The Use of a Magnetic Intramedullary Nail for Management of a Symptomatic Nonunion Following Shortening Osteotomy to Treat Leg-Length Discrepancy
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Table of Contents
We present the case of a 31-year-old female with a history of juvenile rheumatoid arthritis and uveitis who presented to our department with a leg-length discrepancy and low back pain refractory to conservative management. She underwent a shortening osteotomy on her left femur around an intramedullary nail that went on to nonunion. She underwent exchange nailing with a magnetic intramedullary nailing with autologous bone graft harvest from her affected femoral reamings. The magnetic intramedullary nail was extended 2 cm prior to insertion, and then implanted in the usual fashion with immediate compression in the operating room. Postoperatively the patient underwent a compressive program using the magnetic nail and went on to heal her osteotomy site.
Nonunion; limb-length discrepancy; limb lengthening.
Limb-length discrepancy (LLD) is common, with estimates of prevalence ranging from 40–90% of the population.1,2 Nonoperative management is indicated for patients with LLD of 0–2cm, while those with larger discrepancies or continued symptoms after conservative management can benefit from surgical intervention.3,4 Surgery can consist of either shortening or lengthening and can be stabilized with an intramedullary implant or extramedullary fixation. Additionally, magnetic devices have been introduced for both bone transport in limb salvage or in LLD in pediatric and adult populations.5 There is a risk of complications with surgical intervention of up to 34% in patients undergoing shortening procedure for nonunion or malunion.6 The patient in our care underwent an initial shortening osteotomy around a static intramedullary implant that corrected her LLD but went on to a painful nonunion. After discussion with the patient, the plan was for exchange nailing with a magnetic intramedullary implant and local autologous bone graft to heal her nonunion.
Our patient was a 31-year-old woman with a history of juvenile rheumatoid arthritis (JRA) with uveitis who presented with a 17-mm LLD (left longer than right) focused on the femur causing low back pain. She had a growth arrest procedure performed on her left knee as a child and continued to have symptoms related to her LLD. She had done physical therapy and had two SI joint injections with corticosteroid and local anesthetic, which did not provide durable relief. She was evaluated in the office and standing films confirmed her LLD. She was given a shoe lift, and she trialed this for 7 weeks. However, she was unable to fit the shoe lift into her typical footwear and did not want to wear an external shoe lift and was interested in surgery. She saw her rheumatologist as she was on an infusion of infliximab every 6 weeks for her JRA and agreed to stop the medication in the perioperative period. Preoperatively her BMI was 33.7, she was an American Society of Anaesthesiologist (ASA) score III, and she was a nonsmoker. The risk of nonunion given her immunotherapy was discussed.
The patient presented for surgical management with a shortening osteotomy of the left femur around an intramedullary nail. She was supine on a fracture table for the procedure and had a 9x380-mm trochanteric entry nail inserted in the usual fashion. After the nail was inserted, a subvastus approach was made to the femur with an 18-mm osteotomy completed using a 2.5 drill for pilot holes and a sagittal saw to complete the osteotomy. Electrocautery was used to mark the version on the femur prior to completing the osteotomy. Two screws were fixed proximally, one recon screw in the femoral neck, and one in the lesser trochanter. Two screws, one static and one dynamic were placed in the distal interlocks. Her wound was closed in layers with 1 g of Vancomycin powder placed deep. Her estimated blood loss (EBL) was 100 ml, and the operative time was 238 minutes. Postoperatively she was weightbearing as tolerated and discharged to home on postoperative day 4.
At her first postoperative visit 3 weeks later her wounds were healing well. Unfortunately, she did develop labial pressure wounds after being on the fracture table, which were treated conservatively by gynecology. The plan at that time was to hold her Infliximab infusion for a total of 7–9 weeks postoperatively; however, she had a uveitis flare and needed to resume her infusions earlier. At her next follow up 3 months postoperatively, standing films confirmed that her pelvic tilt and LLD had resolved; however, she was still walking with a walker and had not been able to wean to a crutch secondary to pain. She was seen again 5 months postoperatively with concern for a nonunion, was encouraged to continue a home exercise program and was given a bone stimulator. Nonunion labs at that time were notable for WBC 6.7, ESR 6, 25(OH) Vitamin D of 23, TSH 0.96, PTH 34, Albumin 4.1. Unfortunately, by 6 months she still had pain and no further healing and was indicated for exchange nailing with autologous bone grafting.
She was taken back to the operating room 9.5 months following her index procedure for hardware removal and exchange nailing. She was placed in lateral decubitus with a bean bag positioner. Her hardware was removed using her prior incisions. The osteotomy site was revised with a 3.5 drill making a single lateral hole with multiple medial holes to facilitate autologous bone graft retention. The femur was reamed up to 14 mm, and autologous bone graft was seen depositing on the medial side fluoroscopically and placed on the lateral side of the femur. The osteotomy was completed using an osteotome. A magnetic NuVasive Precice rod was used after being extended 2 cm on the back table prior to insertion. Once the nail was in place, Judet decortication was performed on the lateral femur and reamings were deposited laterally. The wound was closed in layers and sterile dressings placed. Operative time was 233 minutes, and EBL was 500 cc. The patient was touchdown weight bearing postoperatively and was discharged on postoperative day 2.
