a 65 years old lady with supracondylar with intercondylar fracture humrus , fracture fixed with locking reconstruction plate with interfragmentary lag screw and two k wires.
Friday, February 20, 2009
TWO WEEK OLD SUPRACONDYLAR FRACTURE HUMRUS
25 yrs male, with supracondylar humrus fracture, treated with reconstruction plate and lag screw
Wednesday, February 18, 2009
EXCHANGE NAILING OR PLATE FIXATION?????
Exchange nailing or plate fixation
orthopedic Trauma Directions 2007; 03; 11-21
Summary
Evidence from nine case series suggests rates of solid union may be lower and the complication frequency higher for exchange nailing of femoral shaft nonunions than with plate fixation. However, no comparative study was found to evaluate the efficacy and safety of these procedures and there were more series describing exchange nailing than plate fixation. Methodologically rigorous comparative studies with larger populations are necessary to establish the long term safety and efficacy of these two operative treatments and to evaluate the superiority of one treatment over another.
Studies for this case
Study 1
Banaszkiewicz PA, Sabboubeh A, McLeod I, et al (2003)Femoral exchange nailing for aseptic non-union: not the end to all problemsInjury; 34(5):349–356.
Study 2
Choi YS, Kim KS (2005)Plate augmentation leaving the nail in situ and bone grafting for non-union of femoral shaft fractures.Int Orthop; 29(5):287–290.
Study 3
Finkemeier CG, Chapman MW (2002)Treatment of femoral diaphyseal nonunions.Clin Orthop Relat Res; (398):223–234.
Study 4
Wu CC, Chen WJ (2002)Exchange nailing for aseptic nonunion of the femoral shaft.Int Orthop; 26(2):80–84.
Study 5
Bellabarba C, Ricci WM, Bolhofner BR (2001)Results of indirect reduction and plating of femoral shaft nonunions after intramedullary nailing.Journal of Orthopaedic Trauma; 15(4):254–263.
Study 6
Hak DJ, Lee SS, Goulet JA, et al (2000)Success of exchange reamed intramedullary nailing for femoral shaft nonunion or delayed union.J Orthop Trauma; 14(3):178–182.
Study 7
Ueng SW, Chao EK, Lee SS, et al (1997)Augmentative plate fixation for the management of femoral nonunion after intramedullary nailing.J Trauma; 43(4):640–644.
Study 8
Weresh MJ, Hakanson R, Stover MD, et al (2000)Failure of exchange reamed intramedullary nails for ununited femoral shaft fracturesJ Orthop Trauma; 14(5):335–338.
Study 9
Wu CC, Chen WJ (1997)Treatment of femoral shaft aseptic nonunions: comparison between closed and open bone-grafting techniquesJ Trauma; 43(1):112–116.
Sampling
A MEDLINE search was conducted for studies published between 1997 and 2006 comparing exchange nailing and plate fixation for treatment of femoral shaft nonunions. No comparative studies were found. Studies were excluded if there were fewer than five patients in any treatment group, if femoral nailing was not the initial treatment for the fracture or if outcomes for nonunion treatment were not separable. Studies were also excluded if there was loss of length of >1.5 cm or 1-stage femoral lengthening was done as part of the treatment. If multiple reports of the same study were found, the primary study report was included. Of 16 case-series identified, 9 remained after these exclusions and are summarized.
Objective
To critically summarize the outcomes and complications for exchange nailing and plating with bone graft for treatment of femoral shaft nonunions.
Common outcome measures
Solid union (radiographic or clinical)
Time to union
Complications (including reoperation for nonunion, malrotation, limited flexion, infection, broken nails, deep venous thrombosis, pulmonary embolism)
Operative time
Interventions
Exchange nailing:
Removal of prior intramedullary nail, over-reaming of intramedullary canal and insertion of exchange nail [Banaszkiewicz, Finkemeier, Wu 02, Hak, Weresh, Wu 97].
Plate fixation:
Plate fixation with and without autologous bone grafting leaving intramedullary nail in situ [Choi, Ueng] Removal of intramedullary nail, plate fixation with and without autologous bone grafting [Bellabarba].
Results
Solid union
Solid union (radiographic or clinical) was achieved in a smaller percentage of patients treated with exchange nailing (75%, range 56%–100%) compared with plate fixation (96%, range 91 –100%) based on pooled estimates.
There were more patients (N = 154) treated by exchange nailing [Banasziewicz, Finkemeier, Wu 02, Hak, Weresh, Wu 97] than those treated with plating (n = 55) [Choi, Bellabarba, Ueng].
