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Forum: OWL Lists: OTA:
[ORT-L] tibial nonunion

 
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bonedoctor at ntlworld
New User

Apr 7, 2006, 1:21 PM

Post #1 of 36 (1707 views)
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[ORT-L] tibial nonunion Can't Post
List members I have the following
Male 26
Non smoker 1 year since nailing spiral frac distal diaphysis pain recently
with minor trauma.
Ct confirms nonunion.
Q.
exchange or exchange and graft or other please discuss with evidence if
known?

Simon Reuben


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Peter_Trafton at brown
New User

Apr 7, 2006, 4:33 PM

Post #2 of 36 (1706 views)
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RE: [ORT-L] tibial nonunion [In reply to] Can't Post
Would help to see AP, Lateral and both oblique radiographs - for diagnosis,
decision re whether to operate, and preoperative planning. Do you have good
x-rays before the recent "minor trauma"? Has there been a change? While
exchange nailing is usually successful if no significant bone loss or occult
infection, the technical details of nail length & placement, distal locking,
and perhaps compression, are important. How's the fibula? How's the
alignment?

Parenthetically, CT scans can be misleading re bone union, with
misinterpretation in both directions. I thus rise to support our continued
use of serial, and multiple view x-rays.

/pgt

-----Original Message-----
From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On Behalf
Of Simon Reuben
Sent: Saturday, April 08, 2006 3:22 AM
To: ORT-L@www2.aaos.org
Subject: [ORT-L] tibial nonunion

List members I have the following
Male 26
Non smoker 1 year since nailing spiral frac distal diaphysis pain recently
with minor trauma.
Ct confirms nonunion.
Q.
exchange or exchange and graft or other please discuss with evidence if
known?

Simon Reuben


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alex at orto
New User

Apr 7, 2006, 10:09 PM

Post #3 of 36 (1700 views)
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Re: [ORT-L] tibial nonunion [In reply to] Can't Post
Hello Simon,

Saturday, April 8, 2006, 2:21:50 AM, you wrote:

SR> Male 26
SR> Non smoker 1 year since nailing spiral frac distal diaphysis pain recently
SR> with minor trauma.
SR> Ct confirms nonunion.


Was the nail dynamized and when?

SR> Q.
SR> exchange or exchange and graft or other please discuss with evidence if
SR> known?

I completely agree with Peter's suggestions. At least routine x-rays
are needed for analysis of probable causes of this nonunion, as well
as for further planning. In general exchage closed reamed nailing
would be considered.

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

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bonedoctor at ntlworld
New User

Apr 10, 2006, 1:35 AM

Post #4 of 36 (1684 views)
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RE: [ORT-L] tibial nonunion [In reply to] Can't Post
Thankyou for your interest.
I will send images within next 5 days. I have no access to them immediately.
Simon reuben

-----Original Message-----
From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On Behalf
Of Peter Trafton
Sent: 08 April 2006 00:33
To: ORT-L@www2.aaos.org
Subject: RE: [ORT-L] tibial nonunion

Would help to see AP, Lateral and both oblique radiographs - for diagnosis,
decision re whether to operate, and preoperative planning. Do you have good
x-rays before the recent "minor trauma"? Has there been a change? While
exchange nailing is usually successful if no significant bone loss or occult
infection, the technical details of nail length & placement, distal locking,
and perhaps compression, are important. How's the fibula? How's the
alignment?

Parenthetically, CT scans can be misleading re bone union, with
misinterpretation in both directions. I thus rise to support our continued
use of serial, and multiple view x-rays.

/pgt

-----Original Message-----
From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On Behalf
Of Simon Reuben
Sent: Saturday, April 08, 2006 3:22 AM
To: ORT-L@www2.aaos.org
Subject: [ORT-L] tibial nonunion

List members I have the following
Male 26
Non smoker 1 year since nailing spiral frac distal diaphysis pain recently
with minor trauma.
Ct confirms nonunion.
Q.
exchange or exchange and graft or other please discuss with evidence if
known?

Simon Reuben


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You will be removed from the list and a confirmation message will be sent to
you.



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william.obremskey at Vanderbilt
New User

Sep 21, 2007, 10:00 AM

Post #5 of 36 (1459 views)
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RE: [ORT-L] Tibial Nonunion [In reply to] Can't Post
If hypertrophic, Agree w/ reamed locked IMN. Doubt fibular osteotomy
needed.
What is wrong w/ reamed IMN first time?

OP1 is overkill

William T Obremskey MD MPH
Vanderbilt Orthopedic Trauma
Associate Professor Divsion of Orthopedic Trauma
Director of Orthopedic Trauma Research and Education
Suite 4200 Medical Center East - South Tower
Nashville, TN 37232-8774
615-936-0112- office
615-936-1566- fax

-----Original Message-----
From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On
Behalf Of Jeff Brooks
Sent: Friday, September 21, 2007 11:46 AM
To: ORT-L@www2.aaos.org
Subject: [ORT-L] Tibial Nonunion

A question for the group:

I have a 60 year old female with a tibial nonunion. It was an open
grade II midshaft short oblique Fx (sorry, no XR pics right now),
Rx-ed with immediate I&D and a minimally-reamed static 9mm nail. Soft
tissues healed well.

Fibula healed, tibia now with hypertrophic nonunion.
Anatomically-aligned. Not infected, ESR CRP normal, although patient
is recently diagnosed type II diabetic. She's a NON-smoker. Otherwise
healthy.

I'm planning a reamed exchange nailing, hopefully up to a 12mm nail,
and statically locking it. Also plan on medullary implantation of OP1
while passing the new nail.

QUESTION: Do I need to do a fibular osteotomy or is the reamed locked
exch-nail enough? Would anyone use OP1 also or is it overkill?


Thoughts appreciated!

Jeff

--
Jeffrey J. Brooks, MD
Orthopaedic Surgery & Sports Medicine Center
1290 Summer Street, #4400
Stamford, CT 06905
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frg at myfastmail
New User

Sep 21, 2007, 10:03 AM

Post #6 of 36 (1459 views)
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Re: [ORT-L] Tibial Nonunion [In reply to] Can't Post
Jeff:
The hypertrophic non-union is a signal of failure of biomecanical
problem and
mecanical factor failure. Probably there are inter-fragmentary
movements.
The solution is a more "rigid" system, but with out statically locking
and
don't need OP!. The hyper-trophic pseudo-arthrosis, don't have problem
with biological factor"
the fibular osteotomy is a good option
Best regards
Flavio


----- Original message -----
From: "Jeff Brooks" <jjbrooksmd@gmail.com>
To: ORT-L@www2.aaos.org
Date: Fri, 21 Sep 2007 12:46:19 -0400
Subject: [ORT-L] Tibial Nonunion

A question for the group:

I have a 60 year old female with a tibial nonunion. It was an open
grade II midshaft short oblique Fx (sorry, no XR pics right now),
Rx-ed with immediate I&D and a minimally-reamed static 9mm nail. Soft
tissues healed well.