The patient was seen two weeks postoperatively and her incisions were well-healing, she had a shortening in the office and maintained touchdown weight bearing. This was repeated for two weeks, and she was made weightbearing as tolerated on postoperative week 6. Her immunosuppressives were resumed 4 months postoperatively once bridging callus was seen. At 6 months postoperatively, her osteotomy site had healed, she had improvements in her pain and gait, and she was referred to spine for persistent lumbar back pain. At her most recent follow up 9 months postoperatively, she had weaned from ambulatory aids for short distances, her back pain and leg pain had improved, and she was considering elective hardware removal.
On exam the patient was well-appearing, with pain at the SI joints bilaterally and a 17-mm LLD (left longer than right) confirmed on block testing and standing films. There were no skin changes over the left leg, and she was neurovascularly intact distally.
Imaging results for this patient can be seen in Figures 1–3.
Figure 1. Presentation images with a 17-mm leg-length discrepancy (right shorter than left), from femur.
Figure 2. Three months postoperative standing films with correction of leg-length discrepancy but persistent pain, requiring walker for ambulation.
Figure 3. Most recent follow up, 9 months after surgery. Able to walk short distances without assistive devices, and considering implant removal after 1 year.
LLD is a common problem, with one study by Gordon et al suggesting that only 10% of 573 patients studied had exactly equal leg lengths, while one paper by Gurney et al. quoted a 40–70% prevalence of LLD in the US population.1,2 Specific to the population of patients with JRA, one historic paper by Simon et al. quoted that of 51 patients with follow up over 4 years in 1981 all had a measurable LLD, with 70% having a LLD over 1.5 cm.7 Prior studies have suggested that a LLD over 2 cm may be associated with hip, knee, and spine osteoarthritis, and this has been used as an indication for surgery.1,8
First-line treatment for LLD is nonoperative management, as differences of up to 2 cm are generally accepted to be well-tolerated without intervention. These can be managed with shoe lifts which can either be inserted into regular footwear or in the form of custom-manufactured shoes with height built-in. Surgical management in the adult patient with closed physes involves either a shortening osteotomy or a lengthening or bone transport. Shortening may be pursued for relatively small LLD, while for larger differences such as after trauma or infection, lengthening may be preferred.4 Shortening osteotomies can be done over an intramedullary device or can be performed with stabilization using plate osteosynthesis. Lengthening can be done over standard intramedullary nails, magnetic nails, or ringed fixators.
The goal of treatment is to reduce pain and improve function in the short term, and to possibly prevent further sequelae of hip, knee, or spinal degenerative changes in the long term.
Patients who have symptomatic LLD, whether after congenital or pediatric acquired conditions as in our patient, or after trauma or infection, can be indicated for surgical correction of LLD.
We present the case of a 31-year-old patient with a history of JRA who had a 17-mm LLD (left longer than right), which was refractory to nonoperative treatment including physical therapy and shoe lifts and who sought surgical intervention. She was taken to the operating room for a shortening osteotomy of her left femur over a static trochanteric entry nail. She was supine on a fracture table for a total of 238 minutes with 100 cc EBL. Unfortunately, she developed labial pressure wounds from the time on the traction table that were managed nonoperatively. She required return to the operating room 9.5 months after her index procedure due to a painful nonunion across her osteotomy site. She underwent exchange nailing with a magnetic implant which was done in the lateral decubitus position with an operative time of 233 minutes and EBL of 500 cc. After a period of touchdown weight bearing for 6 weeks, she was made weightbearing as tolerated and went on to heal her nonunion by 6 months after her exchange nailing. Her incisions healed well, and her pain was improved compared to before her procedures, although she still had some symptomatic low back pain.
This case demonstrates some of the challenges of managing LLD in patients. While patients with LLD of <2 cm may be managed nonoperatively, patients with discrepancies of 4–6 cm may be managed with shortening procedures on the longer limb, and patients with greater than 6 cm of discrepancy may benefit from a combination of lengthening the shorter limb and or shortening the longer limb.4 While patients with open physes may use growth arrest at the physis to induce relative shortening, adults with closed physes necessitate an osteotomy for shortening.3 The use of external fixators to lengthen bone via distraction osteogenesis was pioneered by Ilizarov, but later intramedullary devices were introduced as a tool for lengthening, with the advantages of shortened time for lengthening, avoidance of pin tract infections, and maintaining the angular alignment and avoiding fracture after frame removal.9–11 Motorized driven nails which are able to transport bone without the use of external fixators have been used in limb lengthening, with some positive results but a not insignificant complication rate.5,12–14
The management of nonunions remains a challenge in orthopaedics, with traditional teaching dividing nonunions into atrophic nonunions thought to be a problem of biology, hypertrophic nonunion thought to be due to lack of stability, and oligotrophic nonunions with intermediate features. Our patient presented with an atrophic nonunion without obvious laboratory abnormalities. One contributing factor possibly relating to nonunion in this case was the use of her immunologic therapy. While DMARD medications such as infliximab are recommended to be held 5–9 weeks preoperatively in patients undergoing primary total joint arthroplasty, there do not exist clear guidelines regarding the timing of the use of these medications for lengthening or shortening osteotomies.15 While the patient’s rheumatologist was involved in determining an appropriate time to be off her biologic therapy, a uveitis flare necessitated starting the therapy again.
