Post on 07-May-2015
DOUBLE PLATING DOUBLE PLATING WITH WITH BONE GRAFTING IN ASEPTIC BONE GRAFTING IN ASEPTIC NONUNION OF DIAPHYSEAL NONUNION OF DIAPHYSEAL
FRACTURES OF FEMURFRACTURES OF FEMUR
Dr. SAJEEV. P.SDr. SAJEEV. P.SProf. Cherian M. ThomasProf. Cherian M. ThomasSP Fort Hospital , TrivandrumSP Fort Hospital , Trivandrum
AIMAIM
To assess the efficacy of To assess the efficacy of Double PlatingDouble Plating with bone with bone
grafting in achieving union of grafting in achieving union of aseptic ununited fractures of aseptic ununited fractures of
femoral diaphysisfemoral diaphysis
IntroductionIntroduction
10 % of fractures require SECOND 10 % of fractures require SECOND procedure for fracture healingprocedure for fracture healing
Nonunion after ILN is 1 %Nonunion after ILN is 1 %
Higher incidence of nonunion in open Higher incidence of nonunion in open reduction techniquesreduction techniques
Exchange NailingExchange Nailing (commonest ) (commonest )
Ext.fixatorsExt.fixators
DynamisationDynamisation
Plate OsteosynthesisPlate Osteosynthesis
OptionsOptions
Exchange NailingExchange Nailing
Ideal in hypertrophic nonunionIdeal in hypertrophic nonunion
Previous Closed NailingPrevious Closed Nailing
Wide medullary canalWide medullary canal
Weresh et alWeresh et al (2000 ) (2000 )
47 % failure of Exchange Nailing47 % failure of Exchange Nailing
Routine Exchange Nailing may Routine Exchange Nailing may require reevaluationrequire reevaluation
Exchange nail - unsuitableExchange nail - unsuitable
Narrow medullary canalsNarrow medullary canals
Broken implantsBroken implants
Nonavailability of bigger size nailsNonavailability of bigger size nails
Rotational mal alignmentRotational mal alignment
Gap nonunionGap nonunion
Previous open reductionPrevious open reduction
Plate osteosynthesisPlate osteosynthesis
Implant failure is more in plating with a Implant failure is more in plating with a single Platesingle Plate
Double Plating is an established procedure Double Plating is an established procedure in metaphyseal fractures of femurin metaphyseal fractures of femur
Construct of Double plate is Construct of Double plate is 235235 times times stronger than the single plate on stronger than the single plate on compression sidecompression side
In the literature Large series of In the literature Large series of DOUBLE PLATINGDOUBLE PLATING in diaphyseal femoral fractures in diaphyseal femoral fractures
is not reportedis not reported
Materials and MethodsMaterials and Methods
Prospective studyProspective study
Jan 2005 to May 2007 Jan 2005 to May 2007
20 cases20 cases
Follow up 6 to 35 months ( average 24)Follow up 6 to 35 months ( average 24)
ObservationsObservations
16 male and 4 female16 male and 4 female
Average age 44 yrs (24 to 68 )Average age 44 yrs (24 to 68 )
Primary ProcedurePrimary Procedure
ORIF ORIF IL NailIL Nail 1212
ORIF ORIF K nailK nail 55
ORIF ORIF DCSDCS 22
ORIF ORIF DCPDCP 11
Duration of nonunion - 6 months Duration of nonunion - 6 months to 5 years ( Average 16 months )to 5 years ( Average 16 months )
Earlier bone grafting in 5 casesEarlier bone grafting in 5 cases
5 cases of Broken nails5 cases of Broken nails
9 cases had 2 surgeries before9 cases had 2 surgeries before
ProcedureProcedure
Bone Graft From Iliac crestBone Graft From Iliac crest
Previous implants removedPrevious implants removed
Exposure through previous incisionExposure through previous incision
Fracture ends were freshenedFracture ends were freshened
Intervening fibrous tissue sent for C & SIntervening fibrous tissue sent for C & S
Compression Plating with 4.5 Compression Plating with 4.5 broad DCPbroad DCP on lateral aspect with minimum 8 cortices on lateral aspect with minimum 8 cortices purchase on either sidepurchase on either side
Interfragmentary compression whenever Interfragmentary compression whenever possiblepossible
Smaller 4.5 Smaller 4.5 narrow DCPnarrow DCP on anterior on anterior aspect as second plate at right angle to aspect as second plate at right angle to the broad DCPthe broad DCP
Ends of plates should Ends of plates should notnot be at the same be at the same levellevel
Petalling (shingling ) one inch on either Petalling (shingling ) one inch on either sideside
Bone graft laid more on medial aspectBone graft laid more on medial aspect
Suction drain for 1 daySuction drain for 1 day
Knee stiffness manipulated before the Knee stiffness manipulated before the procedureprocedure
Post opPost op
Parenteral antibiotic for 3 daysParenteral antibiotic for 3 days
Non weight bearing crutch walkingNon weight bearing crutch walking
Xray at 6 weeksXray at 6 weeks 10 weeks 10 weeks 14 weeks 14 weeks then at 6 weeks intervalthen at 6 weeks interval
Union assessedUnion assessed
Absence of pain on full weight bearing Absence of pain on full weight bearing
ClinicallyClinically
Radiologically Radiologically
RESULTSRESULTS
19 cases (19 cases (95 95 %% )united without additional )united without additional proceduresprocedures
Average time for union was Average time for union was 5.5 months5.5 months (3 (3 to 9 months )to 9 months )
1 case required further bone grafting1 case required further bone grafting
