Click images to enlarge.

Discussion

Date: Thu, 14 Dec 1995 17:48:46
From: hwb@eideti.com (Bill Burman)

Of course what I have to say has to be taken with a mountain of salt as I
have not practiced orthopaedics for 5 years.

What I would do at this point is hike out the 5 mm diaphyseal pin. I can't
believe it is doing much. I would wait a few more weeks for that pin tract
to properly clean itself and seal up. Hopefully it has not been infected.

At that time I ought to have pretty good consolidation of the
metaphyseal-epiphyseal fractures. I would remove from the ends of the bone
any hardware which would block the placement of a reamed interlocking
tibial nail. Large reduction forceps and possibly strategically placed
steinman pins would be used to protect against the possibilty of
metaphyseal-epiphyseal refracture during nail placement. The nail needs to
be carefully started as high as possible and more lateral than usual
because of a valgus tendency for nailings of proximal tibia fxs.

If at this time, I did not see much in the way of diaphyseal callus then
prior to nail placement, I would try to do a closed intramedullary iliac
bone grafting with chest tube ala Chapman, JBJS 62A 1004 1980. I realize
this technique was meant for segmental defects of the femur but this might
be an application for it as well. If I couldn't get much graft in this way,
I would put it in posterolateral - if that did not jeopardize the free flap
in some way.

*****************************

From: EDCCYANG@aol.com
Date: Thu, 14 Dec 1995 22:16:30 -0500

You are to be commended for what you've done so far.  It sounds like the
tibia is well aligned and the soft tissues are healed.  Now you just have to
get the bones healed.

I have extensive experience with the hybrid exfix but never have I seen a
tibia this shattered. (or maybe once)

Now I would try the exogen unit, if you have not done so already.  This is
the ultrasound device which has been working great for us!  Their telephone
# is 1-800-836-0849.

I would hold him in the external fixator as long as the pins are clean.
Hopefully, some of the fractures will heal and you can deal with only one or
two nonunion sites.  Consider plating the fibula and getting the fibula
healed, either simultaneously with a fib-pro-tib operation, and /or
posterolateral bone graft.  I have done all of the above to get tibiae to
heal.

Edward Yang,  MD
Elmhurst Hospital
Mount Sinai

****************

Date: Fri, 15 Dec 1995 10:21
From: Jeffrey Anglen 

Bill, for a guy who hasn't practiced clinically for 5 years, you seem to
have a pretty good grip on treating tibia fractures.  The only thing I would
disagree with is conversion to an intramedullary nail after this period of
time.  I would be too afraid of intramedullary infection from a pin site,
even if the pin sites looked OK.  I don't know if the risk is the same with
hybrid fixators as it is with traditional half-pin fixators - that might make
an interesting study - perhaps someone with more experience with
hybrid fixators has a better feel for the relative risk between pin and
wire sites.

I would continue with hybrid fixation, a little weightbearing and early
bone graft of the diaphysis posterolaterally.  I have no experience with
the accordion technique.

How about you guys at Harborview?  Any thoughts on this tibia
fracture?

****************

Date: Sat, 16 Dec 1995 11:45:10 +0530 (IST)
From: "Dr.ML Parihar" 

the accordion manouevre does not work. to my knowledge this is now
universally accepted, especially in the treatment of non-unions. anyone
disagree?

for a comminuted fracture of the tibia why not consider a
tibia-pro-fibula grafting as described by harmon. while on the subject of
bone grafting i would like to hear fromsurgeons who have used bone marrow
injections for the treatment of nonunion or delayed union.
how much to be aspirated? from where?
where do you inject? into the fracture site or in a cuff fashion around
the fracture site?

 Dr. Mangal Parihar

**************************

Date: Sat, 16 Dec 95 22:04:09 +0500
From: "Alexander N. Chelnokov" 

Hi

>   I have not received any further comments/suggestions on the comminuted
>   tibia case since posting the images of the xrays.  There has been
>   considerable useful discussion of posting images to be easily viewed
>   in various manners.