Without modifiable systemic biologic factors, surgical management was planned with exchange nailing and compression. Different options exist for managing nonunion in the femur, from exchange nailing alone compared to compression plating or a combination of the two.16–18 Recently motorized driven nails have been used to provide dynamic compression across a nonunion site, with high rates of union but not insignificant complication profile.6,19 This case highlights an emerging use of motorized intramedullary nailing for management of nonunions following limb-lengthening surgery. Our patient went onto heal her nonunion but still had symptomatic low back pain, highlighting the importance of counseling patients on the risks and benefits of operative vs. nonoperative management of this common condition. Further research is needed to better determine the ideal treatment algorithm for these patients, as well as the timing of immunologic therapy in patients in fracture or nonunion surgery.
- Precice nail, Nuvasive.
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
Citations
- Gordon JE, Davis LE. Leg length discrepancy: the natural history (and what do we really know). J Pediatr Orthop. 2019;39(6):S10-S13. doi:10.1097/BPO.0000000000001396.
- Gurney B, Mermier C, Robergs R, Gibson A, Rivero D. Effects of limb-length discrepancy on gait economy and lower-extremity muscle activity in older adults. J Bone Jt Surg. 2001;83(6):907-915. doi:10.2106/00004623-200106000-00013.
- Hubbard EW, Liu RW, Iobst CA. Understanding skeletal growth and predicting limb-length inequality in pediatric patients. J Am Acad Orthop Surg. 2019;27(9):312-319. doi:10.5435/JAAOS-D-18-00143.
- Stanitski DF. Limb-length inequality: assessment and treatment options. J Am Acad Orthop Surg. 1999;7(3):143-153. doi:10.5435/00124635-199905000-00001.
- Frommer A, Roedl R, Gosheger G, et al. What are the potential benefits and risks of using magnetically driven antegrade intramedullary lengthening nails for femoral lengthening to treat leg length discrepancy? Clin Orthop Relat Res. 2022;480(4):790-803. doi:10.1097/CORR.0000000000002036.
- Zuluaga M, Pérsico F, Medina J, Reina F, Jiménez N, Benedetti F. Precice nail for the management of posttraumatic bone defects with nonunion or malunion: experience from a Latin American center. Injury. 2023;54(May). doi:10.1016/j.injury.2023.110838.
- Simon S, Whiffen J, Shapiro F. Leg-length discrepancies in monoarticular and pauciarticular juvenile rheumatoid arthritis. J Bone Jt Surg - Ser A. 1981;63(2):209-215. doi:10.2106/00004623-198163020-00005.
- Subotnick SI. Limb length discrepancies of the lower extremity (the short leg syndrome). J Orthop Sports Phys Ther. 1981;3(1):11-16. doi:10.2519/jospt.1981.3.1.11.
- Calder PR, Wright J, Goodier WD. An update on the intramedullary implant in limb lengthening: a quinquennial review part 2: extending surgical indications and further innovation. Injury. 2022;53:S88-S94. doi:10.1016/j.injury.2022.06.024.
- Calder PR, Wright J, Goodier WD. An update on the intramedullary implant in limb lengthening: a quinquennial review Part 1: the further influence of the intramedullary nail in limb lengthening. Injury. 2022;53:S81-S87. doi:10.1016/j.injury.2022.06.028.
- Hosny GA. Limb lengthening history, evolution, complications and current concepts. J Orthop Traumatol. 2020;21(1). doi:10.1186/s10195-019-0541-3.
- Frost MW, Rahbek O, Traerup J, Ceccotti AA, Kold S. Systematic review of complications with externally controlled motorized intramedullary bone lengthening nails (Fitbone and Precice) in 983 segments. Acta Orthop. 2020;92(1):120-127. doi:10.1080/17453674.2020.1835321.
- Hammouda AI, Jauregui JJ, Gesheff MG, Standard SC, Conway JD, Herzenberg JE. Treatment of post-traumatic femoral discrepancy with Precice magnetic-powered intramedullary lengthening nails. J Orthop Trauma. 2017;31(7):369-374. doi:10.1097/BOT.0000000000000828.
- Wiebking U, Liodakis E, Kenawey M, Krettek C. Limb lengthening using the Precice nail system: complications and results. Arch Trauma Res. 2016;5(4). doi:10.5812/atr.36273.
