[ORT-L] Pelvic malunion - Orthopedics Forum


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[ORT-L] Pelvic malunion

dzamoran at uci
New User

Apr 15, 2008, 2:36 PM

Post #1 of 8 (4080 views)
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[ORT-L] Pelvic malunion	Can't Post

Looking for some advice.

This a a 45 yo male who had an accident in Panama 3 weeks ago when he
crashed into a tree while on a zip line. He underwernt 3 surgeries in
Panama over a week period for failed fixation. He now presents to me
with a malunion. His PMHx is significant for bipolar disorder and DVT.
He has an IVC currently. He is neuro exam is normal. His posterior
wounds are healing with minimal erythema. No active drainage. He had
been on keflex since the surgery.

His main complaint is pain. He has already lossed fixation anteriorly
and is malreduced posteriorly also. My plan was to revise him next
week.

I was planning on going anterior and removing hardware then posterior
and revising with trans-sacral iliosacral screws and possible tension
band plate also. I would then flip again and reORIF his symphysis
anteriorly.

Appreciate anyones thoughts.

dpz <<pelvis malunion.ppt>>

________________________________________________________________________
____________________________

David P. Zamorano, MD
Director, Orthopaedic Trauma Service
UCI Medical Center
(714) 456-7801 Office
(714) 456-7547 Fax

Attachments:

pelvis malunion.ppt (3.25 MB)

Bruce_Ziran at HMIS
New User

Apr 16, 2008, 9:03 AM

Post #2 of 8 (4073 views)
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Re: [ORT-L] Pelvic malunion [In reply to]	Can't Post

Tough break. I like your plan. Only thing I would add is to
1) rule out infection
2) graft posterior. I like tension band plates. They do very well. We
are submitting our series currently
3) consider fusing symphisis as described by Matta's group.
Intercalary crest graft after denuding symphysis.
4) pray, summon spirits, call a witch doctor.

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

"Zamorano, David"
<dzamoran@uci.edu
> To
Sent by: <ORT-L@www2.aaos.org>
ORT-L-owner@www2. cc
aaos.org
Subject
[ORT-L] Pelvic malunion
04/15/2008 06:21
PM

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

Looking for some advice.

This a a 45 yo male who had an accident in Panama 3 weeks ago when he
crashed into a tree while on a zip line. He underwernt 3 surgeries in
Panama over a week period for failed fixation. He now presents to me with
a malunion. His PMHx is significant for bipolar disorder and DVT. He has
an IVC currently. He is neuro exam is normal. His posterior wounds are
healing with minimal erythema. No active drainage. He had been on keflex
since the surgery.

His main complaint is pain. He has already lossed fixation anteriorly and
is malreduced posteriorly also. My plan was to revise him next week.

I was planning on going anterior and removing hardware then posterior and
revising with trans-sacral iliosacral screws and possible tension band
plate also. I would then flip again and reORIF his symphysis anteriorly.

Appreciate anyones thoughts.

dpz <<pelvis malunion.ppt>>

____________________________________________________________________________________________________

David P. Zamorano, MD
Director, Orthopaedic Trauma Service
UCI Medical Center
(714) 456-7801 Office
(714) 456-7547 Fax (See attached file: pelvis malunion.ppt)

CONFIDENTIALITY NOTICE: This message, including any attachments, is for
the sole use of the intended recipient(s) and may contain confidential and
privileged information. Any unauthorized review, use, disclosure or distribution
is prohibited. If you are not the intended recipient, please contact the
sender by reply e-mail and destroy all copies of the original message.

Attachments:

pelvis malunion.ppt (3.25 MB)

dzamoran at uci
New User

May 23, 2008, 12:22 PM

Post #3 of 8 (3943 views)
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RE: [ORT-L] Pelvic malunion [In reply to]	Can't Post

Drs. Ziran and Routt,

Thanks for the advice on the pelvic malunion. Here is some follow up.
1. patient began to drain from left posterior wound.
2. removed hardware and performed multiple I and ds until wound looked
clean.
3. IV abx during this time
4. Bladder rupture noted on HWR of anterior pelvic ring. Urology
repaired and kept foley. No suprapubic catheter.
5. Once soft tissues looked healthy and CRP trended down, did osteotomy
of sacrum and fixed with trans-sacral screws and tension band.
6. revised front and added ex-fix to supplement because patients bipolar
disorder seemed to be more profound than I originally anticipated and I
questioned his compliance. I thought the ex-fix might slow him down.