Sorry but I missed when you pointed the name and location of the image so pls
repeat...

>   I did institute the "accordion" technique of .25 mm compression at
>   6 am and noon; then .25 distraction at 6 pm and midnite.

We use another schedule - 2 weeks of distraction 0.5mm/day and then
2 weeks of compression 1 mm/day...

>  I also started 10 pound weight bearing.

I do not limit weigth-bearing. More exactly, patient should load his leg
as he can. In case of extra-articular fractures of course.

>  I'd like to bone graft it but I'm not sure
>   where to put the bone graft because there are so many pieces.

Do think about marginal corticotomy and slow tension of fragments to bridge
gaps?

*************************

Date: Sun, 17 Dec 95 21:45:18 -0600
From: "Andrew H. Schmidt" 

After seeing the images, I congratulate Tom on his management of the case
thus far.  Our general philosophy at Hennepin County is that once external
fixation is chosen as the treatment, it should be continued to union.  When
possible, we will convert to a nail within the first couple of weeks, but
not beyond this because of the concern for infection.

In my experience with either plateau or plafond fractures plus diaphyseal
extension, the metaphyseal fractures heal and it is the diaphyseal
component that requires grafting.  I have several times removed the hybrid
fixator, curretted the pin sites, performed an open autogenous grafting,
and reapplied a new half-plane unilateral fixator to the diaphysis.  Of
course, if the hybrid frame was still needed I would not replace it.
However, I find the circular hybrid frames to be such a hassle to take care
of, and the patients dislike them so much, that if the juxta-articular
fractures are healed,  I go ahead and convert to a simpler fixator.

  So, that remains my two-cents worth, which I thought I'd post to the whole
group this time since this case has sparked so much interest.

Andy

Andrew H. Schmidt, M.D.
Staff Physician, Hennepin County Medical Center
Clinical Instructor, University of Minnesota

******************************

Date: Tue, 19 Dec 1995 12:31:57 -0500
From: hwb@eideti.com (Bill Burman)

 I see from the discussion that perhaps I am too aggressive and need to
learn how to relax.

I am learning some new things here. Dr. Ed Yang made a plug for ultrasound
stimulation  - Exogen. Here is the abstract of an article published in the
J Bone Joint Surg Am 1994 Jan;76(1):26-34 by the San Antonio group
(Heckman, Ryaby, McCabe J, Frey JJ, Kilcoyne RF).  The study was paid for
by Exogen.

TI  - "Acceleration of tibial fracture-healing by non-invasive,
      low-intensity pulsed ultrasound."
AB  - "Sixty-seven closed or grade-I open fractures of the tibial shaft
      were examined in a prospective, randomized, double-blind
      evaluation of use of a new ultrasound stimulating device as an
      adjunct to conventional treatment with a cast. Thirty-three
      fractures were treated with the active device and thirty-four,
      with a placebo control device. At the end of the treatment, there
      was a statistically significant decrease in the time to clinical
      healing (86 +/- 5.8 days in the active-treatment group compared
      with 114 +/- 10.4 days in the control group) (p = 0.01) and also
      a significant decrease in the time to over-all (clinical and
      radiographic) healing (96 +/- 4.9 days in the active-treatment
      group compared with 154 +/- 13.7 days in the control group) (p =
      0.0001). The patients' compliance with the use of the device was
      excellent, and there were no serious complications related to its
      use. This study confirms earlier animal and clinical studies that
      demonstrated the efficacy of low-intensity ultrasound stimulation
      in the acceleration of the normal fracture-repair process."


