Date: Wed, 21 Jan 2004 01:33:10 -0800

Subject: Femoral Fracture - Broken Plate

Dear all

Soliciting your opinion on this 42 yr old gentleman, who had a ORIF of his femur about a year back. Says he knows his implant is broken for the last 3 months. Walks with crutches. I'm not sure whether there is much movement at the fracture site. Obviously the choice here is implant removal followed by a) Replating and bone grafting b) IM nailing, but would acute compression result in shortening What about disturbances of endosteal blood supply What would most people opt for.

Thanks a lot.

Dr. M. Amin Chinoy FRCS.

Date: Tue, 20 Jan 2004 16:52:54 -0500

From: James Carr

I would go for plate removal, and perform reamed nailing with a big (13mm or>) locked nail. Issues include preop w/u for infection. Also, you need to plan on a method for re-establishing the medullary canal. I have had best luck with the Kuntscher nonunion chisels, or a spade tip guide wire on power. The distal piece will be a challenge. A last resort would be delivering the bone end in the wound and drilling. I think this case is easiest done in the lateral decubitus position without a fracture table. Length shouldn't be a major issue for a statically locked nail. Bone grafting is generally not required, but may be considered if the biology is poor (at time of surgery), or if large defects present themselves. Plating followed by reamed nailing is generally not a problem.

Jim Carr

James B. Carr, MD
Palmetto Health Orthopedics