Xrays attached

I appreciate any constructive criticism you may have.

dpz

________________________________________________________________________
____________________________

David P. Zamorano, MD
Director, Orthopaedic Trauma Service
UCI Medical Center
(714) 456-7801 Office
(714) 456-7547 Fax

-----Original Message-----
From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On
Behalf Of Bruce_Ziran@HMIS.ORG
Sent: Wednesday, April 16, 2008 9:03 AM
To: ORT-L@www2.aaos.org
Subject: Re: [ORT-L] Pelvic malunion

Tough break. I like your plan. Only thing I would add is to
1) rule out infection
2) graft posterior. I like tension band plates. They do very well.
We are submitting our series currently
3) consider fusing symphisis as described by Matta's group.
Intercalary crest graft after denuding symphysis.
4) pray, summon spirits, call a witch doctor.

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

"Zamorano, David"

<dzamoran@uci.edu

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

ORT-L-owner@www2.
cc
aaos.org

Subject
[ORT-L] Pelvic malunion

04/15/2008 06:21

PM

Please respond to

ORT-L@www2.aaos.o

rg

Looking for some advice.

This a a 45 yo male who had an accident in Panama 3 weeks ago when he
crashed into a tree while on a zip line. He underwernt 3 surgeries in
Panama over a week period for failed fixation. He now presents to me
with a malunion. His PMHx is significant for bipolar disorder and DVT.
He has an IVC currently. He is neuro exam is normal. His posterior
wounds are healing with minimal erythema. No active drainage. He had
been on keflex since the surgery.

His main complaint is pain. He has already lossed fixation anteriorly
and is malreduced posteriorly also. My plan was to revise him next
week.

I was planning on going anterior and removing hardware then posterior
and revising with trans-sacral iliosacral screws and possible tension
band plate also. I would then flip again and reORIF his symphysis
anteriorly.

Appreciate anyones thoughts.

dpz <<pelvis malunion.ppt>>

________________________________________________________________________
____________________________

David P. Zamorano, MD
Director, Orthopaedic Trauma Service
UCI Medical Center
(714) 456-7801 Office
(714) 456-7547 Fax (See attached file: pelvis malunion.ppt)

CONFIDENTIALITY NOTICE: This message, including any attachments, is for
the sole use of the intended recipient(s) and may contain confidential
and privileged information. Any unauthorized review, use, disclosure or
distribution is prohibited. If you are not the intended recipient,
please contact the sender by reply e-mail and destroy all copies of the
original message.

Attachments:

pelvis malunion.ppt (4.80 MB)

Bruce_Ziran at HMIS
New User

May 23, 2008, 2:01 PM

Post #4 of 8 (3941 views)
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RE: [ORT-L] Pelvic malunion [In reply to]	Can't Post

Looks much better. Not surprised about the infection.

I use 4.5 mm recon plates for anterior fixation.. Find it to be stronger
and can bend in-plane enough to get the curve needed. I use a 6 hole which
allows 3 screws on each side. I would still have fused the front with crest
graft. But, i like your "X" method. Pretty slick

I worry a little about so many transacral screws, since I beleive that
space to be rather tight and tough to really know with just fluoro. Have
you considered a CT to verify?
The CT you have did not show a lot of graft in the NU site, did you open
and graft that cleft? You may have but maybe artifact obscures.

Overall, an admirable job with a horrible problem.

Final question, did you summon any witch doctors, use any potions, or
anything?

Seriously though, looks great.

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

"Zamorano, David"
<dzamoran@uci.edu
> To
Sent by: <ORT-L@www2.aaos.org>
ORT-L-owner@www2. cc
aaos.org
Subject
RE: [ORT-L] Pelvic malunion
05/23/2008 04:14
PM

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

Drs. Ziran and Routt,

Thanks for the advice on the pelvic malunion. Here is some follow up.
1. patient began to drain from left posterior wound.
2. removed hardware and performed multiple I and ds until wound looked
clean.
3. IV abx during this time
4. Bladder rupture noted on HWR of anterior pelvic ring. Urology
repaired and kept foley. No suprapubic catheter.
5. Once soft tissues looked healthy and CRP trended down, did osteotomy
of sacrum and fixed with trans-sacral screws and tension band.
6. revised front and added ex-fix to supplement because patients bipolar
disorder seemed to be more profound than I originally anticipated and I
questioned his compliance. I thought the ex-fix might slow him down.

Xrays attached

I appreciate any constructive criticism you may have.

dpz

________________________________________________________________________
____________________________

David P. Zamorano, MD
Director, Orthopaedic Trauma Service
UCI Medical Center
(714) 456-7801 Office
(714) 456-7547 Fax

-----Original Message-----
From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On
Behalf Of Bruce_Ziran@HMIS.ORG
Sent: Wednesday, April 16, 2008 9:03 AM
To: ORT-L@www2.aaos.org
Subject: Re: [ORT-L] Pelvic malunion

Tough break. I like your plan. Only thing I would add is to
1) rule out infection
2) graft posterior. I like tension band plates. They do very well.
We are submitting our series currently
3) consider fusing symphisis as described by Matta's group.
Intercalary crest graft after denuding symphysis.
4) pray, summon spirits, call a witch doctor.