Fibula healed, tibia now with hypertrophic nonunion.
Anatomically-aligned. Not infected, ESR CRP normal, although patient
is recently diagnosed type II diabetic. She's a NON-smoker. Otherwise
healthy.

I'm planning a reamed exchange nailing, hopefully up to a 12mm nail,
and statically locking it. Also plan on medullary implantation of OP1
while passing the new nail.

QUESTION: Do I need to do a fibular osteotomy or is the reamed locked
exch-nail enough? Would anyone use OP1 also or is it overkill?


Thoughts appreciated!

Jeff

--
Jeffrey J. Brooks, MD
Orthopaedic Surgery & Sports Medicine Center
1290 Summer Street, #4400
Stamford, CT 06905
---
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ti.george at gmail
New User

Sep 21, 2007, 10:08 AM

Post #7 of 36 (1459 views)
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Re: [ORT-L] Tibial Nonunion [In reply to] Can't Post
Jeff my thoughts:

Availability of an X-ray would have been great in giving comments. I
presume that you will eventually post it.
How much is the duration after the trauma?

I would think of doing a fibular short segment resection,dynamisation of the
present nail and ambulation with weight bearing followed by an X-ray at 6-8
weeks before more aggressive intervention.

I have had a few instances where convincing the patient about resecting an
united fibular fracture took some time.But it was worth it.

Best wishes.

Dr T I George
(Dr George T Ittoop,)
Sr Specialist, Orthopaedics,
Ibra Regional Hospital,
PO Box no: 3,
Postal code 413.
North Sharquia Region,
Sultanate of Oman.
Cell phone no: 968 95825197
Land phone no: 968 25587087


janglen at iupui
New User

Sep 21, 2007, 10:19 AM

Post #8 of 36 (1459 views)
Shortcut
RE: [ORT-L] Tibial Nonunion [In reply to] Can't Post
Got any pictures?

Jeff Anglen, MD
Professor and Chairman, Department of Orthopaedics
Indiana University School of Medicine
541 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 Jeff Brooks
Sent: Friday, September 21, 2007 12:46 PM
To: ORT-L@www2.aaos.org
Subject: [ORT-L] Tibial Nonunion

A question for the group:

I have a 60 year old female with a tibial nonunion. It was an open
grade II midshaft short oblique Fx (sorry, no XR pics right now),
Rx-ed with immediate I&D and a minimally-reamed static 9mm nail. Soft
tissues healed well.

Fibula healed, tibia now with hypertrophic nonunion.
Anatomically-aligned. Not infected, ESR CRP normal, although patient
is recently diagnosed type II diabetic. She's a NON-smoker. Otherwise
healthy.

I'm planning a reamed exchange nailing, hopefully up to a 12mm nail,
and statically locking it. Also plan on medullary implantation of OP1
while passing the new nail.

QUESTION: Do I need to do a fibular osteotomy or is the reamed locked
exch-nail enough? Would anyone use OP1 also or is it overkill?


Thoughts appreciated!

Jeff

--
Jeffrey J. Brooks, MD
Orthopaedic Surgery & Sports Medicine Center
1290 Summer Street, #4400
Stamford, CT 06905
---
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janglen at iupui
New User

Sep 21, 2007, 10:24 AM

Post #9 of 36 (1459 views)
Shortcut
RE: [ORT-L] Tibial Nonunion [In reply to] Can't Post
Sorry, didn't see the bit about no pics.

I agree that OP-1 is probably not necessary for a hypertrophic NU.

Also, just to stimulate a little discussion, I think bone stimulators
work well in anatomically aligned hypertrophic tibial NUs. Probably as
well as surgery for cases which have failed a previous operation. The
literature would support that, anyway.

JOA

Jeff Anglen, MD
Professor and Chairman, Department of Orthopaedics
Indiana University School of Medicine
541 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 Jeff Brooks
Sent: Friday, September 21, 2007 12:46 PM
To: ORT-L@www2.aaos.org
Subject: [ORT-L] Tibial Nonunion

A question for the group:

I have a 60 year old female with a tibial nonunion. It was an open
grade II midshaft short oblique Fx (sorry, no XR pics right now),
Rx-ed with immediate I&D and a minimally-reamed static 9mm nail. Soft
tissues healed well.

Fibula healed, tibia now with hypertrophic nonunion.
Anatomically-aligned. Not infected, ESR CRP normal, although patient
is recently diagnosed type II diabetic. She's a NON-smoker. Otherwise
healthy.

I'm planning a reamed exchange nailing, hopefully up to a 12mm nail,
and statically locking it. Also plan on medullary implantation of OP1
while passing the new nail.

QUESTION: Do I need to do a fibular osteotomy or is the reamed locked
exch-nail enough? Would anyone use OP1 also or is it overkill?


Thoughts appreciated!

Jeff

--
Jeffrey J. Brooks, MD
Orthopaedic Surgery & Sports Medicine Center
1290 Summer Street, #4400
Stamford, CT 06905
---
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mmcandrew at siumed
New User

Sep 21, 2007, 10:32 AM

Post #10 of 36 (1459 views)
Shortcut
Re: [ORT-L] Tibial Nonunion [In reply to] Can't Post
i would exchange nail only.

Jeff Brooks wrote:

>A question for the group:
>
>I have a 60 year old female with a tibial nonunion. It was an open
>grade II midshaft short oblique Fx (sorry, no XR pics right now),
>Rx-ed with immediate I&D and a minimally-reamed static 9mm nail. Soft
>tissues healed well.
>
>Fibula healed, tibia now with hypertrophic nonunion.
>Anatomically-aligned. Not infected, ESR CRP normal, although patient
>is recently diagnosed type II diabetic. She's a NON-smoker. Otherwise
>healthy.
>
>I'm planning a reamed exchange nailing, hopefully up to a 12mm nail,
>and statically locking it. Also plan on medullary implantation of OP1
>while passing the new nail.
>
>QUESTION: Do I need to do a fibular osteotomy or is the reamed locked
>exch-nail enough? Would anyone use OP1 also or is it overkill?
>
>
>Thoughts appreciated!
>
>Jeff
>
>
>
---
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demore at iot
New User

Sep 21, 2007, 10:33 AM

Post #11 of 36 (1459 views)
Shortcut
RE: [ORT-L] Tibial Nonunion [In reply to] Can't Post
sorry, i'm a brazilian orthopedist and i don't know what's op1. could you explain me?
thanks

Fri, 21 Sep 2007 12:00:33 -0500, "Obremskey, William T" <william.obremskey@Vanderbilt.Edu> escreveu:

> If hypertrophic, Agree w/ reamed locked IMN. Doubt fibular osteotomy
> needed.
> What is wrong w/ reamed IMN first time?
>
> OP1 is overkill
>
> William T Obremskey MD MPH
> Vanderbilt Orthopedic Trauma
> Associate Professor Divsion of Orthopedic Trauma
> Director of Orthopedic Trauma Research and Education
> Suite 4200 Medical Center East - South Tower
> Nashville, TN 37232-8774
> 615-936-0112- office
> 615-936-1566- fax
>
> -----Original Message-----
> From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On
> Behalf Of Jeff Brooks
> Sent: Friday, September 21, 2007 11:46 AM
> To: ORT-L@www2.aaos.org
> Subject: [ORT-L] Tibial Nonunion
>
> A question for the group:
>
> I have a 60 year old female with a tibial nonunion. It was an open
> grade II midshaft short oblique Fx (sorry, no XR pics right now),
> Rx-ed with immediate I&D and a minimally-reamed static 9mm nail. Soft
> tissues healed well.
>
> Fibula healed, tibia now with hypertrophic nonunion.
> Anatomically-aligned. Not infected, ESR CRP normal, although patient
> is recently diagnosed type II diabetic. She's a NON-smoker. Otherwise
> healthy.
>
> I'm planning a reamed exchange nailing, hopefully up to a 12mm nail,
> and statically locking it. Also plan on medullary implantation of OP1
> while passing the new nail.
>
> QUESTION: Do I need to do a fibular osteotomy or is the reamed locked
> exch-nail enough? Would anyone use OP1 also or is it overkill?
>
>
> Thoughts appreciated!
>
> Jeff
>
> --
> Jeffrey J. Brooks, MD
> Orthopaedic Surgery & Sports Medicine Center
> 1290 Summer Street, #4400
> Stamford, CT 06905
> ---
> [This E-mail scanned for viruses by Declude Virus]
>
> ---
> [This E-mail scanned for viruses by Declude Virus]
>
>
>
>
---
[This E-mail scanned for viruses by Declude Virus]



mmcandrew at siumed
New User

Sep 21, 2007, 10:35 AM

Post #12 of 36 (1459 views)
Shortcut
Re: [ORT-L] Tibial Nonunion [In reply to] Can't Post
we did not get a duration of the nonunion but the name connotes adequate
fatigue of the nail and screws to recommend changing those.

Anglen, Jeffrey O wrote:

>Sorry, didn't see the bit about no pics.
>
>I agree that OP-1 is probably not necessary for a hypertrophic NU.
>
>Also, just to stimulate a little discussion, I think bone stimulators
>work well in anatomically aligned hypertrophic tibial NUs. Probably as
>well as surgery for cases which have failed a previous operation. The
>literature would support that, anyway.
>
>JOA
>
>Jeff Anglen, MD
>Professor and Chairman, Department of Orthopaedics
>Indiana University School of Medicine
>541 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 Jeff Brooks
>Sent: Friday, September 21, 2007 12:46 PM
>To: ORT-L@www2.aaos.org
>Subject: [ORT-L] Tibial Nonunion
>
>A question for the group:
>
>I have a 60 year old female with a tibial nonunion. It was an open
>grade II midshaft short oblique Fx (sorry, no XR pics right now),
>Rx-ed with immediate I&D and a minimally-reamed static 9mm nail. Soft
>tissues healed well.
>
>Fibula healed, tibia now with hypertrophic nonunion.
>Anatomically-aligned. Not infected, ESR CRP normal, although patient
>is recently diagnosed type II diabetic. She's a NON-smoker. Otherwise
>healthy.
>
>I'm planning a reamed exchange nailing, hopefully up to a 12mm nail,
>and statically locking it. Also plan on medullary implantation of OP1
>while passing the new nail.
>
>QUESTION: Do I need to do a fibular osteotomy or is the reamed locked
>exch-nail enough? Would anyone use OP1 also or is it overkill?
>
>
>Thoughts appreciated!
>
>Jeff
>
>
>
---
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jjbrooksmd at gmail
New User

Sep 21, 2007, 10:36 AM

Post #13 of 36 (1459 views)
Shortcut
Re: [ORT-L] Tibial Nonunion [In reply to] Can't Post
Wow! Thanks for the rapid response! I dont have digital camera right
now in the office, but just took these with cell phone camera. I think
they show enough.

Time since injury has been almost 2 years. She was referred to me 6
months ago and have been struggling with worker's comp for approval of
the surgery.

I agree that OP1 may not be worth the expense, but it's going to be
paid for by WC and I have it in my toolbox as almost a freebie, is it
more harmful than it's small effect on diminishing the chances of
needing a second procedure?

Thanks very much.

Jeff


On 9/21/07, Anglen, Jeffrey O <janglen@iupui.edu> wrote:
> Got any pictures?
>
> Jeff Anglen, MD
> Professor and Chairman, Department of Orthopaedics
> Indiana University School of Medicine
> 541 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 Jeff Brooks
> Sent: Friday, September 21, 2007 12:46 PM
> To: ORT-L@www2.aaos.org
> Subject: [ORT-L] Tibial Nonunion
>
> A question for the group:
>
> I have a 60 year old female with a tibial nonunion. It was an open
> grade II midshaft short oblique Fx (sorry, no XR pics right now),
> Rx-ed with immediate I&D and a minimally-reamed static 9mm nail. Soft
> tissues healed well.
>
> Fibula healed, tibia now with hypertrophic nonunion.
> Anatomically-aligned. Not infected, ESR CRP normal, although patient
> is recently diagnosed type II diabetic. She's a NON-smoker. Otherwise
> healthy.
>
> I'm planning a reamed exchange nailing, hopefully up to a 12mm nail,
> and statically locking it. Also plan on medullary implantation of OP1
> while passing the new nail.
>
> QUESTION: Do I need to do a fibular osteotomy or is the reamed locked
> exch-nail enough? Would anyone use OP1 also or is it overkill?
>
>
> Thoughts appreciated!
>
> Jeff
>
> --
> Jeffrey J. Brooks, MD
> Orthopaedic Surgery & Sports Medicine Center
> 1290 Summer Street, #4400
> Stamford, CT 06905
> ---
> [This E-mail scanned for viruses by Declude Virus]
>
> ---
> [This E-mail scanned for viruses by Declude Virus]
>
>


