[ORT-L] Leg injury with shortening and nonunion


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[ORT-L] Leg injury with shortening and nonunion

j.c.goslings at amc
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May 27, 2007, 9:07 AM

Post #1 of 11 (6331 views)
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[ORT-L] Leg injury with shortening and nonunion	Can't Post

Dear list members,
Please share your advice in the following case:
a.. 17-year old boy
b.. november 2006 motorcycle accident
c.. grade 2 open comminuted distal femoral fracture
d.. grade 3b open comminuted tibial fracture
e.. no other serious injuries
f.. initial treatment with washout and ex fix
g.. secondary internal fixation with lag screws/LISS (femur) and intramedullary nail following primary shortening of tibia
h.. VAC treatment of wound followed by split skin graft
i.. sensibility intact, ankle function limited
j.. currently in rehabilitation with 9 cm shoe elevation, 10-20 kg weight bearing
The femoral fracture is healing but tibial fracture heals too slow (only medial callus) and a lengthening procedure has not been started yet.
What would you do? Our experience with Ilizarov is limited.
Thank you.
J.C. Goslings
Trauma Unit AMC
Amsterdam

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frg at myfastmail
New User

May 27, 2007, 12:56 PM

Post #2 of 11 (6330 views)
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Re: [ORT-L] Leg injury with shortening and nonunion [In reply to]	Can't Post

You have a very interesting case. And a very good treatment.
Now this young have a hypotrophic pseudoartrose
Is axiomatic. The hypertrophyc pseudoartosis means mechanical
stabilization
failure, the hypotrophic pseudoartrosysis means biological factor
deficence.
A subperiostical decortication of Dunn and a Phemister Chatro
cancelousus bone graft is mandatory.
In this case the less is the better.
Good look
Flavio

----- Original message -----
From: "J.C. Goslings" <j.c.goslings@amc.uva.nl>
To: ORT-L@www2.aaos.org
Date: Sun, 27 May 2007 18:07:44 +0200
Subject: [ORT-L] Leg injury with shortening and nonunion

Dear list members,
Please share your advice in the following case:
a.. 17-year old boy
b.. november 2006 motorcycle accident
c.. grade 2 open comminuted distal femoral fracture
d.. grade 3b open comminuted tibial fracture
e.. no other serious injuries
f.. initial treatment with washout and ex fix
g.. secondary internal fixation with lag screws/LISS (femur) and
intramedullary nail following primary shortening of tibia
h.. VAC treatment of wound followed by split skin graft
i.. sensibility intact, ankle function limited
j.. currently in rehabilitation with 9 cm shoe elevation, 10-20 kg
weight bearing
The femoral fracture is healing but tibial fracture heals too slow (only
medial callus) and a lengthening procedure has not been started yet.
What would you do? Our experience with Ilizarov is limited.
Thank you.
J.C. Goslings
Trauma Unit AMC
Amsterdam
---
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alex at weborto
New User

May 27, 2007, 9:38 PM

Post #3 of 11 (6327 views)
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Re: [ORT-L] Leg injury with shortening and nonunion [In reply to]	Can't Post

Dear J.C.,

Sunday, May 27, 2007, 10:07:44 PM, you wrote:

JCG> slow (only medial callus) and a lengthening procedure has not been started yet.
JCG> What would you do? Our experience with Ilizarov is limited.

There is also valgus malalignment of the tibia. I would remove the
nail and apply an ex-fix - any you are comfortable with. Regardless of
the type of fixator consider transfixation wires through the fibula
and the tibia to prevent dislocation of tib-fib syndesemoses. Also a
foot frame is necessary to prevent ankle subluxation.
Cut the fibula (at the fracture level is enough). Then do perQ
osteotomy of the tibia - 0.5 cm incision anteriorly, predrilling, then
use small chisel and flexion/rotation osteoclasis. To shorten
distraction period the tibia could be cut at more than one level (in
upper third and midshaft).
Also nonunion zone can be distracted, callus response should be
estimated during distraction to decide is it worth to gain some
length at this level, or just stabilize after axial correction, or
compress to good circular contact. When the length is restored (9 cm =
2x4.5cm or for example 2x3.5 cm+ 2 cm at the nonunion level in case of
good regenerate response), immediately closed nailing could be
performed again.

This scenario would be most likely in our settings. Of course other
options exist like intramedullary lengthening using Fitbone, ISKD or
similar expensive device. Since anyway it would be exchange nailing
procedure, there is no need to open the nonunion site - the medial
callus + the nail will be enough for weight-bearing, and the callus
is expected to mature before fatigue fracture of the nail will happen.
Maybe though my view on the nonunion site is too optimistic because
the image is too small.