Also, Dr. Parihar mentions bone marrow injection. In CORR 313 8-18, 1995,
Dr. John Conolly of Orlando, FL writes :

TI - "Injectable Bone Marrow Preparations to Stimulate Osteogenic Repair."
AB - "The great versatility of bone marrow transplants based on stem cell
activity has been demonstrated successfully for a variety of previously
untreatable hemopoetic conditions. Autologous bone marrow delivered by
percutaneous injection or by a direct transplant as a composite graft also
has proven effective for osteogenic stimulation in a series of 100 skeletal
healing problems, including delayed unions and nonunions of fractures,
arthrodeses, and bone defects. The efficiency of marrow to form bone can be
increased by a number of methods, including differential centrifugation and
composite grafts of marrow with demineralized bone matrix and other
carriers or stimulatory factors."

Dr. Connolly concludes his article by saying :

"Marrow and marrow composite grafts, in this author's experience during the
past 8 years, essentially have eliminated the need for open harvesting and
delivery of autologous bone grafts to stimulate osteogenic repair of
delayed unions, nonunions, arthrodeses and bone defects."

Any references for the Ilizarov "accordion maneuver"?

***************************

Date: Tue, 19 Dec 1995 14:11:27
From: hwb@eideti.com (Bill Burman)

I am transmitting another opinion received via the HWB BBS from

Dr. Joldas Kuldjanov
Visiting Professor at Detroit Medical Center
Professor of Orthopedics & Trauma
University of Tashkent, Uzbekistan

Re:  comminuted tibia fx

Thus far, there appears to be no sign healing because of local factors, the
high energy of trauma, stripping of periosteum, soft tissue damage and poor
contact of bone. I would have initially fixed the fracture with a four ring
Ilizarov fixator. 2 rings in metaphyseal zones (distal and proximal) and 2
rings in the diaphyseal region for the purpose of interfragmentary
compression.

The location of wound and soft tissue damage is unknown to me. It is most
likely anteromedial ?

At this point, I would perform open reduction and internal fixation of
fibula with a long semitubular plate. I would add 2 more rings to the
fixator to bring about reduction and interfrag compression of the tibial
comminution. The type of fixator is immaterial but interfrag compression
would be accomplished by olive wires. Also, I would add bone graft and
placement of this would be in accordance with the location of soft tissue
damage. Weight bearing should be as tolerated and there should be caution
about the possibity of equinus. I am not too worried about pin tract
infection. These smaller pins can be easily replaced. I would use the
accordion technique in the event of atrophic non-union.

Best regards and best wishes with the management of this very difficult case.

***********************

Date: Tue, 19 Dec 1995 22:03:13 -0500
From: OTS1@aol.com Roy

I am somewhat amazed at all this discussion, but find it fascinating. I
would treat this guy to completion with the circular frame until the
articular and metaphyseal components healed. Unfortunately, you would get a
mal-/non-union at the diaphysis which would preclude the use of a later nail,
unless you took it all down. If you needed to do that I would then just plate
him with a long 18 - 22 hole 4.5 narrow DC plate on the medial side. This
would obviate the risk for infection. Furthermore you could graft at the time
of plating. So what's the big deal? Routine case,... right?

Anyway, Exogen is too new to try, and Connally's study is severely flawed,
too many variables, no controls, hypertrophic nonunions rodded and then
marrow injected, nonunion healed. Don't you think it would have healed
without the injection? Of course it would have! Anyway, I like this format.
Anyone going to Russia?

***************************

From: "Alexander N. Chelnokov" 
Date: Wed, 20 Dec 95 06:51:16 +0500


Hi

>   Also, Dr. Parihar mentions bone marrow injection. In CORR 313 8-18, 1995,
>   Dr. Connolly concludes his article by saying :
>
>   past 8 years, essentially have eliminated the need for open harvesting and
>   delivery of autologous bone grafts to stimulate osteogenic repair of
>   delayed unions, nonunions, arthrodeses and bone defects."

;) Told like about Ilizarov.

>   Any references for the Ilizarov "accordion maneuver"?