--
Jeffrey J. Brooks, MD
Orthopaedic Surgery & Sports Medicine Center
1290 Summer Street, #4400
Stamford, CT 06905
Attachments: AP.jpg (98.7 KB)
  LAT.jpg (106 KB)


jjbrooksmd at gmail
New User

Sep 21, 2007, 10:40 AM

Post #14 of 36 (1459 views)
Shortcut
Re: [ORT-L] Tibial Nonunion [In reply to] Can't Post
OP1 is BMP-7

pics attached



On 9/21/07, André Demore <demore@iot.com.br> wrote:
> sorry, i'm a brazilian orthopedist and i don't know what's op1. could you explain me?
> thanks
>
> Fri, 21 Sep 2007 12:00:33 -0500, "Obremskey, William T" <william.obremskey@Vanderbilt.Edu> escreveu:
>
>
> > If hypertrophic, Agree w/ reamed locked IMN. Doubt fibular osteotomy
> > needed.
> > What is wrong w/ reamed IMN first time?
> >
> > OP1 is overkill
> >
> > William T Obremskey MD MPH
> > Vanderbilt Orthopedic Trauma
> > Associate Professor Divsion of Orthopedic Trauma
> > Director of Orthopedic Trauma Research and Education
> > Suite 4200 Medical Center East - South Tower
> > Nashville, TN 37232-8774
> > 615-936-0112- office
> > 615-936-1566- fax
> >
> > -----Original Message-----
> > From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On
> > Behalf Of Jeff Brooks
> > Sent: Friday, September 21, 2007 11:46 AM
> > To: ORT-L@www2.aaos.org
> > Subject: [ORT-L] Tibial Nonunion
> >
> > A question for the group:
> >
> > I have a 60 year old female with a tibial nonunion. It was an open
> > grade II midshaft short oblique Fx (sorry, no XR pics right now),
> > Rx-ed with immediate I&D and a minimally-reamed static 9mm nail. Soft
> > tissues healed well.
> >
> > Fibula healed, tibia now with hypertrophic nonunion.
> > Anatomically-aligned. Not infected, ESR CRP normal, although patient
> > is recently diagnosed type II diabetic. She's a NON-smoker. Otherwise
> > healthy.
> >
> > I'm planning a reamed exchange nailing, hopefully up to a 12mm nail,
> > and statically locking it. Also plan on medullary implantation of OP1
> > while passing the new nail.
> >
> > QUESTION: Do I need to do a fibular osteotomy or is the reamed locked
> > exch-nail enough? Would anyone use OP1 also or is it overkill?
> >
> >
> > Thoughts appreciated!
> >
> > Jeff
> >
> > --
> > Jeffrey J. Brooks, MD
> > Orthopaedic Surgery & Sports Medicine Center
> > 1290 Summer Street, #4400
> > Stamford, CT 06905
> > ---
> > [This E-mail scanned for viruses by Declude Virus]
> >
> > ---
> > [This E-mail scanned for viruses by Declude Virus]
> >
> >
> >
> >
> ---
> [This E-mail scanned for viruses by Declude Virus]
>
>


--
Jeffrey J. Brooks, MD
Orthopaedic Surgery & Sports Medicine Center
1290 Summer Street, #4400
Stamford, CT 06905
Attachments: AP.jpg (98.7 KB)
  LAT.jpg (106 KB)


nuno.lopes at netvisao
New User

Sep 21, 2007, 10:43 AM

Post #15 of 36 (1459 views)
Shortcut
RE: [ORT-L] Tibial Nonunion [In reply to] Can't Post
Jeff,

Ream to a 11-12mm non locked nail, resect 1cm of fibula and put the patient
doing full weight bearing

Nuno Craveiro Lopes
Orthopedic Department
Garcia de Orta Hospital
Almada, Portugal

-----Original Message-----
From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On Behalf
Of Jeff Brooks
Sent: sexta-feira, 21 de Setembro de 2007 17:46
To: ORT-L@www2.aaos.org
Subject: [ORT-L] Tibial Nonunion

A question for the group:

I have a 60 year old female with a tibial nonunion. It was an open
grade II midshaft short oblique Fx (sorry, no XR pics right now),
Rx-ed with immediate I&D and a minimally-reamed static 9mm nail. Soft
tissues healed well.

Fibula healed, tibia now with hypertrophic nonunion.
Anatomically-aligned. Not infected, ESR CRP normal, although patient
is recently diagnosed type II diabetic. She's a NON-smoker. Otherwise
healthy.

I'm planning a reamed exchange nailing, hopefully up to a 12mm nail,
and statically locking it. Also plan on medullary implantation of OP1
while passing the new nail.

QUESTION: Do I need to do a fibular osteotomy or is the reamed locked
exch-nail enough? Would anyone use OP1 also or is it overkill?


Thoughts appreciated!

Jeff

--
Jeffrey J. Brooks, MD
Orthopaedic Surgery & Sports Medicine Center
1290 Summer Street, #4400
Stamford, CT 06905
---
[This E-mail scanned for viruses by Declude Virus]


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



william.obremskey at Vanderbilt
New User

Sep 21, 2007, 10:49 AM

Post #16 of 36 (1459 views)
Shortcut
RE: [ORT-L] Tibial Nonunion [In reply to] Can't Post
OP1 would not be harmful, but it is 3cc of paste and you have no way to
deliver to site by putting down canal. If you "have " to use inject it
into fx site. Still do not think you need it.
If you want bone graft, you could use a RIA reamer and capture graft
with a filter and implant at fx site after debridement.

William T Obremskey MD MPH
Vanderbilt Orthopedic Trauma
Associate Professor Divsion of Orthopedic Trauma
Director of Orthopedic Trauma Research and Education
Suite 4200 Medical Center East - South Tower
Nashville, TN 37232-8774
615-936-0112- office
615-936-1566- fax

-----Original Message-----
From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On
Behalf Of Jeff Brooks
Sent: Friday, September 21, 2007 12:37 PM
To: ORT-L@www2.aaos.org
Subject: Re: [ORT-L] Tibial Nonunion

Wow! Thanks for the rapid response! I dont have digital camera right
now in the office, but just took these with cell phone camera. I think
they show enough.

Time since injury has been almost 2 years. She was referred to me 6
months ago and have been struggling with worker's comp for approval of
the surgery.

I agree that OP1 may not be worth the expense, but it's going to be
paid for by WC and I have it in my toolbox as almost a freebie, is it
more harmful than it's small effect on diminishing the chances of
needing a second procedure?

Thanks very much.

Jeff


On 9/21/07, Anglen, Jeffrey O <janglen@iupui.edu> wrote:
> Got any pictures?
>
> Jeff Anglen, MD
> Professor and Chairman, Department of Orthopaedics
> Indiana University School of Medicine
> 541 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 Jeff Brooks
> Sent: Friday, September 21, 2007 12:46 PM
> To: ORT-L@www2.aaos.org
> Subject: [ORT-L] Tibial Nonunion
>
> A question for the group:
>
> I have a 60 year old female with a tibial nonunion. It was an open
> grade II midshaft short oblique Fx (sorry, no XR pics right now),
> Rx-ed with immediate I&D and a minimally-reamed static 9mm nail. Soft
> tissues healed well.
>
> Fibula healed, tibia now with hypertrophic nonunion.
> Anatomically-aligned. Not infected, ESR CRP normal, although patient
> is recently diagnosed type II diabetic. She's a NON-smoker. Otherwise
> healthy.
>
> I'm planning a reamed exchange nailing, hopefully up to a 12mm nail,
> and statically locking it. Also plan on medullary implantation of OP1
> while passing the new nail.
>
> QUESTION: Do I need to do a fibular osteotomy or is the reamed locked
> exch-nail enough? Would anyone use OP1 also or is it overkill?
>
>
> Thoughts appreciated!
>
> Jeff
>
> --
> Jeffrey J. Brooks, MD
> Orthopaedic Surgery & Sports Medicine Center
> 1290 Summer Street, #4400
> Stamford, CT 06905
> ---
> [This E-mail scanned for viruses by Declude Virus]
>
> ---
> [This E-mail scanned for viruses by Declude Virus]
>
>


--
Jeffrey J. Brooks, MD
Orthopaedic Surgery & Sports Medicine Center
1290 Summer Street, #4400
Stamford, CT 06905
---
[This E-mail scanned for viruses by Declude Virus]



jjbrooksmd at gmail
New User

Sep 21, 2007, 10:51 AM

Post #17 of 36 (1459 views)
Shortcut
Re: [ORT-L] Tibial Nonunion [In reply to] Can't Post
OK, but my plan is to ream to 11-12mm statically LOCKED nail (more
stability), and leave that fibula untouched (more stability), with
immediate weight bearing. She's diabetic so maybe OP1 and stimulator
postop. My idea is stable fracture environment (larger nail, locked,
and intact fibula) but wonder if fibula will stress-shield too much.