--
Best regards,
Alexander N. Chelnokov
Ural Scientific Research Institute
of Traumatology and Orthopaedics
7, Bankovsky str. Ekaterinburg 620014 Russia

---
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j.c.goslings at amc
New User

May 28, 2007, 12:57 AM

Post #4 of 11 (6324 views)
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Re: [ORT-L] Leg injury with shortening and nonunion [In reply to]	Can't Post

Thank you so far. From the X-rays and earlier CT the nonunion seems to
be atrophic with a little bridge of callus on the medial side.
Carel Goslings

----- Original Message -----
From: Alexander Chelnokov <alex@weborto.net>
Date: Monday, May 28, 2007 6:38 am
Subject: Re: [ORT-L] Leg injury with shortening and nonunion

> Dear J.C.,
>
> Sunday, May 27, 2007, 10:07:44 PM, you wrote:
>
> JCG> slow (only medial callus) and a lengthening procedure has not
> been started yet.
> JCG> What would you do? Our experience with Ilizarov is limited.
>
> There is also valgus malalignment of the tibia. I would remove the
> nail and apply an ex-fix - any you are comfortable with.
> Regardless of
> the type of fixator consider transfixation wires through the fibula
> and the tibia to prevent dislocation of tib-fib syndesemoses. Also a
> foot frame is necessary to prevent ankle subluxation.
> Cut the fibula (at the fracture level is enough). Then do perQ
> osteotomy of the tibia - 0.5 cm incision anteriorly, predrilling,
then
> use small chisel and flexion/rotation osteoclasis. To shorten
> distraction period the tibia could be cut at more than one level (in
> upper third and midshaft).
> Also nonunion zone can be distracted, callus response should be
> estimated during distraction to decide is it worth to gain some
> length at this level, or just stabilize after axial correction, or
> compress to good circular contact. When the length is restored (9
> cm =
> 2x4.5cm or for example 2x3.5 cm+ 2 cm at the nonunion level in
> case of
> good regenerate response), immediately closed nailing could be
> performed again.
>
> This scenario would be most likely in our settings. Of course other
> options exist like intramedullary lengthening using Fitbone, ISKD or
> similar expensive device. Since anyway it would be exchange nailing
> procedure, there is no need to open the nonunion site - the medial
> callus + the nail will be enough for weight-bearing, and the callus
> is expected to mature before fatigue fracture of the nail will
happen.
> Maybe though my view on the nonunion site is too optimistic because
> the image is too small.
>
> --
> 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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frg at myfastmail
New User

May 28, 2007, 5:09 AM

Post #5 of 11 (6321 views)
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Re: [ORT-L] Leg injury with shortening and nonunion [In reply to]	Can't Post

EXACTLY.
BIOLOGICAL FACTOR DEFICIENCE.
TTO
BIOLOGICAL SOLUTION: BONE GRAFT
BEST REGARDS

----- Original message -----
From: "J.C. Goslings" <j.c.goslings@amc.uva.nl>
To: ORT-L@www2.aaos.org
Date: Mon, 28 May 2007 09:57:53 +0200
Subject: Re: [ORT-L] Leg injury with shortening and nonunion

Thank you so far. From the X-rays and earlier CT the nonunion seems to
be atrophic with a little bridge of callus on the medial side.
Carel Goslings

----- Original Message -----
From: Alexander Chelnokov <alex@weborto.net>
Date: Monday, May 28, 2007 6:38 am
Subject: Re: [ORT-L] Leg injury with shortening and nonunion