I used it last years... It really works.
But for the case maybe better would be to add partial corticotomies and
perform closed slow "bridging" by the fragments.
About reference... This must be accessible for you:

TI: Clinical application of the tension-stress effect for limb lengthening.
AU: Ilizarov-GA
AD: Kurgan All-Union Center for Restorative Traumatology and
Orthopaedics, USSR.
SO: Clin-Orthop. 1990 Jan(250): 8-26
AB: For 40 years, the author has been developing a system of
orthopedics, traumatology, and limb lengthening using a circular
transfixion-wire external skeletal fixator, often in combination with
biomechanic methods of stimulating the formation of new osseous tissue
within a widening osteotomy distraction site. The factors important for
neoosteogenesis after osteotomy include: maximum preservation of
extraosseous and medullary blood supply; stable external fixation; a
delay prior to distraction; a distraction rate of 1 mm per day in
frequent small steps; a period of stable neutral fixation after
lengthening; and physiologic use of the elongating limb. For a
successful fixator application, the apparatus must be applied with
consideration given to the number, size, and location of the rings, the
placement and tension on the wires, the technique of wire insertion, the
effect of soft-tissue transfixion on limb use, and the prevention of
bone and joint deformities caused by countertension in soft tissues.
Clinical application of the author's techniques permits stature increase
in certain forms of dwarfism, correction of deformities and limb-length
inequalities, and stump elongation. For many of these applications,
motorized distraction can provide continuous limb lengthening while the
apparatus is on the patient.

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

********************

Date: Thu, 21 Dec 1995 12:46:14 +0530 (IST)
From: "Dr.ML Parihar" 

On Wed, 20 Dec 1995, Alexander N. Chelnokov wrote:

> >   Any references for the Ilizarov "accordion maneuver"?
>
> I used it last years... It really works.

> TI: Clinical application of the tension-stress effect for limb lengthening.
> AU: Ilizarov-GA

for a start lets try to define what we mean by the 'accordion maneuver'.
i have heard it used to talk about alternating cycles of compression
distraction in the same day, compression for a preiod of 1 or more weeks
followed immediately by distraction for an equal duration; and also for
compression followed by a rest period and then a period of distraction.

though the articles from kurgan talk about successes with the 'accordion
maneuver', most other surgeons that i have had occasion to meet either
personally or at meetings have not found it to be a useful maneuver in
atrophic nonunions which is what it 's use is advocated for.

i personally have not had any experience with it.

 Dr. Mangal Parihar

************************

Date: Sat, 23 Dec 95 10:52:54 CST
From: kenneth.d.johnson@mcmail.vanderbilt.edu

This message was originally written on Dec.18, who knows where it has been?

Congratulations on a job well done to date. Hopefully the leg is straight and 
clean, and the proximal metaphysis fracture is now healed.  Now comes the time 
to think!  I agree with others, a nail would not be advisable at present.  
Perhaps the ultrasound would help, it certainly shouldn't hurt!  No experience 
here.  Personally, I think the fixator and posterolateral bone grafting is your 
best bet.  With the proximal fracture you would have to arthrodese the proximal 
tib-fib joint.  I can't appreciate the x-ray well enough to see how far down the 
bone graft would need to go but you could go as far as the distal tib-fib joint.  
Perhaps within 6-8 weeks of grafting you could consider removing the fixator and 
using a cast.  Also if the amount of graft is a question or better a problem, 
one could consider the use of Colagraft to augment the usual autogenous 
cancellous bone graft.

I can say though that I am glad that it is you and not me!
KDJ 

***********

From: hwb@eideti.com (Bill Burman)
Date:    12/21/95  6:58 PM

Alexander,

Maybe I am missing something but I have re-read :

>TI: Clinical application of the tension-stress effect for limb lengthening.
>AU: Ilizarov-GA
>AD: Kurgan All-Union Center for Restorative Traumatology and
>Orthopaedics, USSR.
>SO: Clin-Orthop. 1990 Jan(250): 8-26

and cannot find specific reference to the efficacy of the "accordion"
technique for atrophic nonunion. Are there any series in the Russian
literature which compare the "accordion" technique to controls or other
treatment methods of  nonunion ?