I looked thru the literature and found little help on locking vs not,
fibular osteotomy vs not, etc so hence my decision to ask the group.

Again, thanks


On 9/21/07, Nuno Craveiro Lopes <nuno.lopes@netvisao.pt> wrote:
> Jeff,
>
> Ream to a 11-12mm non locked nail, resect 1cm of fibula and put the patient
> doing full weight bearing
>
> Nuno Craveiro Lopes
> Orthopedic Department
> Garcia de Orta Hospital
> Almada, Portugal
>
> -----Original Message-----
> From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On Behalf
> Of Jeff Brooks
> Sent: sexta-feira, 21 de Setembro de 2007 17:46
> To: ORT-L@www2.aaos.org
> Subject: [ORT-L] Tibial Nonunion
>
> A question for the group:
>
> I have a 60 year old female with a tibial nonunion. It was an open
> grade II midshaft short oblique Fx (sorry, no XR pics right now),
> Rx-ed with immediate I&D and a minimally-reamed static 9mm nail. Soft
> tissues healed well.
>
> Fibula healed, tibia now with hypertrophic nonunion.
> Anatomically-aligned. Not infected, ESR CRP normal, although patient
> is recently diagnosed type II diabetic. She's a NON-smoker. Otherwise
> healthy.
>
> I'm planning a reamed exchange nailing, hopefully up to a 12mm nail,
> and statically locking it. Also plan on medullary implantation of OP1
> while passing the new nail.
>
> QUESTION: Do I need to do a fibular osteotomy or is the reamed locked
> exch-nail enough? Would anyone use OP1 also or is it overkill?
>
>
> Thoughts appreciated!
>
> Jeff
>
> --
> Jeffrey J. Brooks, MD
> Orthopaedic Surgery & Sports Medicine Center
> 1290 Summer Street, #4400
> Stamford, CT 06905
> ---
> [This E-mail scanned for viruses by Declude Virus]
>
>
> ---
> [This E-mail scanned for viruses by Declude Virus]
>
>


--
Jeffrey J. Brooks, MD
Orthopaedic Surgery & Sports Medicine Center
1290 Summer Street, #4400
Stamford, CT 06905
---
[This E-mail scanned for viruses by Declude Virus]



frg at myfastmail
New User

Sep 21, 2007, 10:52 AM

Post #18 of 36 (1459 views)
Shortcut
Re: [ORT-L] Tibial Nonunion [In reply to] Can't Post
With this picture, don't touches.
Simply take out the distal screw.
Best regards

----- Original message -----
From: "Jeff Brooks" <jjbrooksmd@gmail.com>
To: ORT-L@www2.aaos.org
Date: Fri, 21 Sep 2007 13:36:53 -0400
Subject: Re: [ORT-L] Tibial Nonunion

Wow! Thanks for the rapid response! I dont have digital camera right
now in the office, but just took these with cell phone camera. I think
they show enough.

Time since injury has been almost 2 years. She was referred to me 6
months ago and have been struggling with worker's comp for approval of
the surgery.

I agree that OP1 may not be worth the expense, but it's going to be
paid for by WC and I have it in my toolbox as almost a freebie, is it
more harmful than it's small effect on diminishing the chances of
needing a second procedure?

Thanks very much.

Jeff


On 9/21/07, Anglen, Jeffrey O <janglen@iupui.edu> wrote:
> Got any pictures?
>
> Jeff Anglen, MD
> Professor and Chairman, Department of Orthopaedics
> Indiana University School of Medicine
> 541 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 Jeff Brooks
> Sent: Friday, September 21, 2007 12:46 PM
> To: ORT-L@www2.aaos.org
> Subject: [ORT-L] Tibial Nonunion
>
> A question for the group:
>
> I have a 60 year old female with a tibial nonunion. It was an open
> grade II midshaft short oblique Fx (sorry, no XR pics right now),
> Rx-ed with immediate I&D and a minimally-reamed static 9mm nail. Soft
> tissues healed well.
>
> Fibula healed, tibia now with hypertrophic nonunion.
> Anatomically-aligned. Not infected, ESR CRP normal, although patient
> is recently diagnosed type II diabetic. She's a NON-smoker. Otherwise
> healthy.
>
> I'm planning a reamed exchange nailing, hopefully up to a 12mm nail,
> and statically locking it. Also plan on medullary implantation of OP1
> while passing the new nail.
>
> QUESTION: Do I need to do a fibular osteotomy or is the reamed locked
> exch-nail enough? Would anyone use OP1 also or is it overkill?
>
>
> Thoughts appreciated!
>
> Jeff
>
> --
> Jeffrey J. Brooks, MD
> Orthopaedic Surgery & Sports Medicine Center
> 1290 Summer Street, #4400
> Stamford, CT 06905
> ---
> [This E-mail scanned for viruses by Declude Virus]
>
> ---
> [This E-mail scanned for viruses by Declude Virus]
>
>


--
Jeffrey J. Brooks, MD
Orthopaedic Surgery & Sports Medicine Center
1290 Summer Street, #4400
Stamford, CT 06905
---
[This E-mail scanned for viruses by Declude Virus]



mmcandrew at siumed
New User

Sep 21, 2007, 11:41 AM

Post #19 of 36 (1459 views)
Shortcut
Re: [ORT-L] Tibial Nonunion [In reply to] Can't Post
would not resect the fibula. hypertrophic nonunion not usually
associated with distraction caused by fibula. a tib fib synostosis and
one-bone leg may still be a necessity an option eliminated by fibular
ostectomy.