- Goodman SM, Springer BD, Chen AF, et al. 2022 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty. Arthritis Care Res. 2022;74(9):1399-1408. doi:10.1002/acr.24893.
- Marquez-Lara A, David Luo T, Senehi R, Aneja A, Beard HR, Carroll EA. Exchange nailing for hypertrophic femoral nonunion. J Orthop Trauma. 2017;31(8):S23-S25. doi:10.1097/BOT.0000000000000905.
- Brinker MR, O’Connor DP. Management of aseptic tibial and femoral diaphyseal nonunions without bony defects. Orthop Clin North Am. 2016;47(1):67-75. doi:10.1016/j.ocl.2015.08.009.
- Lynch JR, Taitsman LA, Barei DP, Nork SE. Femoral nonunion: risk factors and treatment options. J Am Acad Orthop Surg. 2008;16(2):88-97. doi:10.5435/00124635-200802000-00006.
- Fragomen AT, Wellman D, Rozbruch SR. The Precice magnetic IM compression nail for long bone nonunions: a preliminary report. Arch Orthop Trauma Surg. 2019;139(11):1551-1560. doi:10.1007/s00402-019-03225-4.
Cite this article
Grisdela PT Jr, Suneja N. The use of a magnetic intramedullary nail for management of a symptomatic nonunion following shortening osteotomy to treat leg-length discrepancy. J Med Insight. 2024;2024(446). doi:10.24296/jomi/446.
Procedure Outline
Table of Contents
- 1. Introduction
- 2. Examination and Subvastus Approach to the Femur
- 3. Examination and X-Ray of Nonunion
- 4. Removal of Intramedullary Nail
- 5. Venting Holes in Nonunion Site for Bone Graft
- 6. Sequential Reaming and Autologous Bone Graft Harvesting
- 7. Placement of the Precice Magnetic Intramedullary Compression Nail
- 8. Intraoperative Compression of the Precice Nail
- 9. Bone Grafting
- 10. Final X-Rays
- 11. Closure
- 12. Post-op Remarks
Transcription
CHAPTER 1
Hi, my name is Nishant Suneja. I'm an orthopaedic trauma surgeon here at the Brigham and Women's Hospital in Boston, and I'm faculty at Harvard Medical School. Today, we have a patient, she's a 32-year-old female, who has significant leg-length discrepancy and pelvic tilt. And this is been bothering her for many, many years. So her initial surgery that was done many months ago was a shortening osteotomy of her femur. We shortened her femur and fixed it with an intermedullary nail. Subsequently, her leg lengths were good and her pelvic tilt was resolved, but she went on to develop a nonunion. She was at a high-risk for getting a nonunion because she has medical conditions such as rheumatoid arthritis for what she's on an immunosuppressant, medications like Remicade. And she also has uveitis which gets treated with immunosuppressants. So, she was at the high-risk for nonunion, which she did develop. So, to treat this nonunion, we had a few options. Her nonunion was atrophic or oligotrophic. There wasn't much callous there, so we thought upsizing the nail or just adding more fixation probably would not fix this problem. So options we had were leaving the nail in place and adding a plate and compressing it. We would also dynamize the nail along with this. Dynamization alone, in this case, wouldn't have worked well again because there was no callous buildup and we were worried that her biology was missing, especially her being on immunosuppressants. So, we chose a nontraditional way of fixing this nonunion by a using a Precice nail, which we lengthened prior to placing it into her femur and subsequently shortened it in order to compress the nonunion. We also plan on decorticating the cortices and adding bone graft, which is from her medullary canal or also synthetic bone graft. So, for nonunions, traditionally, we always will have a nonunion workup, including labs, which will decipher if she has any metabolic abnormalities, including her thyroid, parathyroid hormone, her estrogen levels, if there's an infection that's been ongoing or not. We ruled out all these scenarios so we finally realized that the biology was missing. But, you know, medically, there was nothing more optimization that we could do for her. So, for this surgery she has an intermedullary nail in place and she has a diaphyseal nonunion. So, our plan in this specific case would be to take the intermedullary rod out. We would use the same incisions we used before, perform a subvastus approach, get the rod out, maintain her rotation, which will probably get rotated because the fibrous tissue of the nonunion would keep it in place. We would mark her rotation, take down the nonunion side, ream the intermedullary canal to a bigger sized nail to give her some more stability. Then we would place the new Precice nail that would be elongated outside and then put it in, add the bone graft, shorten the nail while we're in surgery, and then add more further bone graft to add some more biology.