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

"Zamorano, David"

<dzamoran@uci.edu

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

ORT-L-owner@www2.
cc
aaos.org

Subject
[ORT-L] Pelvic malunion

04/15/2008 06:21

PM

Please respond to

ORT-L@www2.aaos.o

rg

Looking for some advice.

This a a 45 yo male who had an accident in Panama 3 weeks ago when he
crashed into a tree while on a zip line. He underwernt 3 surgeries in
Panama over a week period for failed fixation. He now presents to me
with a malunion. His PMHx is significant for bipolar disorder and DVT.
He has an IVC currently. He is neuro exam is normal. His posterior
wounds are healing with minimal erythema. No active drainage. He had
been on keflex since the surgery.

His main complaint is pain. He has already lossed fixation anteriorly
and is malreduced posteriorly also. My plan was to revise him next
week.

I was planning on going anterior and removing hardware then posterior
and revising with trans-sacral iliosacral screws and possible tension
band plate also. I would then flip again and reORIF his symphysis
anteriorly.

Appreciate anyones thoughts.

dpz <<pelvis malunion.ppt>>

________________________________________________________________________
____________________________

David P. Zamorano, MD
Director, Orthopaedic Trauma Service
UCI Medical Center
(714) 456-7801 Office
(714) 456-7547 Fax (See attached file: pelvis malunion.ppt)

CONFIDENTIALITY NOTICE: This message, including any attachments, is for
the sole use of the intended recipient(s) and may contain confidential
and privileged information. Any unauthorized review, use, disclosure or
distribution is prohibited. If you are not the intended recipient,
please contact the sender by reply e-mail and destroy all copies of the
original message.
(See attached file: pelvis malunion.ppt)

CONFIDENTIALITY NOTICE: This message, including any attachments, is for
the sole use of the intended recipient(s) and may contain confidential and
privileged information. Any unauthorized review, use, disclosure or distribution
is prohibited. If you are not the intended recipient, please contact the
sender by reply e-mail and destroy all copies of the original message.

Attachments:

pelvis malunion.ppt (4.80 MB)

mlroutt at u
New User

May 23, 2008, 2:47 PM

Post #5 of 8 (3941 views)
Shortcut

Re: [ORT-L] Pelvic malunion [In reply to]	Can't Post

Too much for email...call anytime to discuss.....206-744-3657 rings my desk
and I can pull up the images there.

> Drs. Ziran and Routt,
>
> Thanks for the advice on the pelvic malunion. Here is some follow up.
> 1. patient began to drain from left posterior wound.
> 2. removed hardware and performed multiple I and ds until wound looked
> clean.
> 3. IV abx during this time
> 4. Bladder rupture noted on HWR of anterior pelvic ring. Urology
> repaired and kept foley. No suprapubic catheter.
> 5. Once soft tissues looked healthy and CRP trended down, did osteotomy
> of sacrum and fixed with trans-sacral screws and tension band.
> 6. revised front and added ex-fix to supplement because patients bipolar
> disorder seemed to be more profound than I originally anticipated and I
> questioned his compliance. I thought the ex-fix might slow him down.
>
> Xrays attached
>
> I appreciate any constructive criticism you may have.
>
> dpz
>
>
> ________________________________________________________________________
> ____________________________
>
> David P. Zamorano, MD
> Director, Orthopaedic Trauma Service
> UCI Medical Center
> (714) 456-7801 Office
> (714) 456-7547 Fax
>
> -----Original Message-----
> From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On
> Behalf Of Bruce_Ziran@HMIS.ORG
> Sent: Wednesday, April 16, 2008 9:03 AM
> To: ORT-L@www2.aaos.org
> Subject: Re: [ORT-L] Pelvic malunion
>
> Tough break. I like your plan. Only thing I would add is to
> 1) rule out infection
> 2) graft posterior. I like tension band plates. They do very well.
> We are submitting our series currently
> 3) consider fusing symphisis as described by Matta's group.
> Intercalary crest graft after denuding symphysis.
> 4) pray, summon spirits, call a witch doctor.
>
> Bruce H. Ziran, M.D.
> Director of Orthopaedic Trauma
> St. Elizabeth Health Center
> Associate Professor of Orthopaedic Surgery Northeast Ohio Universities
> College of Medicine
>
>
>
>
> "Zamorano, David"
>
> <dzamoran@uci.edu
>
>>
> To
> Sent by: <ORT-L@www2.aaos.org>
>
> ORT-L-owner@www2.
> cc
> aaos.org
>
>
> Subject
> [ORT-L] Pelvic malunion
>
> 04/15/2008 06:21
>
> PM
>
>
>
>
>
> Please respond to
>
> ORT-L@www2.aaos.o
>
> rg
>
>
>
>
>
>
>
>
>
> Looking for some advice.
>
>
> This a a 45 yo male who had an accident in Panama 3 weeks ago when he
> crashed into a tree while on a zip line. He underwernt 3 surgeries in
> Panama over a week period for failed fixation. He now presents to me
> with a malunion. His PMHx is significant for bipolar disorder and DVT.
> He has an IVC currently. He is neuro exam is normal. His posterior
> wounds are healing with minimal erythema. No active drainage. He had
> been on keflex since the surgery.
>
>
> His main complaint is pain. He has already lossed fixation anteriorly
> and is malreduced posteriorly also. My plan was to revise him next
> week.
>
>
> I was planning on going anterior and removing hardware then posterior
> and revising with trans-sacral iliosacral screws and possible tension
> band plate also. I would then flip again and reORIF his symphysis
> anteriorly.
>
>
> Appreciate anyones thoughts.
>
>
> dpz <<pelvis malunion.ppt>>
>
>
> ________________________________________________________________________
> ____________________________
>
>
>
> David P. Zamorano, MD
> Director, Orthopaedic Trauma Service
> UCI Medical Center
> (714) 456-7801 Office
> (714) 456-7547 Fax (See attached file: pelvis malunion.ppt)
>
>
>
>
> CONFIDENTIALITY NOTICE: This message, including any attachments, is for
> the sole use of the intended recipient(s) and may contain confidential
> and privileged information. Any unauthorized review, use, disclosure or
> distribution is prohibited. If you are not the intended recipient,
> please contact the sender by reply e-mail and destroy all copies of the
> original message.