Nuno Craveiro Lopes wrote:

>Jeff,
>
>Ream to a 11-12mm non locked nail, resect 1cm of fibula and put the patient
>doing full weight bearing
>
>Nuno Craveiro Lopes
>Orthopedic Department
>Garcia de Orta Hospital
>Almada, Portugal
>
>-----Original Message-----
>From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On Behalf
>Of Jeff Brooks
>Sent: sexta-feira, 21 de Setembro de 2007 17:46
>To: ORT-L@www2.aaos.org
>Subject: [ORT-L] Tibial Nonunion
>
>A question for the group:
>
>I have a 60 year old female with a tibial nonunion. It was an open
>grade II midshaft short oblique Fx (sorry, no XR pics right now),
>Rx-ed with immediate I&D and a minimally-reamed static 9mm nail. Soft
>tissues healed well.
>
>Fibula healed, tibia now with hypertrophic nonunion.
>Anatomically-aligned. Not infected, ESR CRP normal, although patient
>is recently diagnosed type II diabetic. She's a NON-smoker. Otherwise
>healthy.
>
>I'm planning a reamed exchange nailing, hopefully up to a 12mm nail,
>and statically locking it. Also plan on medullary implantation of OP1
>while passing the new nail.
>
>QUESTION: Do I need to do a fibular osteotomy or is the reamed locked
>exch-nail enough? Would anyone use OP1 also or is it overkill?
>
>
>Thoughts appreciated!
>
>Jeff
>
>
>
---
[This E-mail scanned for viruses by Declude Virus]



alex61 at gmail
New User

Sep 21, 2007, 11:58 AM

Post #20 of 36 (1459 views)
Shortcut
Re: [ORT-L] Tibial Nonunion [In reply to] Can't Post
Dear Jeff

Friday, September 21, 2007 10:46:19 PM Jeff wrote:

> Rx-ed with immediate I&D and a minimally-reamed static 9mm nail.

In our population 9 mm nail can be inserted into the tibia of a common
60 y.o. without any reaming.

> I'm planning a reamed exchange nailing, hopefully up to a 12mm nail,
> and statically locking it. Also plan on medullary implantation of OP1

> QUESTION: Do I need to do a fibular osteotomy or is the reamed locked
> exch-nail enough? Would anyone use OP1 also or is it overkill?


Hypertrophic nonunion is always lack of stability with enough healing
potential.
Fibular osteotomy/resection is performed to eliminate any obstacle for
compression of the tibial nonunion, isn't it? A statically locked nail
will stronger prevent compression of the site than the intact fibula.
So why cut the fibula but lock the nail statically. In a simple
scenarios - 1)just static locking, or 2)dynamic + osteotomy of the fibula.

But it is a bit boring to use only static or dynamic locking. You'd
either apply a tension force to lengthening by a temporary distractor
and statically lock the nail in the stressed tibia. Or, if extra 2-3
mm shortening is not crucial, you could use compression end cap and
leave the nail dynamized for further compression by weight-bearing. In
both these approaches the fibula can be left intact. Any other
supplement looks unnecessary.

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

---
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Peter_Trafton at brown
New User

Sep 21, 2007, 12:12 PM

Post #21 of 36 (1459 views)
Shortcut
RE: [ORT-L] Tibial Nonunion [In reply to] Can't Post
Hi Jeff,

Looks like she lost little if any bone at the time of her original fracture.
Court-Brown (1994 JBJS 77B:407) demonstrated healing in essentially all
aseptic tibial shaft nonunions treated with exchange IMN (except for
originally 3B open with significant bone loss). Had to do it twice for 4 of
his 33. Regarding locking, he used it rarely (distal or proximal fxs, or
significant instability). He, and others, did not think fibular osteotomy
was essential.

However, your patient's lateral x-ray suggests that the posterior cortex is
quite thin already in the proximal segment. You might want to check that
with obliques, rotational fluoro, or even a CT, because reaming up to 13+mm
could leave a posterior hole thus threatening stability.

After assessing residual bone thickness, I personally would ream only as
much as I thought safe, and might lock only distally (perhaps with
multiplanar screws / ? dynamic slot proximally), and encourage weight
bearing as tolerated. I'd leave the fibula - have never osteotomized it with
exchange nailing, except if required to correct deformity. Healing seems as
predictable for my pts as Charles C-B, et al, have described.

Although diabetes mellitus is clearly associated with various healing
problems, I don't think there are any data that establish BMPs or "bone
stimulators" as (cost-)effective antidotes. Thus I would not use with
exchange nailing.

Best,

/peter

-----Original Message-----
From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On Behalf
Of Jeff Brooks
Sent: Friday, September 21, 2007 1:52 PM
To: ORT-L@www2.aaos.org
Subject: Re: [ORT-L] Tibial Nonunion

OK, but my plan is to ream to 11-12mm statically LOCKED nail (more
stability), and leave that fibula untouched (more stability), with
immediate weight bearing. She's diabetic so maybe OP1 and stimulator
postop. My idea is stable fracture environment (larger nail, locked,
and intact fibula) but wonder if fibula will stress-shield too much.

I looked thru the literature and found little help on locking vs not,
fibular osteotomy vs not, etc so hence my decision to ask the group.

Again, thanks


On 9/21/07, Nuno Craveiro Lopes <nuno.lopes@netvisao.pt> wrote:
> Jeff,
>
> Ream to a 11-12mm non locked nail, resect 1cm of fibula and put the
patient
> doing full weight bearing
>
> Nuno Craveiro Lopes
> Orthopedic Department
> Garcia de Orta Hospital
> Almada, Portugal
>
> -----Original Message-----
> From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On
Behalf
> Of Jeff Brooks
> Sent: sexta-feira, 21 de Setembro de 2007 17:46
> To: ORT-L@www2.aaos.org
> Subject: [ORT-L] Tibial Nonunion
>
> A question for the group:
>
> I have a 60 year old female with a tibial nonunion. It was an open
> grade II midshaft short oblique Fx (sorry, no XR pics right now),
> Rx-ed with immediate I&D and a minimally-reamed static 9mm nail. Soft
> tissues healed well.
>
> Fibula healed, tibia now with hypertrophic nonunion.
> Anatomically-aligned. Not infected, ESR CRP normal, although patient
> is recently diagnosed type II diabetic. She's a NON-smoker. Otherwise
> healthy.
>
> I'm planning a reamed exchange nailing, hopefully up to a 12mm nail,
> and statically locking it. Also plan on medullary implantation of OP1
> while passing the new nail.
>
> QUESTION: Do I need to do a fibular osteotomy or is the reamed locked
> exch-nail enough? Would anyone use OP1 also or is it overkill?
>
>
> Thoughts appreciated!
>
> Jeff
>
> --
> Jeffrey J. Brooks, MD
> Orthopaedic Surgery & Sports Medicine Center
> 1290 Summer Street, #4400
> Stamford, CT 06905
> ---
> [This E-mail scanned for viruses by Declude Virus]
>
>
> ---
> [This E-mail scanned for viruses by Declude Virus]
>
>


--
Jeffrey J. Brooks, MD
Orthopaedic Surgery & Sports Medicine Center
1290 Summer Street, #4400
Stamford, CT 06905
---
[This E-mail scanned for viruses by Declude Virus]

---
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demore at iot
New User

Sep 21, 2007, 12:15 PM

Post #22 of 36 (1459 views)
Shortcut
Re: [ORT-L] Tibial Nonunion [In reply to] Can't Post
thank you very much