CHAPTER 2
Incision. All right, so this is a 32-year-old female who has significant leg-length discrepancy and a pelvic tilt that was troubling her for many years. Lap, please. We performed a shortening osteotomy on her and her pelvic tilt and her leg length is now correct. However, she has developed what we have is an atrophic nonunion of her femoral diaphysis. She was on immunosuppressants all her life for rheumatoid arthritis including Remicade and that's a huge risk factor for her developing a nonunion. Today, we are here for our repair of her nonunion and we're going to do that with a compression nail. We have chief resident here, Phil, who's taking away the scar tissue from our previous surgery. Okay, so we just removed the scar tissue. She had some keloid formation from her previous surgery. So this is a direct lateral approach to her femur. We'll do a subvastus approach here, going through fat and previous scar tissue. Tony, can we get the Norfolk retractor? Excellent, just make sure we don't slide to close to you. All right, can I get a Cobb, please? Just taking off the fat from the IT band. Try to find the previous incision. It's much harder in a revision case like this because there's a lot of scar tissue built up on the IT band. It's important is to find that layer, so when we're closing it, it's much easier. Okay, there it is. Okay. Tony, do we have those Norfolk retractors yet? Bovie. A lot more scar tissue in these cases. Making it slightly harder compared to first approach. Okay. So, that's your IT band. I think we take it right along this line right there. Okay, what do you need? A Bonney, please. Take this line. Yeah. A little deeper. It's going to be thicker compared to the previous surgery. There's a muscle there. Okay. Are you sure you're through? That's vastus, perfect. Okay. Good, we're incising the IT band here and the muscle that's bulging below, that's the vastus letralis. Keep going, more proximal. Okay, let's put this slightly deeper. All right, so now we'll be doing a subvastus approach, taking the vastus muscle anteriorly. We'll leave it a little cuff for repair for the septum at the end. So, feel the septum with your finger. So you're right at the septum, right there. See that? Septum's right there. So taking it right at this level, leaving a little cuff. I think if you take it right at that level, you'll avoid the perforators. Tony, do you have a Bonney pickups for me? A little left? Yeah, that's perfect. Is she paralyzed? Yep. Thank you. Suction. Just the fascia. Good, excellent. Keep going. So there's scar there. So this is exactly same approach last time. Keep posterior. That's muscle, right? Keep going. Keep opening the fascia. Tony, do you have a rake? Bit more posterior. See that scar there? Pull it forward. Yeah. So we're still going through the vastus muscle, leaving about a centimeter of vastus behind to the posterior septum. That way we don't run into peripherals going into the posterior compartment. Keep going proximal and distal. More proximal. More proximal. Yeah, finish that. Okay, I'll help you. Excellent, come distal now. More posterior. That's it. Good, yep, so keep going. Just keep going proximal and distal, so we don't just go central. Now, once the bone is exposed we'll get an X-Ray. Tony, can you come with the C-Arm, please? Okay. More distal, right here. And when you have a chance, we'll take a long Bovie tip. Keep going distal. So you're not going to get much bleeding if you're going through scar tissue, right? Very good. This is the area where you have bleeding so be careful. Make sure you can feel bone. That's bone right there. So this bone goes through this area. You finished proximally? Or you want me to do it? I can see better from here. Yeah, keep going, hold on, there's a perforator right there. Right on bone, which is good. Okay, go distal. Go ahead and finish this. Can we get the table down, please? Can we get table down? Who's up there? Anesthesia? And then don't go underneath the bone. Okay, I think it's pretty good. Okay, let's get a Cobb. And then, Tony, we'll use a Bennett retractor after this. Good, good, good, good. What do you want for retraction? Bennett. Bennett. Yeah, the big Bennett. Wanna Bovie that more or? That's it. Just maybe get a little cut over here, so you can get in. Just a bit of bleeding. That's the femur bone right there you can see. Very nice. All right, Tony, we'll take the Bennett now. Okay, you can come out. There you go. So that is the subvastus approach to the femur. That's the femur, that's the old nonunion site. We moving the vastus muscle out of the way, continuing with our subvastus exposure through the same scar tissue from the previous surgery. Okay, go ahead, expose a little bit more proximal. Suction. Switch with me, take this guy. I got that guy. The femoral shaft is exposed laterally and that's the completion of our subvastus approach. Okay, can we come in with X-Ray, please? Sure. We'll go straight to a lateral, shot there.
CHAPTER 3
So that's her nonunion site right there. Suction. That's her nonunion site. Shot there. All right, so you can see this is a more of an atrophic and oligotrophic nonunion. There's no callous buildup. All right, so we'll go ahead and take this rod out now. Okay. That's causing the nonunion. Let's go.