All cases united eventuallyAll cases united eventually
1 case of Superficial infection1 case of Superficial infection
Average further shortening of 1 cmAverage further shortening of 1 cm
DISCUSSIONDISCUSSION
Treatment of Nonunion of Diaphyseal Treatment of Nonunion of Diaphyseal fractures of Femur by Plate fractures of Femur by Plate
Osteosynthesis has almost been Osteosynthesis has almost been condemned condemned
due to increased risk of infectiondue to increased risk of infection
necessity of opening the nonunion site which necessity of opening the nonunion site which
may further damage the blood supply may further damage the blood supply
due to frequent implant failuredue to frequent implant failure
INFECTIONINFECTION
The review of literature shows that there is The review of literature shows that there is little difference in the reported incidence of little difference in the reported incidence of infection which is between 5 to 10 % infection which is between 5 to 10 % irrespective of the type of implant or irrespective of the type of implant or technique usedtechnique used
In the present study also there was only In the present study also there was only one case of superficial infection ( 5% ) one case of superficial infection ( 5% ) even though all 20 cases had previous even though all 20 cases had previous open reductionsopen reductions
AvascularityAvascularity
Rand et.al compared the effects of Rand et.al compared the effects of compression plating and open nailing after compression plating and open nailing after reaming at the fracture site in tibia of dogsreaming at the fracture site in tibia of dogs
No decreased vascularity of the cortex after No decreased vascularity of the cortex after plate fixationplate fixation
Higher values of blood flow at the fracture Higher values of blood flow at the fracture site after reaming and rod fixation due to site after reaming and rod fixation due to some compensatory mechanismsome compensatory mechanism
Rate of union and maturation of fracture Rate of union and maturation of fracture was slower with rod fixationwas slower with rod fixation
IMPLANT BREAKAGEIMPLANT BREAKAGE
Breakage of plate is another reason for Breakage of plate is another reason for its condemnation. its condemnation.
As the construct of double plate is far As the construct of double plate is far stronger than a single plate, there is stronger than a single plate, there is less chance of failure.less chance of failure.
In our study there was no breakage of In our study there was no breakage of implant. implant.
BONE GRAFTINGBONE GRAFTING Powered reaming in an already reamed Powered reaming in an already reamed medullary canal produces necrotic debris medullary canal produces necrotic debris and micro sequestrae along with some and micro sequestrae along with some osteogenic materialosteogenic material
Cancellous bone has superior osteogenic Cancellous bone has superior osteogenic properties and helps to achieve union in properties and helps to achieve union in less time and is advocated for atrophic less time and is advocated for atrophic nonunionsnonunions
In our study bone grafting was done in all casesIn our study bone grafting was done in all cases
AdvantagesAdvantages
Compression at fracture siteCompression at fracture site
AdvantagesAdvantages
Compression at fracture siteCompression at fracture site
More stable constructMore stable construct
AdvantagesAdvantages
Compression at fracture siteCompression at fracture site
More stable constructMore stable construct
Minimum learning curveMinimum learning curve
AdvantagesAdvantages
Compression at fracture siteCompression at fracture site
More stable constructMore stable construct
Minimum learning curveMinimum learning curve
No need of C – armNo need of C – arm
AdvantagesAdvantages
Compression at fracture siteCompression at fracture site
More stable constructMore stable construct
Minimum learning curveMinimum learning curve
No need of C – armNo need of C – arm
Not technically demandingNot technically demanding
AdvantagesAdvantages
Compression at fracture siteCompression at fracture site
More stable constructMore stable construct
Minimum learning curveMinimum learning curve
No need of C – armNo need of C – arm
Not technically demandingNot technically demanding
No sophisticated instrumentsNo sophisticated instruments
Sound Principles of internal Sound Principles of internal fixation with highly stable fixation with highly stable
construct and provision of construct and provision of an environment conducive an environment conducive
to bone healing has a to bone healing has a significant value in many significant value in many cases of difficult aseptic cases of difficult aseptic
nonunion of femurnonunion of femur
CONCLUSIONCONCLUSION
Double PlatingDouble Plating with Bone grafting with Bone grafting is an effective and easy option is an effective and easy option
in treatment of nonunion of in treatment of nonunion of femoral shaft in which the femoral shaft in which the
fracture site was opened in an fracture site was opened in an earlier procedureearlier procedure
THANK YOUTHANK YOU