M.L. Chip Routt, Jr.,M.D.
Professor-Orthopedic Surgery
Harborview Medical Center
325 Ninth Avenue
Box 359798
Seattle, WA 98104-2499
phone 206-731-3658
FAX 206-731-3227
--

---
[This E-mail scanned for viruses by Declude Virus]

mlroutt at u
New User

May 23, 2008, 3:20 PM

Post #6 of 8 (3941 views)
Shortcut

Re: [ORT-L] Pelvic malunion [In reply to]	Can't Post

Sorry...I didn't recognize that this was a group emailing...but you can
still call if you'd like.

The reductions look nice...they represent a lot of work....sorry about the
infection.

The bladder hole is not uncommon in such scenarios...it probably was normal,
but when it adheres after the initial surgery and you try to peel it away,
it yields...it's happened to me for re-dos too.

The iliosacral screws are probably fine...the low anterior screw in the
upper sacral segment is the safest. The posterior screw in the upper segment
should be more cranial and horizontal (on the outlet image) in order to
avoid the S1 nerve root tunnels.

The second sacral segment screw is anterior enough but declining...it should
also be more horizontal...oblique long screws increase risk and demand
precision.

The aim and starting point for such long screws is even more important than
for shorter screws...with the upper segment screws, you've extended thru to
the contralateral SI joint and lateral ilium which should improve the
fixation construct.

If you extend the upper 2 screws to the contralateral side, you might as
well extend the 2nd sacral segment screw also...starting point and aim
matter.

The posterior plate is a frail pelvic recon plate...these are flexible in
numerous planes and can allow displacement...you've applied it obliquely,
but used iliosacral screws to support it...it's not a tension band since
there is no muscle force acting on it converting tension forces into
compressive ones...it may be a "tensioned" implant, but not a tension band.

You may consider a 3.5mm DCP for these unstable situations in the
future...they aren't so flexible...but still also support them with
iliosacral fixation.

If you use such posterior pelvic flexible implants enough, you'll note
displacements especially when used without IS screw support.

The cruciate transymphyseal screws look fancy but one or both of them is not
completely contained in the ramus...at least one (and maybe both) is
extruded...get a CT and you'll see that the right sided one is anteriorly
extruded and paralleling (superimposed upon it on the outlet image) the
inferior ramus, and/or the left sided one extrudes posteriorly but parallels
the ramus...you can adjust the inlet and outlet C-arm tilts intra-op to
demonstrate and avoid this.

The widened symphysis after sufficient posterior fixation may or may not
have needed re-fixation..was it unstable and widened, or just widened?

Some patients need an activity restriction frame...I've used such before but
it just seems mean...but maybe he needs it.

I would've fetched the "sinking screw".