> Dear J.C.,
>
> Sunday, May 27, 2007, 10:07:44 PM, you wrote:
>
> JCG> slow (only medial callus) and a lengthening procedure has not
> been started yet.
> JCG> What would you do? Our experience with Ilizarov is limited.
>
> There is also valgus malalignment of the tibia. I would remove the
> nail and apply an ex-fix - any you are comfortable with.
> Regardless of
> the type of fixator consider transfixation wires through the fibula
> and the tibia to prevent dislocation of tib-fib syndesemoses. Also a
> foot frame is necessary to prevent ankle subluxation.
> Cut the fibula (at the fracture level is enough). Then do perQ
> osteotomy of the tibia - 0.5 cm incision anteriorly, predrilling,
then
> use small chisel and flexion/rotation osteoclasis. To shorten
> distraction period the tibia could be cut at more than one level (in
> upper third and midshaft).
> Also nonunion zone can be distracted, callus response should be
> estimated during distraction to decide is it worth to gain some
> length at this level, or just stabilize after axial correction, or
> compress to good circular contact. When the length is restored (9
> cm =
> 2x4.5cm or for example 2x3.5 cm+ 2 cm at the nonunion level in
> case of
> good regenerate response), immediately closed nailing could be
> performed again.
>
> This scenario would be most likely in our settings. Of course other
> options exist like intramedullary lengthening using Fitbone, ISKD or
> similar expensive device. Since anyway it would be exchange nailing
> procedure, there is no need to open the nonunion site - the medial
> callus + the nail will be enough for weight-bearing, and the callus
> is expected to mature before fatigue fracture of the nail will
happen.
> Maybe though my view on the nonunion site is too optimistic because
> the image is too small.
>
> --
> 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]
>
>
---
[This E-mail scanned for viruses by Declude Virus]

jjbrooksmd at gmail
New User

May 28, 2007, 5:35 AM

Post #6 of 11 (6321 views)
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Re:[ORT-L] Leg injury with shortening and nonunion [In reply to]	Can't Post

following this case discussion with interest. Some questions:

1) Has the patient stopped smoking?
2) Are you sure there's not a smoldering infection at the tibia Fx
site? (C reactive protein, Fx site aspiration....)
3) Where does the 9cm come from? Are you sure it's 9cm of tibial
shortening, as it looks like less. Does he have a knee or hip
flexion contracture which has increased his lift requirement?
4) How many days passed between initial ex fix and conversion to IM
nail?

Thanks for sharing this challenging case with us.

Jeff

Jeffrey J. Brooks, MD
Stamford, CT

On May 28, 2007, at 8:08 AM, frg@myfastmail.com wrote:

> hELLO aLEXANDER:
> tHANKS FOR YOUR E-MAIL
> IN MY OPINION IS A HYPOTROPHIC PSEUDOARTROSIS
> WITH LOSS OF BIOLOGIAL FACTOR.
> THE SOLUTION IS BIOLOGICAL TOO.
> BONE GRAFT.
>
> bEST REGARDS
>
>
> ----- Original message -----
> From: "Alexander Chelnokov" <alex@weborto.net>
> To: "frg@myfastmail.com" <ORT-L@www2.aaos.org>
> Date: Mon, 28 May 2007 11:05:29 +0600
> Subject: Re[2]: [ORT-L] Leg injury with shortening and nonunion
>
> Hello Flavio,
>
> Monday, May 28, 2007, 1:56:14 AM, you wrote:
>
> fmc> A subperiostical decortication of Dunn and a Phemister Chatro
> fmc> cancelousus bone graft is mandatory.
>
> Why so agressive procedure for the situation evaluated as
> hypertrophic nonunion? For this sort of nonunion pure stabilization is
> enough, and it even provides regenerate on distraction.
>
> --
> 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]
>
> ---
> [This E-mail scanned for viruses by Declude Virus]
>

Jeffrey J Brooks, MD
Hand & Upper Extremity Surgery
Orthopaedic Trauma Surgery

Orthopaedic Surgery & Sports medicine center
1290 Summer Street, #4400
Stamford, CT 06905
(203) 323-7331

The information contained in this electronic mail transmittal may
contain healthcare information and is protected by law. This message
is intended only for the use of the designated recipient(s) named
above. If the reader of this transmission is not the intended
recipient(s), you are notified that any disclosure, dissemination,
distribution or duplication of its contents is strictly prohibited.
If you have received this transmittal in error, please notify the
sender by return e-mail and delete the transmittal immediately. Thank
you.

---
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nswolfso at usc
New User

May 28, 2007, 10:16 AM

Post #7 of 11 (6321 views)
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Re: [ORT-L] Leg injury with shortening and nonunion [In reply to]	Can't Post

Hello :

Interesting case. The good thing is the fact that the patient is young and, if other health, socioeconomic etc. factors are within acceptable range , it is obviously worse wile going all the way to salvage his extremity.

9 cm shoe elevation is likely due to the shortening of both tibia and femur. So, as far as leg equalization is concerned, I would not do it completely on the tibial side, and would not expect complete equalization of length at the first stage ( 1-2 years) of treatment. If residual shortening will be an issue ( 2-4 cm) I would address it later on.

