget the
>> exact distribution of abnormalities but they included most
>> frequently Vitamin D deficiency, abnormalities of calcium and
>> parathyroid function, and some other metabolic problems.
>>
>> Bottom line in my opinion: be sure this young healthy kid is
>> thoroughly worked up metabolically before any more surgery.
>>
>> Jeff
>>
>> PS - I can send the .pdf of that article if you want to see it.
>
>
> A question for the list members.
>
> 16 yr old boy, high energy motorcycle trauma trauma in July 2005 with:
> - hip dislocation + acetabular fracture L
> - distal femoral fracture L
> - tibial shaft fracture L
> - metatarsal fractures L
>
> Treatment:
> july 05: LISS femur, LCP plate tibia, double recon. plate post.
> acetabulum
> oct 05: cancellous bone graft femur
> aug 06: blade plate + bone graft
> nov 06: revision blade plate
> feb 07: retrograde nail + bone graft + BMP
> may 07: dynamisation nail
> sept 07: locking screw removal (max. dynamisation reached)
> nov 07: persistant non-union distal femur; other fractures healed
> uneventfully.
> All with gradual/partial weightbearing etc. Currently 50-100%
> weight bearing, no pain.
> Soft tissues are intact. No smoking or diabetes.
> CRP <2
>
> What would you do?
>
> Kind regards,
> Carel Goslings
> Trauma Unit AMC
> Amsterdam, NL
> ---
> [This E-mail scanned for viruses by Declude Virus]
>

Attachments:

MetabolicandEndocrineAbnormalitiesinPatientsWithNonunions.MarkBrinkeret.alJOT2007-21pp557-570.pdf (271 KB)

emalpgi at gmail
New User

Dec 3, 2007, 8:02 AM

Post #10 of 10 (728 views)
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Re: [ORT-L] Distal femur non union [In reply to]	Can't Post

dear goslings,
first please rule out any metablic abnormalities, and ct scan clealy
shows the end of fracutures are sclerotic and it will not unite,
unless u freshen them, i would go for . IMPLANT REMOVAL, FRESHENING
THE FACTURE ENDS, PRIMARY DOCKING AND ILIZAROV, OR MONORAIL FIXATOR,
IF SHORTENING MORE THAN 2CM I WOULD DO PROXIMAL CORTICOTOMY....,AND
90% SURE THAT this will unite
but all the best

On 11/26/07, J.C. Goslings <j.c.goslings@amc.uva.nl> wrote:
>
> A question for the list members.
>
> 16 yr old boy, high energy motorcycle trauma trauma in July 2005 with:
> - hip dislocation + acetabular fracture L
> - distal femoral fracture L
> - tibial shaft fracture L
> - metatarsal fractures L
>
> Treatment:
> july 05: LISS femur, LCP plate tibia, double recon. plate post. acetabulum
> oct 05: cancellous bone graft femur
> aug 06: blade plate + bone graft
> nov 06: revision blade plate
> feb 07: retrograde nail + bone graft + BMP
> may 07: dynamisation nail
> sept 07: locking screw removal (max. dynamisation reached)
> nov 07: persistant non-union distal femur; other fractures healed
> uneventfully.
> All with gradual/partial weightbearing etc. Currently 50-100% weight
> bearing, no pain.
> Soft tissues are intact. No smoking or diabetes.
> CRP <2
>
> What would you do?
>
> Kind regards,
> Carel Goslings
> Trauma Unit AMC
> Amsterdam, NL
>

--
may Almighty bless us all

Dr Emal Wardak
MBBS "SMS, Jaipur"
MS Ortho "resident" PGI Chd
---
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