Lots to discuss-

chip

> Drs. Ziran and Routt,
>
> Thanks for the advice on the pelvic malunion. Here is some follow up.
> 1. patient began to drain from left posterior wound.
> 2. removed hardware and performed multiple I and ds until wound looked
> clean.
> 3. IV abx during this time
> 4. Bladder rupture noted on HWR of anterior pelvic ring. Urology
> repaired and kept foley. No suprapubic catheter.
> 5. Once soft tissues looked healthy and CRP trended down, did osteotomy
> of sacrum and fixed with trans-sacral screws and tension band.
> 6. revised front and added ex-fix to supplement because patients bipolar
> disorder seemed to be more profound than I originally anticipated and I
> questioned his compliance. I thought the ex-fix might slow him down.
>
> Xrays attached
>
> I appreciate any constructive criticism you may have.
>
> dpz
>
>
> ________________________________________________________________________
> ____________________________
>
> David P. Zamorano, MD
> Director, Orthopaedic Trauma Service
> UCI Medical Center
> (714) 456-7801 Office
> (714) 456-7547 Fax
>
> -----Original Message-----
> From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On
> Behalf Of Bruce_Ziran@HMIS.ORG
> Sent: Wednesday, April 16, 2008 9:03 AM
> To: ORT-L@www2.aaos.org
> Subject: Re: [ORT-L] Pelvic malunion
>
> Tough break. I like your plan. Only thing I would add is to
> 1) rule out infection
> 2) graft posterior. I like tension band plates. They do very well.
> We are submitting our series currently
> 3) consider fusing symphisis as described by Matta's group.
> Intercalary crest graft after denuding symphysis.
> 4) pray, summon spirits, call a witch doctor.
>
> Bruce H. Ziran, M.D.
> Director of Orthopaedic Trauma
> St. Elizabeth Health Center
> Associate Professor of Orthopaedic Surgery Northeast Ohio Universities
> College of Medicine
>
>
>
>
> "Zamorano, David"
>
> <dzamoran@uci.edu
>
>>
> To
> Sent by: <ORT-L@www2.aaos.org>
>
> ORT-L-owner@www2.
> cc
> aaos.org
>
>
> Subject
> [ORT-L] Pelvic malunion
>
> 04/15/2008 06:21
>
> PM
>
>
>
>
>
> Please respond to
>
> ORT-L@www2.aaos.o
>
> rg
>
>
>
>
>
>
>
>
>
> Looking for some advice.
>
>
> This a a 45 yo male who had an accident in Panama 3 weeks ago when he
> crashed into a tree while on a zip line. He underwernt 3 surgeries in
> Panama over a week period for failed fixation. He now presents to me
> with a malunion. His PMHx is significant for bipolar disorder and DVT.
> He has an IVC currently. He is neuro exam is normal. His posterior
> wounds are healing with minimal erythema. No active drainage. He had
> been on keflex since the surgery.
>
>
> His main complaint is pain. He has already lossed fixation anteriorly
> and is malreduced posteriorly also. My plan was to revise him next
> week.
>
>
> I was planning on going anterior and removing hardware then posterior
> and revising with trans-sacral iliosacral screws and possible tension
> band plate also. I would then flip again and reORIF his symphysis
> anteriorly.
>
>
> Appreciate anyones thoughts.
>
>
> dpz <<pelvis malunion.ppt>>
>
>
> ________________________________________________________________________
> ____________________________
>
>
>
> David P. Zamorano, MD
> Director, Orthopaedic Trauma Service
> UCI Medical Center
> (714) 456-7801 Office
> (714) 456-7547 Fax (See attached file: pelvis malunion.ppt)
>
>
>
>
> CONFIDENTIALITY NOTICE: This message, including any attachments, is for
> the sole use of the intended recipient(s) and may contain confidential
> and privileged information. Any unauthorized review, use, disclosure or
> distribution is prohibited. If you are not the intended recipient,
> please contact the sender by reply e-mail and destroy all copies of the
> original message.

M.L. Chip Routt, Jr.,M.D.
Professor-Orthopedic Surgery
Harborview Medical Center
325 Ninth Avenue
Box 359798
Seattle, WA 98104-2499
phone 206-731-3658
FAX 206-731-3227
--

---
[This E-mail scanned for viruses by Declude Virus]

danschlatterer at yahoo
New User

May 24, 2008, 7:52 AM

Post #7 of 8 (3937 views)
Shortcut

RE: [ORT-L] Pelvic malunion [In reply to]	Can't Post

hello,
in terms of the trans-ilio-sacral-ilio screws, is there an option for a nut/washer on the end of
the screw? especially in weak bone this could potentially help with fixation. chip/bruce, any
experience/insight on this? in terms of symphysis fixation I have gone back on one (mayber two!!)
patients with infections up front and with six screws in a 6 hole plate. the far lateral screws
can be a challenge to remove so I now prefer a 4 hole plate. limited experience but that is my
take on it. and I use the symphysis plate from the stryker system which is probably stronger than
a recon plate. thanks for showing your case, lots of work.
dan
--- Bruce_Ziran@HMIS.ORG wrote:

> Looks much better. Not surprised about the infection.
>
> I use 4.5 mm recon plates for anterior fixation.. Find it to be stronger
> and can bend in-plane enough to get the curve needed. I use a 6 hole which
> allows 3 screws on each side. I would still have fused the front with crest
> graft. But, i like your "X" method. Pretty slick
>
> I worry a little about so many transacral screws, since I beleive that
> space to be rather tight and tough to really know with just fluoro. Have
> you considered a CT to verify?
> The CT you have did not show a lot of graft in the NU site, did you open
> and graft that cleft? You may have but maybe artifact obscures.
>
> Overall, an admirable job with a horrible problem.
>
> Final question, did you summon any witch doctors, use any potions, or
> anything?
>
> Seriously though, looks great.
>
> Bruce H. Ziran, M.D.
> Director of Orthopaedic Trauma
> St. Elizabeth Health Center
> Associate Professor of Orthopaedic Surgery
> Northeast Ohio Universities College of Medicine
>
>
>
> "Zamorano, David"
> <dzamoran@uci.edu
> > To
> Sent by: <ORT-L@www2.aaos.org>
> ORT-L-owner@www2. cc
> aaos.org
> Subject
> RE: [ORT-L] Pelvic malunion
> 05/23/2008 04:14
> PM
>
>
> Please respond to
> ORT-L@www2.aaos.o
> rg
>
>
>
>
>
>
> Drs. Ziran and Routt,
>
> Thanks for the advice on the pelvic malunion. Here is some follow up.
> 1. patient began to drain from left posterior wound.
> 2. removed hardware and performed multiple I and ds until wound looked
> clean.
> 3. IV abx during this time
> 4. Bladder rupture noted on HWR of anterior pelvic ring. Urology
> repaired and kept foley. No suprapubic catheter.
> 5. Once soft tissues looked healthy and CRP trended down, did osteotomy
> of sacrum and fixed with trans-sacral screws and tension band.
> 6. revised front and added ex-fix to supplement because patients bipolar
> disorder seemed to be more profound than I originally anticipated and I
> questioned his compliance. I thought the ex-fix might slow him down.
>
> Xrays attached
>
> I appreciate any constructive criticism you may have.
>
> dpz
>
>
> ________________________________________________________________________
> ____________________________
>
> David P. Zamorano, MD
> Director, Orthopaedic Trauma Service
> UCI Medical Center
> (714) 456-7801 Office
> (714) 456-7547 Fax
>
> -----Original Message-----
> From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On
> Behalf Of Bruce_Ziran@HMIS.ORG
> Sent: Wednesday, April 16, 2008 9:03 AM
> To: ORT-L@www2.aaos.org
> Subject: Re: [ORT-L] Pelvic malunion
>
> Tough break. I like your plan. Only thing I would add is to
> 1) rule out infection
> 2) graft posterior. I like tension band plates. They do very well.
> We are submitting our series currently
> 3) consider fusing symphisis as described by Matta's group.
> Intercalary crest graft after denuding symphysis.
> 4) pray, summon spirits, call a witch doctor.
>
> Bruce H. Ziran, M.D.
> Director of Orthopaedic Trauma
> St. Elizabeth Health Center
> Associate Professor of Orthopaedic Surgery Northeast Ohio Universities
> College of Medicine
>
>
>
>
> "Zamorano, David"
>
> <dzamoran@uci.edu
>
> >
> To
> Sent by: <ORT-L@www2.aaos.org>
>
> ORT-L-owner@www2.
> cc
> aaos.org
>
>
> Subject
> [ORT-L] Pelvic malunion
>
> 04/15/2008 06:21
>
> PM
>
>
>
>
>
> Please respond to
>
> ORT-L@www2.aaos.o
>
> rg
>
>
>
>
>
>
>
>
>
> Looking for some advice.
>
>
> This a a 45 yo male who had an accident in Panama 3 weeks ago when he
> crashed into a tree while on a zip line. He underwernt 3 surgeries in
> Panama over a week period for failed fixation. He now presents to me
> with a malunion. His PMHx is significant for bipolar disorder and DVT.
> He has an IVC currently. He is neuro exam is normal. His posterior
> wounds are healing with minimal erythema. No active drainage. He had
> been on keflex since the surgery.
>
>
> His main complaint is pain. He has already lossed fixation anteriorly
> and is malreduced posteriorly also. My plan was to revise him next
> week.
>
>
> I was planning on going anterior and removing hardware then posterior
> and revising with trans-sacral iliosacral screws and possible tension
> band plate also. I would then flip again and reORIF his symphysis
> anteriorly.
>
>
> Appreciate anyones thoughts.
>
>
> dpz <<pelvis malunion.ppt>>
>
>
> ________________________________________________________________________
> ____________________________
>
>
>
> David P. Zamorano, MD
> Director, Orthopaedic Trauma Service
> UCI Medical Center
> (714) 456-7801 Office
> (714) 456-7547 Fax (See attached file: pelvis malunion.ppt)
>
>
>
>
> CONFIDENTIALITY NOTICE: This message, including any attachments, is for
> the sole use of the intended recipient(s) and may contain confidential
> and privileged information. Any unauthorized review, use, disclosure or
> distribution is prohibited. If you are not the intended recipient,
> please contact the sender by reply e-mail and destroy all copies of the
> original message.
> (See attached file: pelvis malunion.ppt)
>
>
>
> CONFIDENTIALITY NOTICE: This message, including any attachments, is for
> the sole use of the intended recipient(s) and may contain confidential and
> privileged information. Any unauthorized review, use, disclosure or distribution
> is prohibited. If you are not the intended recipient, please contact the
> sender by reply e-mail and destroy all copies of the original message.
>
=== message truncated ===