So, back to the patient's current status: nonunion of tibia and shortening.
My plan would be:
1) rule out infection.
2) remove the nail
3) complete fibular osteotomy at the site of the old fracture and going through the same incision ( posterolateral approach) refresh the non union side, take tissue cultures, take down the bone bridge from the posteromedial region, so everything is obviously unstable and free, but not devascularised. You can do it this way.
4) close the skin; drain in for 2-3 days.
5) ream the canal
6) Apply Circular Ilizarov frame, use half pins and wires.
7)Proximal osteotomy of the tibia and , depends upon tibial defect, compress it, and do proximal tibial lengthening or compression and bone transport.

Considering patient's age and more so skeletal age ( growth plate is open), he should form good bone. The reason it did not happen with the nail is likely due to compromised stability and biology.
Bone graft?: may need it if and when there is no healing at the nonunion site after bone lengthening/docking is completed . I would not do it right away ( ? infection).

Good luck

Nikolaj

Nikolaj Wolfson, MD, FRCSC
Assistant Professor of Clinical Orthopaedics
Department of Orthopaedic Surgery
Keck School of Medicine
University of Southern California
nswolfso@usc.edu
(323) 226-7346 phone
http://www.usc.edu/medicine/orthopaedic_surgery

----- Original Message -----
From: "J.C. nonunion" <j.c.goslings@amc.uva.nl>
Date: Sunday, May 27, 2007 9:15 am
Subject: [ORT-L] Leg injury with shortening and nonunion
To: ORT-L@www2.aaos.org

> Dear list members,
> Please share your advice in the following case:
> a.. 17-year old boy
> b.. november 2006 motorcycle accident
> c.. grade 2 open comminuted distal femoral fracture
> d.. grade 3b open comminuted tibial fracture
> e.. no other serious injuries
> f.. initial treatment with washout and ex fix
> g.. secondary internal fixation with lag screws/LISS (femur) and
> intramedullary nail following primary shortening of tibia
> h.. VAC treatment of wound followed by split skin graft
> i.. sensibility intact, ankle function limited
> j.. currently in rehabilitation with 9 cm shoe elevation, 10-20
> kg weight bearing
> The femoral fracture is healing but tibial fracture heals too slow
> (only medial callus) and a lengthening procedure has not been
> started yet.
> What would you do? Our experience with Ilizarov is limited.
> Thank you.
> J.C. nonunion
> Trauma Unit AMC
> Amsterdam
---
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j.c.goslings at amc
New User

May 29, 2007, 3:38 AM

Post #8 of 11 (6305 views)
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Re: Re:[ORT-L] Leg injury with shortening and nonunion [In reply to]	Can't Post

Hello,
Here are some answers to the questions:
1.. no smoking
2.. CRP was 1.6 on Dec 19 2006 and 1.4 on March 19 2007; have not repeated it thereafter
3.. no contractures; I think part of the 9 cm must be in the femur but will make new X-rays and/or scanogram/CT-scout
4.. interval ex fix until conversion to ORIF/nail was 3 days (25 and 28 Nov 2006), skin graft was 14 Dec 2006 with 3 VAC changes in between. Ex fix (prox. tibia - foot) was removed 19 Dec 2006 and replaced with 'peroneus brace' to prevent uncontrolled ankle flexion
5.. soft tissues medially are skingraft-to-bone like on the picture sent (circular injury)
Your advices are appreciated.
Care Goslings

----- Original Message -----
From: "Jeff Brooks" <jjbrooksmd@gmail.com>
To: <ORT-L@www2.aaos.org>
Sent: Monday, May 28, 2007 2:35 PM
Subject: Re:[ORT-L] Leg injury with shortening and nonunion