CHAPTER 4
So it's a diaphyseal nonunion. Some ways of treating diaphyseal nonunion is to dynamize the nail, you know, but in this case, when we have no callous, even upsizing the nail may not be that beneficial. The nonunion bone wants reduction of fracture gap, more stability and stimulus to bone growth. Either with a bone graft or constant compression. Go ahead. So we're using the old incision from which the recon nail was placed. We'll use the same incision to get the rod out. Okay, I'll take a knife. Probably come distal with the X-Ray. Knife down for a second on the table. Take a lap. Shot there. Shot there. Shot there. Shot there. Shot there. Shot there. Go north, please, yep. Shot there. Give me a wire. The black one. All right, so the exposure for removal of the nail now. Tony, do you have an Army-Navy? Shot there. So here we're looking for the tip of the nail. Once we find that, we can cannulate and jig into the nail to remove it. X-Ray again. Come to a lateral. So give him a wire. See if you can place the wire right in there. I'm a little more lateral than I was. That's okay. Stand back, please. Shot there, please. Yeah, I can help you to give you a little bit better exposure there. Shot there. Tony, can I get a little bit more bump or just raise the main stand up a little bit. Can you come to the other view, please? Should go more medial, more deeper in there. Shot. I'll make a path on top of that. Just clean up with Bovie. That's fine. That's perfect, yeah. It's facing 46. So you can see your path. We can get the extractor ready. X-Ray there. Save that. So let me take a look quickly. Yeah, there's a straight path there. Very good. Okay, let's get that extractor bolt. I can put it on this if it's easier. Yeah, put it on that one. Make sure you see the metal. Can you see it? You want a freer? Ready? Yep. Okay, pull out the wire. Back to you. X-Ray there, please. Save that. Lined up, mallet. X-Ray there, please. The other one, Tony. The other one? Yes. Just gentle taps and get it lined up. Just very gentle. Shot. Save, keep going. That looks like threads are engaging. Shot. Okay, start turning it. Let's check the other view real quick. We'll lock this in. Take all the screws out. Because there's no set screw in this nail- No. The cephalomedullary nail has a set screw. Mallet back. Shot there. Save that. Go ahead, tap it a little bit. X-Ray. That looks good. A little more. Okay, turn, turn. They're threading tight. Excellent. Shot there. X-Ray, please. Back to the AP. Raise your hand a little bit more that way. So more anterior, yep. Check the mediolateral. Push in. Shot there. Okay, bring your hand more medial. Just drop your hand down. Shot there. Okay, go ahead. Going? Yes. More anterior. Shot there. It's getting there. Keep going. X-Ray. It's pretty solid. You got it. Okay, so let's go and get all the screws out now. So we cannulate the nail with this jig. Now all the screws can come out. Okay, let's go to the knee first. X-Ray. Actually come up here first. Schnidt. A little bit north. X-Ray, please. X-Ray, please. X-Ray there. Mallet. It's going in. Its coming? Yep. X-Ray, please. Save, yep. Get it lined up right? X-Ray. Good, keep going. X-Ray. Schnidt, please. Norfolk to me. Table down, please. Keep going, I can grab it. That's good, thank you. Keep going. All right, screw out One screw out. Okay, let's find the next one. Right, let's expose. X-Ray, please. X-Ray there. So we got to go much higher. You can use the same incision. So just take the fat down here. Pickups, please. Old scar tissue, I can feel it. Schnidt, please. Put the Bennett right there. We continue with our subvastus approach, more proximal. That's the whole screw you just took out, right? Mallet, please. Shot there. We tapped the screw so it lines up with the screw. We tapped the screwdriver so it becomes more colinear with the screw and doesn't strip the screw head. Schnidt. Shot there. Save. Okay, hardware is out, X-Ray there. Come to the knee. Come, Phil, switch with me. You felt the screw head with the Schnidt? I think so. Shot there. Shot there. Shot there. Shot there. Shot there. X-Ray. X-Ray. Straight up and down. X-Ray, X-Ray. Maybe it's not clean enough on the screw head? Shot there. I can feel that's on bone there. Shot there. Shot. So you keep your hand parallel to the floor this time, right? Don't go in this direction because the screw head looks like it's pointing straight up with a leg like this. This is how it should be. Okay, you good there? Mallet. Make sure you're in, otherwise wind up stripping it. Shot there. X-Ray. Okay, take it out. X-Ray there. You're good. Shot there. No, take it out. So, you use it as a guide for the other? Screw back. So, again, it's going to be straight up and down, right? Because the screw head looks perpendicular. Shot there. Shot there. Shot there. Shot there. Shot there. X-Ray. Okay. Okay. Take the slap hammer, shot there. Save that, okay. No, table's fine. Okay, that's fine. Okay. Come north. Inside. Shot there. Can I get a Norfolk retractor. So it's very important we look at the nonunion site while doing this, let me put the leg down, pull this back, make sure it doesn't rotate or gap at the site, so it stays the way it is. Okay. Go ahead. Shot there. Okay, the nail's out. Here we go.