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mlroutt at u
New User

May 24, 2008, 8:42 AM

Post #8 of 8 (3937 views)
Shortcut

Re: [ORT-L] Pelvic malunion [In reply to]	Can't Post

The screws which progress from ilium thru sacrum and exit the contralateral
ilium (if well located and appropriately sized) do not need a "nut" to
maintain or fortify it...the same is true for screws used between the
posterior iliac areas.

You can use a "nut" if you choose to, but it's hard to understand why when
you've just inserted a 170 mm length 7.3mm diameter screw that exits intact
cortical bone...we used "nuts" in the late 80s and early 90s but I don't
know why (other than we didn't know what we were doing).

The symphysis is a normally flexible-mobile zone....when acutely injured
and plated it requires several weeks to months of structural and relative
stability while "healing"...the implant size, length, etc matter
little...they need to fit and maintain the reduction while it heals...the
symphyseal plate implants can be "tensioned" if contoured and then applied
appropriately...the peripheral plate ends and screws should be oriented to
resist distraction...the surgeon has numerous options for anterior ring
fixation even for previously operated "salvage" instances.

A "probably stronger" symphyseal plate typically means that the screws
disengage (or break) or the screws shake around in the parasymphyseal bone
instead of plate fatigue failure at 6-12 months...the area moves, so some
style of implant fatigue is expected...maybe plate breaks, maybe screws
disengage a bit, maybe screws break, maybe screws shake around in the bone
among others.

