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doctorbones at rediffmail
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Nov 26, 2005, 8:57 AM

Post #1 of 7 (926 views)
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[ORT-L]	Can't Post

dear colleagues,thanks for the input.here are images of the immediate post op and at three months post op period.i had to stop distraction at four cms of lengthening as the patient did not have enough flexion at the knee for ground clearance.

any experience with unilateral distraction fixators(do they also cause post removal stiffness )also the corticotomy did not distract at 4x.25 mm/day so i increased it to6x.25 then it distracted smoothly.
remember reading in JBJS that biphosphonates decrease lengthening associated osteoporosis any experience with that?

presently patient has had the fixator for three months,is walking full wt bearing without pain.the rt lower limb is three cms short but the patient manages well without any compensatory footwear.i have not tried to correct the recurvatum in the distal fragment.should i try to reconstruct the quad mechanism ? the patient does not agree for fusion.looking forward to your views,
-prashant.

- prashant.

Attachments:

0003_3_1.jpg (501 KB)

IMG_0013_13_1.JPG (336 KB)

IMG_0017_15_1.JPG (350 KB)

IMG_0018_16_1.JPG (315 KB)

IMG_0010_6_1.JPG (327 KB)

janglen at iupui
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Dec 12, 2005, 12:23 PM

Post #2 of 7 (915 views)
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RE: [ORT-L] [In reply to]	Can't Post

This discussion list is meant for orthopaedic surgeons or other medical professionals involved in the care of orthopaedic trauma patients to discuss clinical or political issues of professional interest. I am not sure how you got access to it, but please do not use it for marketing, recruiting or solicitation purposes.

Jeff Anglen, MD

Professor and Chairman, Department of Orthopaedics

Indiana University School of Medicine

540 Clinical Drive, Suite 600

Indianapolis, IN 46202

317-274-7913

janglen@iupui.edu

-----Original Message-----
From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On Behalf Of Brent Russell
Sent: Monday, December 12, 2005 3:11 PM
To: ORT-L@www2.aaos.org
Subject: [ORT-L]

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janglen at iupui
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Sep 24, 2006, 6:40 PM

Post #3 of 7 (785 views)
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RE: [ORT-L] [In reply to]	Can't Post

MJ -

Send some pics with the hardware out, it's hard to make out the distal fragment.
It looks to me like there is enough there to do bicolumnar plating through a posterior approach with olecranon osteotomy, cancellous bone grafting of the defect with BMP and a stimulator, explore the radial nerve and lysis of joint adhesions. If the bone is weak and porotic, a locking plate system might be useful. In my experience , it is certainly possible to graft and heal such a gap in the humerus in a young healthy person, getting the elbow function back is another issue. What is his function like now?

Jeff

________________________________

From: ORT-L-owner@www2.aaos.org on behalf of mjalbert55@bellsouth.net
Sent: Sun 9/24/2006 8:05 PM
To: ORT-L@www2.aaos.org
Subject: [ORT-L]

Attached are x-rays of a 21 year old male who is 3 years out from multiple injuries sustained in a motorcycle accident. This was initially an open injury. Several attempts were made to fix this fracture at a nearby teaching facility. The most recent procedure was one year ago. His fixation failed last January. At that time he was told that he would have to wait for another doctor to care for him (rotation of residents I presume). No history of infection. Non-smoker. Due to his head injury his employment options are limited. He is capable of driving a truck if he had a functioning arm.

This is his non-dominant arm. He has a compete radial nerve palsy which has never been addressed. All previous humeral surgeries were done via a lateral approach.

I removed the floating hardware via the lateral approach through cement-like scar. Cultures and path were negative. The distal humeral segment, not surprising, is completely disvascular. Soft tissues will support further reconstruction via anterior or posterior approaches.

Any thoughts on the reconstructive options?