CHAPTER 5
Now I'll take a drill bit. 2-4, 2-7, whatever you have in your set, we'll make some venting holes in the nonunion site. Can she get a gram of TXA, please? She did. She did in the beginning? One more probably now. Shot there. Shot there. Shot there. Shot there. So, Rodney, why don't you come at an angle like this? Shot there. Shot there. Shot there. X-Ray. I have something for like a 2-5 there. Shot there. X-Ray. So we're going to drill straight through that. Suction there. Drop with the drill. So we'll make one hole in the lateral cortex, but hopefully three exit points on the medial side. So when you're reaming, all the bone graft goes medially and stays inside. Shot there. X-Ray. X-Ray. Shot there. Shot there. It went pretty easily. X-Ray. Do you have a bigger drill than this? What do you want? What size did you get? Do you have a 2-8 or what do you recommend? I have a sterile 3-5. 3-5, that'll be best, we'll take that. Oh, actually I hope we do, I'm not 100% sure. Okay. Is Joe still here? Yeah, I'm still here. Joe, you have a bigger drill? I can go see. Okay. I got a 3-5, yeah. I'll take it. Okay. Shot there. Save that, please. Okay, that's fine. Shot there. Let's get a 3-5 on this. Suction. Shot there. X-Ray again. Okay, so now try to run the same path. Looks like it's going to move. So why don't we mark our rotation now first. Tony, back to you. Suction. Yes, yes. Mark a few lines to give us the rotation, okay? Let's do it over here. Okay, so we got our rotation there, Bennett, please. Okay, Tony, I'll take the drill back. After the drill we'll take the long guidewire and we'll start reaming. Yes. Shot. X-Ray there. Shot there. Okay. Now coming back out. Keeping the same lateral hole. Shot there. Now going slightly to a different point. Shot there. And this is slightly more anteromedial. Okay, another one. Shot there. Yep, and then try to even drop my hand more. Same start point again. Again, new cortex there. Shot there. Okay, and then we'll do one more posteromedial. Suction, please. Shot there. X-Ray. X-Ray. Again, new cortex. Shot there. Shot there. Okay, we'll take the ball-tip wire, now we have at least four holes on the medial side and one on the lateral side. So all the bone graft that comes out will go medial and stays there and helps in the healing process. Go for it.
CHAPTER 6
Yeah. Joe has it. Apparently he's going to get it. You in? X-Ray, please. Okay. X-Ray. It's one of his stuff. It's Centesis stuff. Just turn it all the way. X-Ray there, please. Okay, we can start reaming this now. So let's start with the 9-5 reamer. So we'll try to ream to a 12. So the previous nail was nine, right? 9 mm, so we're going to upsize the nail. Give it more stability. X-Ray. Come a little distal, Rodney. That's it, shot there. Little bit more distal. Shot there. That's it, you can come back out. Let's go up by one. So this is 9-5, you want to go up 10-5? Yes. Okay. You good? Yep. We will go up to 11-5 next. Slow. I'm watching to see if any bone's coming out. Nothing, right? Okay, come back out. You should get something here. Okay, so go slow on this one. 12-5? 12-5 and that should be it, I think. You want to X-Ray? Yeah, sure. X-Ray there, please. Yep. Nothing? Some resistance, but no real chatter. That's a little bit there. Keep going. Bring it back. X-Ray there. Okay, so ream it. Just keep reaming it. Back and forth it. Keep going, keep going. Ream that area again. Okay, go ahead, come out. Let's go up another one. Okay, can I get a specimen jar and a pickups? Yep, perfect. If we don't have enough, we can ream and get more. Okay. Keep this bone graft. We'll mix the revision in this once we get it. We're going to have more of this coming. Maybe we can even go to a 13 reamer. It's a 10-7 nail right? 10-7, yep. - We could go 13, probably, get some more bone graft. There's some chatter there, huh? Yeah. What size is this reamer? 12-5. This one is 12-5 in your hand. Usually does. Yeah. Okay, that's it. You don't have to go all the way deep. Now on the way back, make sure you ream. Give me that... Back and forth, then come out. You can come out now. Come out. What happened, stuck? Not out yet. We're stuck there. Keep reaming, shot there. Yeah, so ream that area. Go ahead. Come out, come out, come out. Let's go with 13 reamer. Bring it, lift it up. That's it, right? Okay, thank you. Thanks. We have the revision? Yeah. Let's get some more bone graft. Okay. Ream it now, when you're going in ream that area back and forth it now. Now you have chatter, right? It's better. Better grip on the way going anterior. So we don't need anymore. This is good enough, yeah. Pickups. Close it, so... You think you can get to 14? We can. So go to the 12-5 nail? It's temping right? Yeah. She's got enough bore diameter. And based on the pre-op plan, right? Can get about 20 - almost 25 mm... Might as well if we want to get to 14. You stuck there? There it is. Back and forth it. Let's go up on it. 14? Yeah. Let's take a look at the reamer in there, shot there. Measure the length too, right? X-Ray, yeah. Go back in. Shot there. So that is a 12-5, right? Shot there. This is 13 or 12-5? What you have in your hand is- 13, 1-3. Yeah, so I think we'll go with the 12-5 nail, then. Because we can easily get a 12 in there, 12-5 in. It's a 13 reamer, yeah. What are you going to do next? Let's do a 14 next. You can go up by one? Yes. Okay. You good, you good. We have plenty of bone graft. Yeah. So we have some bone graft coming on this side but most of it has gone on the medial side, right? Yeah. There's only one hole here. Okay. Okay, start off and go