Chip

> hello,
> in terms of the trans-ilio-sacral-ilio screws, is there an option for a
> nut/washer on the end of
> the screw? especially in weak bone this could potentially help with fixation.
> chip/bruce, any
> experience/insight on this? in terms of symphysis fixation I have gone back on
> one (mayber two!!)
> patients with infections up front and with six screws in a 6 hole plate. the
> far lateral screws
> can be a challenge to remove so I now prefer a 4 hole plate. limited
> experience but that is my
> take on it. and I use the symphysis plate from the stryker system which is
> probably stronger than
> a recon plate. thanks for showing your case, lots of work.
> dan
> --- Bruce_Ziran@HMIS.ORG wrote:
>
>> Looks much better. Not surprised about the infection.
>>
>> I use 4.5 mm recon plates for anterior fixation.. Find it to be stronger
>> and can bend in-plane enough to get the curve needed. I use a 6 hole which
>> allows 3 screws on each side. I would still have fused the front with crest
>> graft. But, i like your "X" method. Pretty slick
>>
>> I worry a little about so many transacral screws, since I beleive that
>> space to be rather tight and tough to really know with just fluoro. Have
>> you considered a CT to verify?
>> The CT you have did not show a lot of graft in the NU site, did you open
>> and graft that cleft? You may have but maybe artifact obscures.
>>
>> Overall, an admirable job with a horrible problem.
>>
>> Final question, did you summon any witch doctors, use any potions, or
>> anything?
>>
>> Seriously though, looks great.
>>
>> Bruce H. Ziran, M.D.
>> Director of Orthopaedic Trauma
>> St. Elizabeth Health Center
>> Associate Professor of Orthopaedic Surgery
>> Northeast Ohio Universities College of Medicine
>>
>>
>>
>> "Zamorano, David"
>> <dzamoran@uci.edu
>>> To
>> Sent by: <ORT-L@www2.aaos.org>
>> ORT-L-owner@www2. cc
>> aaos.org
>> Subject
>> RE: [ORT-L] Pelvic malunion
>> 05/23/2008 04:14
>> PM
>>
>>
>> Please respond to
>> ORT-L@www2.aaos.o
>> rg
>>
>>
>>
>>
>>
>>
>> Drs. Ziran and Routt,
>>
>> Thanks for the advice on the pelvic malunion. Here is some follow up.
>> 1. patient began to drain from left posterior wound.
>> 2. removed hardware and performed multiple I and ds until wound looked
>> clean.
>> 3. IV abx during this time
>> 4. Bladder rupture noted on HWR of anterior pelvic ring. Urology
>> repaired and kept foley. No suprapubic catheter.
>> 5. Once soft tissues looked healthy and CRP trended down, did osteotomy
>> of sacrum and fixed with trans-sacral screws and tension band.
>> 6. revised front and added ex-fix to supplement because patients bipolar
>> disorder seemed to be more profound than I originally anticipated and I
>> questioned his compliance. I thought the ex-fix might slow him down.
>>
>> Xrays attached
>>
>> I appreciate any constructive criticism you may have.
>>
>> dpz
>>
>>
>> ________________________________________________________________________
>> ____________________________
>>
>> David P. Zamorano, MD
>> Director, Orthopaedic Trauma Service
>> UCI Medical Center
>> (714) 456-7801 Office
>> (714) 456-7547 Fax
>>
>> -----Original Message-----
>> From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On
>> Behalf Of Bruce_Ziran@HMIS.ORG
>> Sent: Wednesday, April 16, 2008 9:03 AM
>> To: ORT-L@www2.aaos.org
>> Subject: Re: [ORT-L] Pelvic malunion
>>
>> Tough break. I like your plan. Only thing I would add is to
>> 1) rule out infection
>> 2) graft posterior. I like tension band plates. They do very well.
>> We are submitting our series currently
>> 3) consider fusing symphisis as described by Matta's group.
>> Intercalary crest graft after denuding symphysis.
>> 4) pray, summon spirits, call a witch doctor.
>>
>> Bruce H. Ziran, M.D.
>> Director of Orthopaedic Trauma
>> St. Elizabeth Health Center
>> Associate Professor of Orthopaedic Surgery Northeast Ohio Universities
>> College of Medicine
>>
>>
>>
>>
>> "Zamorano, David"
>>
>> <dzamoran@uci.edu
>>
>>>
>> To
>> Sent by: <ORT-L@www2.aaos.org>
>>
>> ORT-L-owner@www2.
>> cc
>> aaos.org
>>
>>
>> Subject
>> [ORT-L] Pelvic malunion
>>
>> 04/15/2008 06:21
>>
>> PM
>>
>>
>>
>>
>>
>> Please respond to
>>
>> ORT-L@www2.aaos.o
>>
>> rg
>>
>>
>>
>>
>>
>>
>>
>>
>>
>> Looking for some advice.
>>
>>
>> This a a 45 yo male who had an accident in Panama 3 weeks ago when he
>> crashed into a tree while on a zip line. He underwernt 3 surgeries in
>> Panama over a week period for failed fixation. He now presents to me
>> with a malunion. His PMHx is significant for bipolar disorder and DVT.
>> He has an IVC currently. He is neuro exam is normal. His posterior
>> wounds are healing with minimal erythema. No active drainage. He had
>> been on keflex since the surgery.
>>
>>
>> His main complaint is pain. He has already lossed fixation anteriorly
>> and is malreduced posteriorly also. My plan was to revise him next
>> week.
>>
>>
>> I was planning on going anterior and removing hardware then posterior
>> and revising with trans-sacral iliosacral screws and possible tension
>> band plate also. I would then flip again and reORIF his symphysis
>> anteriorly.
>>
>>
>> Appreciate anyones thoughts.
>>
>>
>> dpz <<pelvis malunion.ppt>>
>>
>>
>> ________________________________________________________________________
>> ____________________________
>>
>>
>>
>> David P. Zamorano, MD
>> Director, Orthopaedic Trauma Service
>> UCI Medical Center
>> (714) 456-7801 Office
>> (714) 456-7547 Fax (See attached file: pelvis malunion.ppt)
>>
>>
>>
>>
>> CONFIDENTIALITY NOTICE: This message, including any attachments, is for
>> the sole use of the intended recipient(s) and may contain confidential
>> and privileged information. Any unauthorized review, use, disclosure or
>> distribution is prohibited. If you are not the intended recipient,
>> please contact the sender by reply e-mail and destroy all copies of the
>> original message.
>> (See attached file: pelvis malunion.ppt)
>>
>>
>>
>> CONFIDENTIALITY NOTICE: This message, including any attachments, is for
>> the sole use of the intended recipient(s) and may contain confidential and
>> privileged information. Any unauthorized review, use, disclosure or
>> distribution
>> is prohibited. If you are not the intended recipient, please contact the
>> sender by reply e-mail and destroy all copies of the original message.
>>
> === message truncated ===
>
>
>
>
> ---
> [This E-mail scanned for viruses by Declude Virus]
>

M.L. Chip Routt, Jr.,M.D.
Professor-Orthopedic Surgery
Harborview Medical Center
325 Ninth Avenue
Box 359798
Seattle, WA 98104-2499
phone 206-731-3658
FAX 206-731-3227
--

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