> following this case discussion with interest. Some questions:
>
> 1) Has the patient stopped smoking?
> 2) Are you sure there's not a smoldering infection at the tibia Fx
> site? (C reactive protein, Fx site aspiration....)
> 3) Where does the 9cm come from? Are you sure it's 9cm of tibial
> shortening, as it looks like less. Does he have a knee or hip
> flexion contracture which has increased his lift requirement?
> 4) How many days passed between initial ex fix and conversion to IM
> nail?
>
> Thanks for sharing this challenging case with us.
>
> Jeff
>
> Jeffrey J. Brooks, MD
> Stamford, CT
>
> On May 28, 2007, at 8:08 AM, frg@myfastmail.com wrote:
>
>> hELLO aLEXANDER:
>> tHANKS FOR YOUR E-MAIL
>> IN MY OPINION IS A HYPOTROPHIC PSEUDOARTROSIS
>> WITH LOSS OF BIOLOGIAL FACTOR.
>> THE SOLUTION IS BIOLOGICAL TOO.
>> BONE GRAFT.
>>
>> bEST REGARDS
>>
>>
>> ----- Original message -----
>> From: "Alexander Chelnokov" <alex@weborto.net>
>> To: "frg@myfastmail.com" <ORT-L@www2.aaos.org>
>> Date: Mon, 28 May 2007 11:05:29 +0600
>> Subject: Re[2]: [ORT-L] Leg injury with shortening and nonunion
>>
>> Hello Flavio,
>>
>> Monday, May 28, 2007, 1:56:14 AM, you wrote:
>>
>> fmc> A subperiostical decortication of Dunn and a Phemister Chatro
>> fmc> cancelousus bone graft is mandatory.
>>
>> Why so agressive procedure for the situation evaluated as
>> hypertrophic nonunion? For this sort of nonunion pure stabilization is
>> enough, and it even provides regenerate on distraction.
>>
>> --
>> 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]
>>
>> ---
>> [This E-mail scanned for viruses by Declude Virus]
>>
>
> Jeffrey J Brooks, MD
> Hand & Upper Extremity Surgery
> Orthopaedic Trauma Surgery
>
> Orthopaedic Surgery & Sports medicine center
> 1290 Summer Street, #4400
> Stamford, CT 06905
> (203) 323-7331
>
>
> The information contained in this electronic mail transmittal may
> contain healthcare information and is protected by law. This message
> is intended only for the use of the designated recipient(s) named
> above. If the reader of this transmission is not the intended
> recipient(s), you are notified that any disclosure, dissemination,
> distribution or duplication of its contents is strictly prohibited.
> If you have received this transmittal in error, please notify the
> sender by return e-mail and delete the transmittal immediately. Thank
> you.
>
>
>
>
> ---
> [This E-mail scanned for viruses by Declude Virus]
>
>

j.c.goslings at amc
New User

Jun 26, 2007, 6:57 AM

Post #9 of 11 (5866 views)
Shortcut

Re: Re:[ORT-L] Leg injury with shortening and nonunion [In reply to]	Can't Post

Dear list members,
Attached the X-rays as requested. Tibia is 9,5 cm shortened, femur 2,0 cm.
Plan to remove nail, debride fracture, add cancellous bone, and apply ringfixator under compression, (later to be followed by distraction proximally).
Kind regards,
Carel Goslings
Trauma Unit AMC
Amsterdam NL

----- Original Message -----
From: J.C. Goslings
To: ORT-L@www2.aaos.org
Sent: Tuesday, May 29, 2007 12:38 PM
Subject: Re: Re:[ORT-L] Leg injury with shortening and nonunion

Hello,
Here are some answers to the questions:
1.. no smoking
2.. CRP was 1.6 on Dec 19 2006 and 1.4 on March 19 2007; have not repeated it thereafter
3.. no contractures; I think part of the 9 cm must be in the femur but will make new X-rays and/or scanogram/CT-scout
4.. interval ex fix until conversion to ORIF/nail was 3 days (25 and 28 Nov 2006), skin graft was 14 Dec 2006 with 3 VAC changes in between. Ex fix (prox. tibia - foot) was removed 19 Dec 2006 and replaced with 'peroneus brace' to prevent uncontrolled ankle flexion
5.. soft tissues medially are skingraft-to-bone like on the picture sent (circular injury)
Your advices are appreciated.
Care Goslings

----- Original Message -----
From: "Jeff Brooks" <jjbrooksmd@gmail.com>
To: <ORT-L@www2.aaos.org>
Sent: Monday, May 28, 2007 2:35 PM
Subject: Re:[ORT-L] Leg injury with shortening and nonunion