Fri, 21 Sep 2007 13:40:30 -0400, "Jeff Brooks" <jjbrooksmd@gmail.com> escreveu:

>
> OP1 is BMP-7
>
> pics attached
>
>
>
> On 9/21/07, André Demore <demore@iot.com.br> wrote:
> > sorry, i'm a brazilian orthopedist and i don't know what's op1. could you explain me?
> > thanks
> >
> > Fri, 21 Sep 2007 12:00:33 -0500, "Obremskey, William T" <william.obremskey@Vanderbilt.Edu> escreveu:
> >
> >
> > > If hypertrophic, Agree w/ reamed locked IMN. Doubt fibular osteotomy
> > > needed.
> > > What is wrong w/ reamed IMN first time?
> > >
> > > OP1 is overkill
> > >
> > > William T Obremskey MD MPH
> > > Vanderbilt Orthopedic Trauma
> > > Associate Professor Divsion of Orthopedic Trauma
> > > Director of Orthopedic Trauma Research and Education
> > > Suite 4200 Medical Center East - South Tower
> > > Nashville, TN 37232-8774
> > > 615-936-0112- office
> > > 615-936-1566- fax
> > >
> > > -----Original Message-----
> > > From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On
> > > Behalf Of Jeff Brooks
> > > Sent: Friday, September 21, 2007 11:46 AM
> > > To: ORT-L@www2.aaos.org
> > > Subject: [ORT-L] Tibial Nonunion
> > >
> > > A question for the group:
> > >
> > > I have a 60 year old female with a tibial nonunion. It was an open
> > > grade II midshaft short oblique Fx (sorry, no XR pics right now),
> > > Rx-ed with immediate I&D and a minimally-reamed static 9mm nail. Soft
> > > tissues healed well.
> > >
> > > Fibula healed, tibia now with hypertrophic nonunion.
> > > Anatomically-aligned. Not infected, ESR CRP normal, although patient
> > > is recently diagnosed type II diabetic. She's a NON-smoker. Otherwise
> > > healthy.
> > >
> > > I'm planning a reamed exchange nailing, hopefully up to a 12mm nail,
> > > and statically locking it. Also plan on medullary implantation of OP1
> > > while passing the new nail.
> > >
> > > QUESTION: Do I need to do a fibular osteotomy or is the reamed locked
> > > exch-nail enough? Would anyone use OP1 also or is it overkill?
> > >
> > >
> > > Thoughts appreciated!
> > >
> > > Jeff
> > >
> > > --
> > > Jeffrey J. Brooks, MD
> > > Orthopaedic Surgery & Sports Medicine Center
> > > 1290 Summer Street, #4400
> > > Stamford, CT 06905
> > > ---
> > > [This E-mail scanned for viruses by Declude Virus]
> > >
> > > ---
> > > [This E-mail scanned for viruses by Declude Virus]
> > >
> > >
> > >
> > >
> > ---
> > [This E-mail scanned for viruses by Declude Virus]
> >
> >
>
>
> --
> Jeffrey J. Brooks, MD
> Orthopaedic Surgery & Sports Medicine Center
> 1290 Summer Street, #4400
> Stamford, CT 06905
>
>
---
[This E-mail scanned for viruses by Declude Virus]



nuno.lopes at netvisao
New User

Sep 21, 2007, 12:22 PM

Post #23 of 36 (1459 views)
Shortcut
RE: [ORT-L] Tibial Nonunion [In reply to] Can't Post
Jeff,

As stated, problem with this fracture is not osteogenic response, but lack
of compression on fracture/pseudarthrosis site, because fibula has united
earlier than tibia and does not permit compression on tibial fracture.
That is way you need not only cu but resect 1cm of fibula (I do it far from
the pseudarthrosis site), ream to stimulate osteogenese (no need of OP, BMP
or stimulator), use of non-locked nail and immediate walking, to compress
the pseudarthrosis site.


Nuno Craveiro Lopes

-----Original Message-----
From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On Behalf
Of Jeff Brooks
Sent: sexta-feira, 21 de Setembro de 2007 18:52
To: ORT-L@www2.aaos.org
Subject: Re: [ORT-L] Tibial Nonunion

OK, but my plan is to ream to 11-12mm statically LOCKED nail (more
stability), and leave that fibula untouched (more stability), with
immediate weight bearing. She's diabetic so maybe OP1 and stimulator
postop. My idea is stable fracture environment (larger nail, locked,
and intact fibula) but wonder if fibula will stress-shield too much.

I looked thru the literature and found little help on locking vs not,
fibular osteotomy vs not, etc so hence my decision to ask the group.

Again, thanks


On 9/21/07, Nuno Craveiro Lopes <nuno.lopes@netvisao.pt> wrote:
> Jeff,
>
> Ream to a 11-12mm non locked nail, resect 1cm of fibula and put the
patient
> doing full weight bearing
>
> Nuno Craveiro Lopes
> Orthopedic Department
> Garcia de Orta Hospital
> Almada, Portugal
>
> -----Original Message-----
> From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On
Behalf
> Of Jeff Brooks
> Sent: sexta-feira, 21 de Setembro de 2007 17:46
> To: ORT-L@www2.aaos.org
> Subject: [ORT-L] Tibial Nonunion
>
> A question for the group:
>
> I have a 60 year old female with a tibial nonunion. It was an open
> grade II midshaft short oblique Fx (sorry, no XR pics right now),
> Rx-ed with immediate I&D and a minimally-reamed static 9mm nail. Soft
> tissues healed well.
>
> Fibula healed, tibia now with hypertrophic nonunion.
> Anatomically-aligned. Not infected, ESR CRP normal, although patient
> is recently diagnosed type II diabetic. She's a NON-smoker. Otherwise
> healthy.
>
> I'm planning a reamed exchange nailing, hopefully up to a 12mm nail,
> and statically locking it. Also plan on medullary implantation of OP1
> while passing the new nail.
>
> QUESTION: Do I need to do a fibular osteotomy or is the reamed locked
> exch-nail enough? Would anyone use OP1 also or is it overkill?
>
>
> Thoughts appreciated!
>
> Jeff
>
> --
> Jeffrey J. Brooks, MD
> Orthopaedic Surgery & Sports Medicine Center
> 1290 Summer Street, #4400
> Stamford, CT 06905
> ---
> [This E-mail scanned for viruses by Declude Virus]
>
>
> ---
> [This E-mail scanned for viruses by Declude Virus]
>
>


--
Jeffrey J. Brooks, MD
Orthopaedic Surgery & Sports Medicine Center
1290 Summer Street, #4400
Stamford, CT 06905
---
[This E-mail scanned for viruses by Declude Virus]


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



jjbrooksmd at gmail
New User

Sep 21, 2007, 12:43 PM

Post #24 of 36 (1459 views)
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Re: [ORT-L] Tibial Nonunion [In reply to] Can't Post
Wow, this is great. Thanks for all the thoughts.