Time to union
Pooled estimates of the mean time to achieve union were similar for both treatments: 5.2 months (4–9) when exchange nailing was used, and time to union 5.9 (4.2–7.2) months when plate fixation was used. [Banasziewicz, Wu 02, Wu 97, Choi, Bellabarba, Ueng].
Complications
The frequency of complications appears somewhat higher for nailing than for plate fixation. Since patients may have experienced more than one complication, the total number of complications divided by the total number of patients is reported.
The pooled estimate for the frequency of complications was 27% (0%–67%) with exchange nailing [Banasziewicz, Finkemeier, Wu 02, Weresh, Wu 97] and 18% (0%–30%) with plate fixation [Bellabarba, Ueng].
Complications described included nonunion, malrotation, limited flexion, infection, broken nails, deep venous thrombosis and pulmonary embolism.
Operative time
Pooled estimates for mean operative time were 96 minutes (36–150 minutes) for exchange nailing [Banasziewicz, Wu 97] and 125 minutes (66–164 minutes) for plate fi xation [Choi, Bellabarba].
Mike Bemelman > NetherlandsChristian van der Werken > Netherlands
IM nailing is currently the treatment of choice for the great majority of femoral shaft fractures. Surgery is really minimally invasive, the biomechanics are almost optimal, and the healing rates are very high, especially after reaming of the medullary canal. These benefits are also valid for the treatment of femoral shaft nonunions.
To our surprise the presented analysis revealed some evidence that suggests that the rates of solid union may be lower and the complication frequency higher for exchangenailing of femoral shaft nonunion than with plate fixation in combination with cancellous bone grafting on broad indication.
This evidence is only level IV—based on case series— and possibly even weaker because the presented data is extracted from a small number of mainly retrospective (8/9) clinical studies, in a heterogeneous group of patients who were treated by many different doctors and with a variety of materials and methods.
In our experience, exchange nailing with reaming of the medullary canal has several distinct advantages over plate fixation and bone grafting. Surgery is in general rather simple and elegant with a shorter operation time. Access is through an existing scar while no comorbidity (pain, physical and cosmetic) is added for surgical exposure of the nonunion area and bone graft harvesting. After nailing full weight bearing is generally the rule.
Nevertheless there are still rational indications for plate fixation, eg, nonunions in combination with a deformity, in cases in which the nail and/or locking bolds are broken (especially if the nail is solid) and in situations where the nail is inserted too deeply or through a joint.
orthopedic Trauma Directions 2007; 03; 11-21
Summary
Evidence from nine case series suggests rates of solid union may be lower and the complication frequency higher for exchange nailing of femoral shaft nonunions than with plate fixation. However, no comparative study was found to evaluate the efficacy and safety of these procedures and there were more series describing exchange nailing than plate fixation. Methodologically rigorous comparative studies with larger populations are necessary to establish the long term safety and efficacy of these two operative treatments and to evaluate the superiority of one treatment over another.
Studies for this case
Study 1
Banaszkiewicz PA, Sabboubeh A, McLeod I, et al (2003)Femoral exchange nailing for aseptic non-union: not the end to all problemsInjury; 34(5):349–356.
Study 2
Choi YS, Kim KS (2005)Plate augmentation leaving the nail in situ and bone grafting for non-union of femoral shaft fractures.Int Orthop; 29(5):287–290.
Study 3
Finkemeier CG, Chapman MW (2002)Treatment of femoral diaphyseal nonunions.Clin Orthop Relat Res; (398):223–234.
Study 4
Wu CC, Chen WJ (2002)Exchange nailing for aseptic nonunion of the femoral shaft.Int Orthop; 26(2):80–84.
Study 5
Bellabarba C, Ricci WM, Bolhofner BR (2001)Results of indirect reduction and plating of femoral shaft nonunions after intramedullary nailing.Journal of Orthopaedic Trauma; 15(4):254–263.
Study 6
Hak DJ, Lee SS, Goulet JA, et al (2000)Success of exchange reamed intramedullary nailing for femoral shaft nonunion or delayed union.J Orthop Trauma; 14(3):178–182.
Study 7
Ueng SW, Chao EK, Lee SS, et al (1997)Augmentative plate fixation for the management of femoral nonunion after intramedullary nailing.J Trauma; 43(4):640–644.
Study 8
Weresh MJ, Hakanson R, Stover MD, et al (2000)Failure of exchange reamed intramedullary nails for ununited femoral shaft fracturesJ Orthop Trauma; 14(5):335–338.