> following this case discussion with interest. Some questions:
>
> 1) Has the patient stopped smoking?
> 2) Are you sure there's not a smoldering infection at the tibia Fx
> site? (C reactive protein, Fx site aspiration....)
> 3) Where does the 9cm come from? Are you sure it's 9cm of tibial
> shortening, as it looks like less. Does he have a knee or hip
> flexion contracture which has increased his lift requirement?
> 4) How many days passed between initial ex fix and conversion to IM
> nail?
>
> Thanks for sharing this challenging case with us.
>
> Jeff
>
> Jeffrey J. Brooks, MD
> Stamford, CT
>
> On May 28, 2007, at 8:08 AM, frg@myfastmail.com wrote:
>
>> hELLO aLEXANDER:
>> tHANKS FOR YOUR E-MAIL
>> IN MY OPINION IS A HYPOTROPHIC PSEUDOARTROSIS
>> WITH LOSS OF BIOLOGIAL FACTOR.
>> THE SOLUTION IS BIOLOGICAL TOO.
>> BONE GRAFT.
>>
>> bEST REGARDS
>>
>>
>> ----- Original message -----
>> From: "Alexander Chelnokov" <alex@weborto.net>
>> To: "frg@myfastmail.com" <ORT-L@www2.aaos.org>
>> Date: Mon, 28 May 2007 11:05:29 +0600
>> Subject: Re[2]: [ORT-L] Leg injury with shortening and nonunion
>>
>> Hello Flavio,
>>
>> Monday, May 28, 2007, 1:56:14 AM, you wrote:
>>
>> fmc> A subperiostical decortication of Dunn and a Phemister Chatro
>> fmc> cancelousus bone graft is mandatory.
>>
>> Why so agressive procedure for the situation evaluated as
>> hypertrophic nonunion? For this sort of nonunion pure stabilization is
>> enough, and it even provides regenerate on distraction.
>>
>> --
>> 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]
>>
>> ---
>> [This E-mail scanned for viruses by Declude Virus]
>>
>
> Jeffrey J Brooks, MD
> Hand & Upper Extremity Surgery
> Orthopaedic Trauma Surgery
>
> Orthopaedic Surgery & Sports medicine center
> 1290 Summer Street, #4400
> Stamford, CT 06905
> (203) 323-7331
>
>
> The information contained in this electronic mail transmittal may
> contain healthcare information and is protected by law. This message
> is intended only for the use of the designated recipient(s) named
> above. If the reader of this transmission is not the intended
> recipient(s), you are notified that any disclosure, dissemination,
> distribution or duplication of its contents is strictly prohibited.
> If you have received this transmittal in error, please notify the
> sender by return e-mail and delete the transmittal immediately. Thank
> you.
>
>
>
>
> ---
> [This E-mail scanned for viruses by Declude Virus]
>
>

Attachments:

Leg length.jpg (102 KB)

j.c.goslings at amc
New User

Jul 17, 2007, 4:43 AM

Post #10 of 11 (5813 views)
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Re: Re:[ORT-L] Leg injury with shortening and nonunion [In reply to]	Can't Post

Attached the pictures of the intervention.
Tibial fracture had almost healed in the last 2 months. Nail was removed and canal reamed. Distraction over proximal osteotomy.
Kind regards,
Carel Goslings/Kees Jan Ponsen
Trauma Unit AMC
Amsterdam
----- Original Message -----
From: J.C. Goslings
To: ORT-L@www2.aaos.org
Sent: Tuesday, June 26, 2007 3:57 PM
Subject: Re: Re:[ORT-L] Leg injury with shortening and nonunion

Dear list members,
Attached the X-rays as requested. Tibia is 9,5 cm shortened, femur 2,0 cm.
Plan to remove nail, debride fracture, add cancellous bone, and apply ringfixator under compression, (later to be followed by distraction proximally).
Kind regards,
Carel Goslings
Trauma Unit AMC
Amsterdam NL

----- Original Message -----
From: J.C. Goslings
To: ORT-L@www2.aaos.org
Sent: Tuesday, May 29, 2007 12:38 PM
Subject: Re: Re:[ORT-L] Leg injury with shortening and nonunion

Hello,
Here are some answers to the questions:
1.. no smoking
2.. CRP was 1.6 on Dec 19 2006 and 1.4 on March 19 2007; have not repeated it thereafter
3.. no contractures; I think part of the 9 cm must be in the femur but will make new X-rays and/or scanogram/CT-scout
4.. interval ex fix until conversion to ORIF/nail was 3 days (25 and 28 Nov 2006), skin graft was 14 Dec 2006 with 3 VAC changes in between. Ex fix (prox. tibia - foot) was removed 19 Dec 2006 and replaced with 'peroneus brace' to prevent uncontrolled ankle flexion
5.. soft tissues medially are skingraft-to-bone like on the picture sent (circular injury)
Your advices are appreciated.
Care Goslings

----- Original Message -----
From: "Jeff Brooks" <jjbrooksmd@gmail.com>
To: <ORT-L@www2.aaos.org>
Sent: Monday, May 28, 2007 2:35 PM
Subject: Re:[ORT-L] Leg injury with shortening and nonunion