I love this list forum!

So, my initial reason for posting is the issue of fibular osteotomy
and it seems we have two opposing views in this discussion. My gut
feeling is to agree with Dr. Trafton as noted by Court-Brown's study
(thanks for pointing that out, Peter) and stay away from the fibula.

I'm planning on exchange nail, probably to 2mm larger than the 9 in
there, dynamically locked, and not touching the fibula. I'm sure the
healed fibula will "microbend" and transfer some stress to the new
tibia/nail construct medially with postop weight bearing, so will
probably dynamically lock.

This discussion reminds me that this job is partly science, partly "art".



On 9/21/07, Nuno Craveiro Lopes <nuno.lopes@netvisao.pt> wrote:
> Jeff,
>
> As stated, problem with this fracture is not osteogenic response, but lack
> of compression on fracture/pseudarthrosis site, because fibula has united
> earlier than tibia and does not permit compression on tibial fracture.
> That is way you need not only cu but resect 1cm of fibula (I do it far from
> the pseudarthrosis site), ream to stimulate osteogenese (no need of OP, BMP
> or stimulator), use of non-locked nail and immediate walking, to compress
> the pseudarthrosis site.
>
>
> Nuno Craveiro Lopes
>
> -----Original Message-----
> From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On Behalf
> Of Jeff Brooks
> Sent: sexta-feira, 21 de Setembro de 2007 18:52
> To: ORT-L@www2.aaos.org
> Subject: Re: [ORT-L] Tibial Nonunion
>
> OK, but my plan is to ream to 11-12mm statically LOCKED nail (more
> stability), and leave that fibula untouched (more stability), with
> immediate weight bearing. She's diabetic so maybe OP1 and stimulator
> postop. My idea is stable fracture environment (larger nail, locked,
> and intact fibula) but wonder if fibula will stress-shield too much.
>
> I looked thru the literature and found little help on locking vs not,
> fibular osteotomy vs not, etc so hence my decision to ask the group.
>
> Again, thanks
>
>
> On 9/21/07, Nuno Craveiro Lopes <nuno.lopes@netvisao.pt> wrote:
> > Jeff,
> >
> > Ream to a 11-12mm non locked nail, resect 1cm of fibula and put the
> patient
> > doing full weight bearing
> >
> > Nuno Craveiro Lopes
> > Orthopedic Department
> > Garcia de Orta Hospital
> > Almada, Portugal
> >
> > -----Original Message-----
> > From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On
> Behalf
> > Of Jeff Brooks
> > Sent: sexta-feira, 21 de Setembro de 2007 17:46
> > To: ORT-L@www2.aaos.org
> > Subject: [ORT-L] Tibial Nonunion
> >
> > A question for the group:
> >
> > I have a 60 year old female with a tibial nonunion. It was an open
> > grade II midshaft short oblique Fx (sorry, no XR pics right now),
> > Rx-ed with immediate I&D and a minimally-reamed static 9mm nail. Soft
> > tissues healed well.
> >
> > Fibula healed, tibia now with hypertrophic nonunion.
> > Anatomically-aligned. Not infected, ESR CRP normal, although patient
> > is recently diagnosed type II diabetic. She's a NON-smoker. Otherwise
> > healthy.
> >
> > I'm planning a reamed exchange nailing, hopefully up to a 12mm nail,
> > and statically locking it. Also plan on medullary implantation of OP1
> > while passing the new nail.
> >
> > QUESTION: Do I need to do a fibular osteotomy or is the reamed locked
> > exch-nail enough? Would anyone use OP1 also or is it overkill?
> >
> >
> > Thoughts appreciated!
> >
> > Jeff
> >
> > --
> > Jeffrey J. Brooks, MD
> > Orthopaedic Surgery & Sports Medicine Center
> > 1290 Summer Street, #4400
> > Stamford, CT 06905
> > ---
> > [This E-mail scanned for viruses by Declude Virus]
> >
> >
> > ---
> > [This E-mail scanned for viruses by Declude Virus]
> >
> >
>
>
> --
> Jeffrey J. Brooks, MD
> Orthopaedic Surgery & Sports Medicine Center
> 1290 Summer Street, #4400
> Stamford, CT 06905
> ---
> [This E-mail scanned for viruses by Declude Virus]
>
>
> ---
> [This E-mail scanned for viruses by Declude Virus]
>
>


--
Jeffrey J. Brooks, MD
Orthopaedic Surgery & Sports Medicine Center
1290 Summer Street, #4400
Stamford, CT 06905
---
[This E-mail scanned for viruses by Declude Virus]



nswolfso at usc
New User

Sep 21, 2007, 3:11 PM

Post #25 of 36 (1458 views)
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Re: [ORT-L] Tibial Nonunion [In reply to] Can't Post
Jeff:

Would be nice to see X-rays to give an opinion.
I presume you are talking about diaphyseal non union.
In my opinion there are different strategies depends on location, timing , pattern .etc. of the the hypertrophic union. It is my observation that nonunions almost never are anatomically aligned, whether they are hypo, normo or hypertrophic.

So, option for fibular osteotomy I base on different factors related to the particular patient and non union. Sometimes it is osteotomy, sometimes it is osteectomy, sometimes non. With nail as a fixation device and reaming as a bone grafting tool it may not be needed. Is there a synostosis between tibia and fibula? If there is it may require different strategy.

Please show us X rays.

Thanks,

Nik

Would like to see the
Nikolaj Wolfson, MD, FRCSC
Assistant Professor of Orthopaedic Surgery
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: Jeff Brooks <jjbrooksmd@gmail.com>
Date: Friday, September 21, 2007 9:52 am
Subject: [ORT-L] Tibial Nonunion
To: ORT-L@www2.aaos.org

> A question for the group:
>
> I have a 60 year old female with a tibial nonunion. It was an open
> grade II midshaft short oblique Fx (sorry, no XR pics right now),
> Rx-ed with immediate I&D and a minimally-reamed static 9mm nail. Soft
> tissues healed well.
>
> Fibula healed, tibia now with hypertrophic nonunion.
> Anatomically-aligned. Not infected, ESR CRP normal, although patient
> is recently diagnosed type II diabetic. She's a NON-smoker. Otherwise
> healthy.
>
> I'm planning a reamed exchange nailing, hopefully up to a 12mm nail,
> and statically locking it. Also plan on medullary implantation of OP1
> while passing the new nail.
>
> QUESTION: Do I need to do a fibular osteotomy or is the reamed locked
> exch-nail enough? Would anyone use OP1 also or is it overkill?
>
>
> Thoughts appreciated!
>
> Jeff
>
> --
> Jeffrey J. Brooks, MD
> Orthopaedic Surgery & Sports Medicine Center
> 1290 Summer Street, #4400
> Stamford, CT 06905
> ---
> [This E-mail scanned for viruses by Declude Virus]
>
>
---
[This E-mail scanned for viruses by Declude Virus]


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