Study 9
Wu CC, Chen WJ (1997)Treatment of femoral shaft aseptic nonunions: comparison between closed and open bone-grafting techniquesJ Trauma; 43(1):112–116.
Sampling
A MEDLINE search was conducted for studies published between 1997 and 2006 comparing exchange nailing and plate fixation for treatment of femoral shaft nonunions. No comparative studies were found. Studies were excluded if there were fewer than five patients in any treatment group, if femoral nailing was not the initial treatment for the fracture or if outcomes for nonunion treatment were not separable. Studies were also excluded if there was loss of length of >1.5 cm or 1-stage femoral lengthening was done as part of the treatment. If multiple reports of the same study were found, the primary study report was included. Of 16 case-series identified, 9 remained after these exclusions and are summarized.
Objective
To critically summarize the outcomes and complications for exchange nailing and plating with bone graft for treatment of femoral shaft nonunions.
Common outcome measures
Solid union (radiographic or clinical)
Time to union
Complications (including reoperation for nonunion, malrotation, limited flexion, infection, broken nails, deep venous thrombosis, pulmonary embolism)
Operative time
Interventions
Exchange nailing:
Removal of prior intramedullary nail, over-reaming of intramedullary canal and insertion of exchange nail [Banaszkiewicz, Finkemeier, Wu 02, Hak, Weresh, Wu 97].
Plate fixation:
Plate fixation with and without autologous bone grafting leaving intramedullary nail in situ [Choi, Ueng] Removal of intramedullary nail, plate fixation with and without autologous bone grafting [Bellabarba].
Results
Solid union
Solid union (radiographic or clinical) was achieved in a smaller percentage of patients treated with exchange nailing (75%, range 56%–100%) compared with plate fixation (96%, range 91 –100%) based on pooled estimates.
There were more patients (N = 154) treated by exchange nailing [Banasziewicz, Finkemeier, Wu 02, Hak, Weresh, Wu 97] than those treated with plating (n = 55) [Choi, Bellabarba, Ueng].
Time to union
Pooled estimates of the mean time to achieve union were similar for both treatments: 5.2 months (4–9) when exchange nailing was used, and time to union 5.9 (4.2–7.2) months when plate fixation was used. [Banasziewicz, Wu 02, Wu 97, Choi, Bellabarba, Ueng].
Complications
The frequency of complications appears somewhat higher for nailing than for plate fixation. Since patients may have experienced more than one complication, the total number of complications divided by the total number of patients is reported.
The pooled estimate for the frequency of complications was 27% (0%–67%) with exchange nailing [Banasziewicz, Finkemeier, Wu 02, Weresh, Wu 97] and 18% (0%–30%) with plate fixation [Bellabarba, Ueng].
Complications described included nonunion, malrotation, limited flexion, infection, broken nails, deep venous thrombosis and pulmonary embolism.
Operative time
Pooled estimates for mean operative time were 96 minutes (36–150 minutes) for exchange nailing [Banasziewicz, Wu 97] and 125 minutes (66–164 minutes) for plate fi xation [Choi, Bellabarba].
Mike Bemelman > NetherlandsChristian van der Werken > Netherlands
IM nailing is currently the treatment of choice for the great majority of femoral shaft fractures. Surgery is really minimally invasive, the biomechanics are almost optimal, and the healing rates are very high, especially after reaming of the medullary canal. These benefits are also valid for the treatment of femoral shaft nonunions.
To our surprise the presented analysis revealed some evidence that suggests that the rates of solid union may be lower and the complication frequency higher for exchangenailing of femoral shaft nonunion than with plate fixation in combination with cancellous bone grafting on broad indication.
This evidence is only level IV—based on case series— and possibly even weaker because the presented data is extracted from a small number of mainly retrospective (8/9) clinical studies, in a heterogeneous group of patients who were treated by many different doctors and with a variety of materials and methods.
In our experience, exchange nailing with reaming of the medullary canal has several distinct advantages over plate fixation and bone grafting. Surgery is in general rather simple and elegant with a shorter operation time. Access is through an existing scar while no comorbidity (pain, physical and cosmetic) is added for surgical exposure of the nonunion area and bone graft harvesting. After nailing full weight bearing is generally the rule.
Nevertheless there are still rational indications for plate fixation, eg, nonunions in combination with a deformity, in cases in which the nail and/or locking bolds are broken (especially if the nail is solid) and in situations where the nail is inserted too deeply or through a joint.
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