rosnarazak
New
1. Failed intramedullary fixation for impending pathologic fracture, right femur.
2. History of metastatic breast cancer to right femur.
OPERATION PERFORMED:
1. Open fixation of distal femoral cortical defect secondary to anterior nail breach, right femur using distal periarticular locking plate and screw fixation.
2. Removal and subsequent reinsertion of antegrade femoral nail with revision of length and screw fixation
IMPLANTS:
1. Synthes trochanteric entry femoral nail, 10 mm in diameter by 320 mm length with 80 mm bladed lag screw.
2. Synthes 6-hole distal periarticular locking plate applied to the right distal femur with 5.0 mm and 4.5 mm locking and cortical screws. One of the screws used to secure the plate traverses and stabilizes the nail through the dynamic hole of the intramedullary rod.
3. Explanted implant--Synthes 10 mm x 360 mm trochanteric femoral nail antegrade fashion with a 75 mm bladed lag screw and a distal 5.0 mm locking screw.
I made incisions over the previous healed locations. Dissection was taken down to bone. Distal locking screw was removed. I was able to work at the nail insertion site and reduced the tension by undoing the static fixation proximally. The bladed lag screw was excised in a standard fashion using extractors. The femoral nail was then excised through attachment proximally and a reverse slap hammer was used to remove the nail.
The intention of removal was to shorten the nail, avoid the anterior cortical defect, knowing that by shortening the nail would have good coverage down to about the distal 3rd, but would need to have a spanning fixation over the anterior cortical defect encompassing the remainder of her distal femur. Using a shorter nail afforded some of the proximal fixation for the known medial calcar lesion and adding the distal fixation would cover the distal portion and avoid having a supracondylar fracture. The open fixation was indicated to be treated for an impending fracture.
Now, we advanced a 10 mm x 320 mm nail, which was a shorter length. We were able to make alignments to allow for fixation of the proximal aspect with another bladed lag screw. The lateral jig was affixed. This was aligned appropriately. The 80 mm bladed lag screw was then advanced gaining an additional 5 mm of purchase and avoiding the subchondral bone. Static fixation was performed proximally.
Distally, I noted that the anterior cortex of the nail was now well seated underneath the cortex and in the intramedullary position without obvious risk for anterior erosion or fracture. I moved distally, templated a plate over top of the anterior femur and felt a 6-hole plate was appropriate. A direct lateral approach was made dissection down from the skin through the subcutaneous tissue to the fascia, which was incised in line with our longitudinal incision. A subperiosteal dissection of the vastus musculature was performed from its posterior attachments. The musculature was mobilized from posterior to anterior on the femur, exposing the lateral shaft. The distal periarticular plate was placed and had a good coverage. A provisional wire afforded fixation to allow for plate application. I then used this provisional pin application to evaluate a locking hole of the plate and whether it would match up with the distal machining of the femoral rod. There was one locking hole that appeared lined up well with the dynamic hole of the femoral nail. Using a freehand technique and a near perfect circle application, I drilled the lateral cortex of the femur, went through the nail in the dynamic slot and then had bicortical purchase. The measurement yielded a 44 mm and a locking screw was placed with good fixation and purchase. Distally, the plate had been previously held with K-wires. The distal metaphyseal and periarticular guides were placed. Guidewires were advanced. The distal most anterior screw fixation was unicortical, four distal screw holes were filled. These had excellent purchase and achieved fixation distal to the cortical defect. Proximally, several centimeters above the distal level of the nail, I placed unicortical screws with good fixation. A locking screw did encompass the dynamic femoral hole distally. Subtle additional metaphyseal screws were placed. This completed fixation of the femur. We now had a femur that had fixation proximally all the way up to the hip and then all the way distal to the distal condylar region.
Copious irrigation was performed and a layered closure ensued with staples being used for the skin.
2. History of metastatic breast cancer to right femur.
OPERATION PERFORMED:
1. Open fixation of distal femoral cortical defect secondary to anterior nail breach, right femur using distal periarticular locking plate and screw fixation.
2. Removal and subsequent reinsertion of antegrade femoral nail with revision of length and screw fixation
IMPLANTS:
1. Synthes trochanteric entry femoral nail, 10 mm in diameter by 320 mm length with 80 mm bladed lag screw.
2. Synthes 6-hole distal periarticular locking plate applied to the right distal femur with 5.0 mm and 4.5 mm locking and cortical screws. One of the screws used to secure the plate traverses and stabilizes the nail through the dynamic hole of the intramedullary rod.
3. Explanted implant--Synthes 10 mm x 360 mm trochanteric femoral nail antegrade fashion with a 75 mm bladed lag screw and a distal 5.0 mm locking screw.
I made incisions over the previous healed locations. Dissection was taken down to bone. Distal locking screw was removed. I was able to work at the nail insertion site and reduced the tension by undoing the static fixation proximally. The bladed lag screw was excised in a standard fashion using extractors. The femoral nail was then excised through attachment proximally and a reverse slap hammer was used to remove the nail.
The intention of removal was to shorten the nail, avoid the anterior cortical defect, knowing that by shortening the nail would have good coverage down to about the distal 3rd, but would need to have a spanning fixation over the anterior cortical defect encompassing the remainder of her distal femur. Using a shorter nail afforded some of the proximal fixation for the known medial calcar lesion and adding the distal fixation would cover the distal portion and avoid having a supracondylar fracture. The open fixation was indicated to be treated for an impending fracture.
Now, we advanced a 10 mm x 320 mm nail, which was a shorter length. We were able to make alignments to allow for fixation of the proximal aspect with another bladed lag screw. The lateral jig was affixed. This was aligned appropriately. The 80 mm bladed lag screw was then advanced gaining an additional 5 mm of purchase and avoiding the subchondral bone. Static fixation was performed proximally.
Distally, I noted that the anterior cortex of the nail was now well seated underneath the cortex and in the intramedullary position without obvious risk for anterior erosion or fracture. I moved distally, templated a plate over top of the anterior femur and felt a 6-hole plate was appropriate. A direct lateral approach was made dissection down from the skin through the subcutaneous tissue to the fascia, which was incised in line with our longitudinal incision. A subperiosteal dissection of the vastus musculature was performed from its posterior attachments. The musculature was mobilized from posterior to anterior on the femur, exposing the lateral shaft. The distal periarticular plate was placed and had a good coverage. A provisional wire afforded fixation to allow for plate application. I then used this provisional pin application to evaluate a locking hole of the plate and whether it would match up with the distal machining of the femoral rod. There was one locking hole that appeared lined up well with the dynamic hole of the femoral nail. Using a freehand technique and a near perfect circle application, I drilled the lateral cortex of the femur, went through the nail in the dynamic slot and then had bicortical purchase. The measurement yielded a 44 mm and a locking screw was placed with good fixation and purchase. Distally, the plate had been previously held with K-wires. The distal metaphyseal and periarticular guides were placed. Guidewires were advanced. The distal most anterior screw fixation was unicortical, four distal screw holes were filled. These had excellent purchase and achieved fixation distal to the cortical defect. Proximally, several centimeters above the distal level of the nail, I placed unicortical screws with good fixation. A locking screw did encompass the dynamic femoral hole distally. Subtle additional metaphyseal screws were placed. This completed fixation of the femur. We now had a femur that had fixation proximally all the way up to the hip and then all the way distal to the distal condylar region.
Copious irrigation was performed and a layered closure ensued with staples being used for the skin.