************************

Date: Wed, 20 Dec 1995 18:34:33 -0700 (MST)
From: TDECOSTE@medusa.unm.edu

I'd like to get Dr. Kuldjanov's email address but can't decipher
it from the message I received.
His suggestion for additional diaphyseal wires and rings is most
appealing to me but I'm not sure which pieces of diaphyseal
comminution would be appropriate.
Tom DeCoster.  Merry Christmas

****************************

Date: Sat, 23 Dec 1995
From: hwb@eideti.com (Bill Burman)

In reply to Dr. Tom Decoster's request for more specifics, Dr. Joldas Kuldjanov
 from Detroit Medical Center has faxed to the HWB Foundation a diagram of a 
 preoperative plan illustrating the placement of additional rings and olive 
 wires for posting with the discussion of this case at :

http://www.hwbf.org/hwb/

Click images to enlarge.

*********************

Date: Sun, 24 Dec 95 18:42:09 +0500
From: "Alexander N. Chelnokov" 

Hi
>   > >   Any references for the Ilizarov "accordion maneuver"?
>   > I used it last years... It really works.
>   > TI: Clinical application of the tension-stress effect for limb lengthening.
>   > AU: Ilizarov-GA
>
>   for a start lets try to define what we mean by the 'accordion maneuver'.
>   i have heard it used to talk about alternating cycles of compression
>   distraction in the same day, compression for a preiod of 1 or more weeks
>   followed immediately by distraction for an equal duration; and also for
>   compression followed by a rest period and then a period of distraction.

I mean rather different thing - a cycle of distraction 0.25-0.5 mm/day, 10-15
days and then compression 10-15 days, 0.5-1 mm/day.

>   though the articles from kurgan talk about successes with the 'accordion
>   maneuver', most other surgeons that i have had occasion to meet either
>   personally or at meetings have not found it to be a useful maneuver in
>   atrophic nonunions which is what it 's use is advocated for.
For ^^^^^^^^^^^^^^^^^^ it is not indicated.
Generally, we use this in fractures where we expect union within 2-4 months but
haven't. If atrophic nonunion or union at limited zone occurs - there are some 
ways developed in Kurgan Institute to increase bone diameter and/or bridge 
the gap.

>   Maybe I am missing something but I have re-read :
>   >TI: Clinical application of the tension-stress effect for limb lengthening.
>   >AU: Ilizarov-GA
>   and cannot find specific reference to the efficacy of the "accordion"

This approach anyway is based on "tension-stress effect" which must be
described at that paper...

> Are there any series in the Russian
>   literature which compare the "accordion" technique to controls or other
>   treatment methods of  nonunion ?

I don't remember such narrow focused papers. I have to explore this.

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

*************************

From: Benjamin Frederick Bohren 
Date: Thu, 4 Jan 1996 15:27:04 -0500

Here is the message:
In response for Dr. James Kellam,

First comment, if major muscle damage at time of injury would seriously have
considered amputation.  this is an ideal case for the limb salvage study of
doctor M. Bosse.

since salavage has commenced, would wait 8-12 weeks and do a posterior lateral
bone-graft using ONLY autogenous bone graft. At the first evidence of infection
or failure of grafting would suggest to patient that a below knee amputation
would be the most expedient way to a functional outcome.

Love Jim

****************

From: BOBMOL@aol.com (Bob Molinari)
Date: Fri, 5 Jan 1996 23:27:52 -0500

"I would recommend  grafting the tibia with either allograft banked bone, a
bone graft substitute,  or autogenous  bone graft from the iliac crest
prior to using the ultrasound(exogen). Healing is going to be a problem in
this case secondary to the severe loss of bone. I also would not use a
plate on this fracture as it would require a huge exposure and increase the
risk of infection."