MJA

ti.george at gmail
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Sep 24, 2006, 6:41 PM

Post #4 of 7 (785 views)
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Re: [ORT-L] [In reply to]	Can't Post

Dear MJA,

Can we have a look at the post implant removal X-ray? Also a clinical
picture of the affected arm. I am begining to think of a functional
non-union which could be supported by a brace(under the presumtion that
elbow is stiff). The brace could be adjusted in such a way as to have the
non-union acting as the elbow.

At this stage the option available for radial nerve will be reconstructions
using tendon transfers to restore funtion. If median nerve and ulnar nerve
are funtional, if the hand is supple, you could get a good functioning hand
after tendon transfers.

Keep us posted and good luck.

Dr. T. I. George,
Senior Orthopaedic Surgeon
And
Head of Orthopaedics Unit-III,
Little Flower Hospital and research Centre,
Angamaly, Kerala State,
India.

Bruce_Ziran at HMIS
New User

Sep 25, 2006, 5:38 AM

Post #5 of 7 (780 views)
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Re: [ORT-L] [In reply to]	Can't Post

The biggest concern is what you state as a dysvascular distal segment. It
is probably why previous efforts had failed. It also appears that there is
a trochlear deficiency, somewhat of a "fishmouth" as they used to call it.
I agree with Jeff, that the last chance is to try the high power stuff, in
hopes of stirring up a bit of vascularity. I understand that BMP-2 works
earlier in the cascade, so it may lure angiogenesis a bit more. If all else
fails, a resection and fascial interposition with shortening may work. I
have seen poor results with total elbow in young and active. Tough problem.
Good luck.

Bruce H. Ziran, M.D.
Director of Orthopaedic Trauma
St. Elizabeth Health Center
Associate Professor of Orthopaedic Surgery
Northeast Ohio Universities College of Medicine

<mjalbert55@bells
outh.net>
Sent by: To
ORT-L-owner@www2. <ORT-L@www2.aaos.org>
aaos.org cc

Subject
09/24/2006 09:05 [ORT-L]
PM

Please respond to
ORT-L@www2.aaos.o
rg

Attached are x-rays of a 21 year old male who is 3 years out from multiple
injuries sustained in a motorcycle accident. This was initially an open
injury. Several attempts were made to fix this fracture at a nearby
teaching facility. The most recent procedure was one year ago. His
fixation failed last January. At that time he was told that he would have
to wait for another doctor to care for him (rotation of residents I
presume). No history of infection. Non-smoker. Due to his head injury
his employment options are limited. He is capable of driving a truck if he
had a functioning arm.

This is his non-dominant arm. He has a compete radial nerve palsy which
has never been addressed. All previous humeral surgeries were done via a
lateral approach.

I removed the floating hardware via the lateral approach through
cement-like scar. Cultures and path were negative. The distal humeral
segment, not surprising, is completely disvascular. Soft tissues will
support further reconstruction via anterior or posterior approaches.

Any thoughts on the reconstructive options?

MJA

(See attached file: elb1.jpg)(See attached file: elb2.jpg)(See attached
file: elb3.jpg)

Attachments:

elb1.jpg (21.5 KB)

elb2.jpg (26.9 KB)

elb3.jpg (21.6 KB)

nswolfso at usc
New User

Sep 25, 2006, 9:21 AM

Post #6 of 7 (778 views)
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Re: [ORT-L] [In reply to]	Can't Post

Interesting case, but not unusual.

My opinion:

Semicircular Ex Fix, small wires. This is to be done after the site of nonunion is excised, bone ends are refreshed, and appropriate frame construct is made. Possible use of bone graft, BMP, etc. The fixator might be extended to the forearm, to allow Range of Motion in the elbow joint while the nonunion site is compressed. More proximal osteotomy can be done for the humerus lengthening, either same time ( my preference, has better biomechanical stability on the nonunion site and likely more bone stimulating factors), or as a second stage. I would give this patient a chance to keep his own elbow joint. He has a chance and deserves it.
For reference see publications by Dr. O. V. Oganesyan.