> following this case discussion with interest. Some questions:
>
> 1) Has the patient stopped smoking?
> 2) Are you sure there's not a smoldering infection at the tibia Fx
> site? (C reactive protein, Fx site aspiration....)
> 3) Where does the 9cm come from? Are you sure it's 9cm of tibial
> shortening, as it looks like less. Does he have a knee or hip
> flexion contracture which has increased his lift requirement?
> 4) How many days passed between initial ex fix and conversion to IM
> nail?
>
> Thanks for sharing this challenging case with us.
>
> Jeff
>
> Jeffrey J. Brooks, MD
> Stamford, CT
>
> On May 28, 2007, at 8:08 AM, frg@myfastmail.com wrote:
>
>> hELLO aLEXANDER:
>> tHANKS FOR YOUR E-MAIL
>> IN MY OPINION IS A HYPOTROPHIC PSEUDOARTROSIS
>> WITH LOSS OF BIOLOGIAL FACTOR.
>> THE SOLUTION IS BIOLOGICAL TOO.
>> BONE GRAFT.
>>
>> bEST REGARDS
>>
>>
>> ----- Original message -----
>> From: "Alexander Chelnokov" <alex@weborto.net>
>> To: "frg@myfastmail.com" <ORT-L@www2.aaos.org>
>> Date: Mon, 28 May 2007 11:05:29 +0600
>> Subject: Re[2]: [ORT-L] Leg injury with shortening and nonunion
>>
>> Hello Flavio,
>>
>> Monday, May 28, 2007, 1:56:14 AM, you wrote:
>>
>> fmc> A subperiostical decortication of Dunn and a Phemister Chatro
>> fmc> cancelousus bone graft is mandatory.
>>
>> Why so agressive procedure for the situation evaluated as
>> hypertrophic nonunion? For this sort of nonunion pure stabilization is
>> enough, and it even provides regenerate on distraction.
>>
>> --
>> 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]
>>
>> ---
>> [This E-mail scanned for viruses by Declude Virus]
>>
>
> Jeffrey J Brooks, MD
> Hand & Upper Extremity Surgery
> Orthopaedic Trauma Surgery
>
> Orthopaedic Surgery & Sports medicine center
> 1290 Summer Street, #4400
> Stamford, CT 06905
> (203) 323-7331
>
>
> The information contained in this electronic mail transmittal may
> contain healthcare information and is protected by law. This message
> is intended only for the use of the designated recipient(s) named
> above. If the reader of this transmission is not the intended
> recipient(s), you are notified that any disclosure, dissemination,
> distribution or duplication of its contents is strictly prohibited.
> If you have received this transmittal in error, please notify the
> sender by return e-mail and delete the transmittal immediately. Thank
> you.
>
>
>
>
> ---
> [This E-mail scanned for viruses by Declude Virus]
>
>

Attachments:

Osteotomy.jpg (137 KB)

Ring fixator.jpg (35.4 KB)

lgzjr at sign-post
New User

Jul 17, 2007, 7:36 AM

Post #11 of 11 (5813 views)
Shortcut

RE: Re:[ORT-L] Leg injury with shortening and nonunion [In reply to]	Can't Post

Dear Dr. Goslings

Your plan is excellent. Thank you for the follow-up. I was in Iraq in
March and found many civilians with nonunions from bone loss and infection.
I want to help them. The system you're using is effective but expensive.
Do you know of a low-cost, yet effective system to do bone transport? We
are working on this problem using a cable system at SIGN, but I don't have
much experience. Any thoughts?

Best regards,

Lew Zirkle

SIGN

Dictated using Dragon Naturally Speaking software. I apologize for
mistakes.

SIGN

Creating Equality of Fracture Care Worldwide

www.sign-post.org

-----Original Message-----
From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On Behalf
Of J.C. Goslings
Sent: Tuesday, July 17, 2007 4:44 AM
To: ORT-L@www2.aaos.org
Subject: Re: Re:[ORT-L] Leg injury with shortening and nonunion

Attached the pictures of the intervention.

Tibial fracture had almost healed in the last 2 months. Nail was removed and
canal reamed. Distraction over proximal osteotomy.

Kind regards,

Carel Goslings/Kees Jan Ponsen

Trauma Unit AMC

Amsterdam

----- Original Message -----

From: J.C. <mailto:j.c.goslings@amc.uva.nl> Goslings

To: ORT-L@www2.aaos.org

Sent: Tuesday, June 26, 2007 3:57 PM

Subject: Re: Re:[ORT-L] Leg injury with shortening and nonunion

Dear list members,

Attached the X-rays as requested. Tibia is 9,5 cm shortened, femur 2,0 cm.

Plan to remove nail, debride fracture, add cancellous bone, and apply
ringfixator under compression, (later to be followed by distraction
proximally).