Nikolaj Wolfson, MD, FRCSC
Assistant Professor of Clinical Orthopaedics,
Department of Orthopaedic Surgery,
LAC USC,
Los Angeles, California

----- Original Message -----
From: mjalbert55@bellsouth.net
Date: Sunday, September 24, 2006 9:07 pm
Subject: [ORT-L]
To: ORT-L@www2.aaos.org

> Attached are x-rays of a 21 year old male who is 3 years out from
> multiple injuries sustained in a motorcycle accident. This was
> initially an open injury. Several attempts were made to fix this
> fracture at a nearby teaching facility. The most recent
> procedure was one year ago. His fixation failed last January. At
> that time he was told that he would have to wait for another
> doctor to care for him (rotation of residents I presume). No
> history of infection. Non-smoker. Due to his head injury his
> employment options are limited. He is capable of driving a truck
> if he had a functioning arm.
>
> This is his non-dominant arm. He has a compete radial nerve
> palsy which has never been addressed. All previous humeral
> surgeries were done via a lateral approach.
>
> I removed the floating hardware via the lateral approach through
> cement-like scar. Cultures and path were negative. The distal
> humeral segment, not surprising, is completely disvascular. Soft
> tissues will support further reconstruction via anterior or
> posterior approaches.
>
> Any thoughts on the reconstructive options?
>
> MJA
>
>

Attachments:

nswolfso.vcf (0.24 KB)

frg at myfastmail
New User

Sep 25, 2006, 12:33 PM

Post #7 of 7 (762 views)
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Re: [ORT-L] [In reply to]	Can't Post

This is an exellent case for Ilizarov´s lengthening rings

----- Original message -----
From: "Nikolaj Wolfson" <nswolfso@usc.edu>
To: ORT-L@www2.aaos.org
Date: Mon, 25 Sep 2006 12:21:06 -0400
Subject: Re: [ORT-L]

Interesting case, but not unusual.

My opinion:

Semicircular Ex Fix, small wires. This is to be done after the site of
nonunion is excised, bone ends are refreshed, and appropriate frame
construct is made. Possible use of bone graft, BMP, etc. The fixator
might be extended to the forearm, to allow Range of Motion in the elbow
joint while the nonunion site is compressed. More proximal osteotomy can
be done for the humerus lengthening, either same time ( my preference,
has better biomechanical stability on the nonunion site and likely more
bone stimulating factors), or as a second stage. I would give this
patient a chance to keep his own elbow joint. He has a chance and
deserves it.
For reference see publications by Dr. O. V. Oganesyan.

Nikolaj Wolfson, MD, FRCSC
Assistant Professor of Clinical Orthopaedics,
Department of Orthopaedic Surgery,
LAC USC,
Los Angeles, California

----- Original Message -----
From: mjalbert55@bellsouth.net
Date: Sunday, September 24, 2006 9:07 pm
Subject: [ORT-L]
To: ORT-L@www2.aaos.org

> Attached are x-rays of a 21 year old male who is 3 years out from
> multiple injuries sustained in a motorcycle accident. This was
> initially an open injury. Several attempts were made to fix this
> fracture at a nearby teaching facility. The most recent
> procedure was one year ago. His fixation failed last January. At
> that time he was told that he would have to wait for another
> doctor to care for him (rotation of residents I presume). No
> history of infection. Non-smoker. Due to his head injury his
> employment options are limited. He is capable of driving a truck
> if he had a functioning arm.
>
> This is his non-dominant arm. He has a compete radial nerve
> palsy which has never been addressed. All previous humeral
> surgeries were done via a lateral approach.
>
> I removed the floating hardware via the lateral approach through
> cement-like scar. Cultures and path were negative. The distal
> humeral segment, not surprising, is completely disvascular. Soft
> tissues will support further reconstruction via anterior or
> posterior approaches.
>
> Any thoughts on the reconstructive options?
>
> MJA
>
>
---
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