Kind regards,

Carel Goslings

Trauma Unit AMC

Amsterdam NL

----- Original Message -----

From: J.C. <mailto:j.c.goslings@amc.uva.nl> Goslings

To: ORT-L@www2.aaos.org

Sent: Tuesday, May 29, 2007 12:38 PM

Subject: Re: Re:[ORT-L] Leg injury with shortening and nonunion

Hello,

Here are some answers to the questions:

1. no smoking

2. CRP was 1.6 on Dec 19 2006 and 1.4 on March 19 2007; have not
repeated it thereafter

3. no contractures; I think part of the 9 cm must be in the femur but
will make new X-rays and/or scanogram/CT-scout

4. interval ex fix until conversion to ORIF/nail was 3 days (25 and 28
Nov 2006), skin graft was 14 Dec 2006 with 3 VAC changes in between. Ex fix
(prox. tibia - foot) was removed 19 Dec 2006 and replaced with 'peroneus
brace' to prevent uncontrolled ankle flexion

5. soft tissues medially are skingraft-to-bone like on the picture sent
(circular injury)

Your advices are appreciated.

Care Goslings

----- Original Message -----

From: "Jeff Brooks" < <mailto:jjbrooksmd@gmail.com> jjbrooksmd@gmail.com>

To: < <mailto:ORT-L@www2.aaos.org> ORT-L@www2.aaos.org>

Sent: Monday, May 28, 2007 2:35 PM

Subject: Re:[ORT-L] Leg injury with shortening and nonunion

> following this case discussion with interest. Some questions:
>
> 1) Has the patient stopped smoking?
> 2) Are you sure there's not a smoldering infection at the tibia Fx
> site? (C reactive protein, Fx site aspiration....)
> 3) Where does the 9cm come from? Are you sure it's 9cm of tibial
> shortening, as it looks like less. Does he have a knee or hip
> flexion contracture which has increased his lift requirement?
> 4) How many days passed between initial ex fix and conversion to IM
> nail?
>
> Thanks for sharing this challenging case with us.
>
> Jeff
>
> Jeffrey J. Brooks, MD
> Stamford, CT
>
> On May 28, 2007, at 8:08 AM, <mailto:frg@myfastmail.com>
frg@myfastmail.com wrote:
>
>> hELLO aLEXANDER:
>> tHANKS FOR YOUR E-MAIL
>> IN MY OPINION IS A HYPOTROPHIC PSEUDOARTROSIS
>> WITH LOSS OF BIOLOGIAL FACTOR.
>> THE SOLUTION IS BIOLOGICAL TOO.
>> BONE GRAFT.
>>
>> bEST REGARDS
>>
>>
>> ----- Original message -----
>> From: "Alexander Chelnokov" < <mailto:alex@weborto.net> alex@weborto.net>
>> To: " <mailto:frg@myfastmail.com> frg@myfastmail.com" <
<mailto:ORT-L@www2.aaos.org> ORT-L@www2.aaos.org>
>> Date: Mon, 28 May 2007 11:05:29 +0600
>> Subject: Re[2]: [ORT-L] Leg injury with shortening and nonunion
>>
>> Hello Flavio,
>>
>> Monday, May 28, 2007, 1:56:14 AM, you wrote:
>>
>> fmc> A subperiostical decortication of Dunn and a Phemister Chatro
>> fmc> cancelousus bone graft is mandatory.
>>
>> Why so agressive procedure for the situation evaluated as
>> hypertrophic nonunion? For this sort of nonunion pure stabilization is
>> enough, and it even provides regenerate on distraction.
>>
>> --
>> 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]
>>
>> ---
>> [This E-mail scanned for viruses by Declude Virus]
>>
>
> Jeffrey J Brooks, MD
> Hand & Upper Extremity Surgery
> Orthopaedic Trauma Surgery
>
> Orthopaedic Surgery & Sports medicine center
> 1290 Summer Street, #4400
> Stamford, CT 06905
> (203) 323-7331
>
>
> The information contained in this electronic mail transmittal may
> contain healthcare information and is protected by law. This message
> is intended only for the use of the designated recipient(s) named
> above. If the reader of this transmission is not the intended
> recipient(s), you are notified that any disclosure, dissemination,
> distribution or duplication of its contents is strictly prohibited.
> If you have received this transmittal in error, please notify the
> sender by return e-mail and delete the transmittal immediately. Thank
> you.
>
>
>
>
> ---
> [This E-mail scanned for viruses by Declude Virus]
>
>

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