slow. Back and forth it. Huh? Graft. I'll have more grafts in a second. So, Tony, we'll go to 14-5 and then that's it. Okay. Okay? Making progress? Yeah. Shot there. Oh, yeah. Come out. You don't have to go all the way. Just stay there and just try to get it out there. A bit more pushing. Stop there. Go in reverse for a second and pull back. Okay, go forward, yeah. Shot there. You're out, right? Take it out, shot there. Yeah, okay. Shot there. Come out, come out more. Can come out by hand, do you think? No, do it with this guy. Because the opening reamer for this nail was only small. Rodney, go north. That's it, shot there. Okay, yep. Go ahead. Okay, we'll get the last reamer. Yep, 4.5. So just do this side, right? Let's go back and forth here multiple times, so on the way back it won't be a big hassle. So, you don't cross back? No, you definitely cross back side to side, but spend some time there when you're crossing it. There you go, that's it. Yeah, keep running it here. Shot there. Back and forth, this area. Keep going. Yep, yep, back and forth. Good. Back and forth, yeah. You're actually reaming it, right. You're not trying to pass through. Slowly. Pull it back a little bit. Full speed, now back and forth again. X-Ray there. Good. Loosen it quickly. That's it, okay. So what size nail did we template, the length? For some reason you guys templated a 245 and a 365 and I wasn't part of that one, but we have a 305 or a 335. Okay, either one will do. So maybe - I don't know what length that other nail was. Tony, what length was the nail? I have it right here. But your nail's a straight nail, right? Yes. But troc entry? Yes. Okay. We have both, but... Troc entry is what I'll use. So this is? This is a 380. 380. So we did the 335 and lengthened it out to 360. Yeah, but your nail doesn't have a curve, so going 335 will be too much, right? Without a curve in her bow, it may be a mismatch. Yeah. So... I mean is it? Yeah. She does have a anterior bow. So we could even measure 305 and see what that looks like with the wire. Okay, you good? Yep. My bone graft. So these are straight nails. So, if you go too long with them, you're going to break your anterior cortex. Okay, Tony, you're good. You can mix all the revision in here. So, now, Rodney, you come a little distal. Let's see where the ball-tip ends. Right there, shot there. Okay, so let's bring the ball-tip back a little bit. X-Ray, please. X-Ray. Shot there. So we need the nonunion site to be how much outside of the... Eight plus... Three plus - well, in this case we're not lengthening. Yeah, so it doesn't really matter much. One plus four or five. Okay. It's not really even an issue with this case. Yeah, because it's compressing. Okay, let's get a lateral real quick. Let's look at the bow of the femur. The issue will become, if she has a short radius of curvature, which means she's more rounded and I put a straight nail along, it will perforate the anterior cortex. If she has a flatter radius of curvature, which is larger, a long nail will be just fine. Ah, look at that nice bone graft. Good, perfect. Thanks, Tony. Okay, X-Ray. She does have a nice curvature. See that? Yeah. Yeah. So, if your nail ends a little bit more proximal to this... Shot there. We'll be fine over there. Length, give me the measuring device. Metal goes down to the bone, it'll just push you out. You have to kind of hold the wire a little, you know, to push it down. X-Ray. The wire got pushed down, pull the wire back out. The wire won't come out, so you can't push down too hard. Shot there. X-Ray. Shot there. Okay, go ahead. Just slide this guy, the wire should go down. Okay. X-Ray. All right, so we are measuring a 235. What options do we have for the nail? So we have 245... Yeah. Which will become 25 longer. Longer, yeah. So, and then we have 305 and 335. So I think we go with the option, the first one. The short one? The short one. And lengthen it by two and then compress it, right? Okay. Let's go to AP real quick before we decide on this. Otherwise, we do the 305. Let's just check. How much on AP and how short it looks. She needs support beyond that as well. Not just compression. Let's do 305. That's too short. Okay, so it'll be a 330? Yeah, 25, yeah. Let me show it to you. So we have a 12.5 by 305. Expiration is 2025. Okay. Troc entry. Yeah, so we can lengthen it to 20 mm, right? To 325, basically? Yeah. In his pre-op plan he did 25. Let's do 20, 20 is enough, yeah. So the wire can come out. It's a noncannular nail, take the wire out. Sure, go north. Shot there. That's down. That's down all the way there. X-Ray. What's that measuring? 230, huh? So what's 305 going to look like? Yeah, that's all I can get down there. One second, what's the other one you have? One second, hold on. You said the other one is 240, right? 245 is the other one. 245. Come distal. Shot there. Okay, let's push the wire to 245. So just push that guy on the top, push it down a little bit. Okay, keep going, keep going. Okay, that's fine. 250 is fine, shot there. Come north now. So, 245 plus 20. So 245 plus 25, that will make it 270. So let's go to 270 and see what that looks like. So that's 270 right there. Shot there. Okay, come distal. X-Ray. That would be plenty actually. Go distal. Shot there. Yeah. I think I'll go with - it's not open yet, right? No. So I think we go with that one. Yeah. We go down? Yeah. The 245? There's no reason to go beyond that, right? You already maximized support, yeah. That's why Adam templated it. That made sense. Okay, let's do it. Okay. And we'll lengthen by 25. So we'll get it to 270. Okay, back to the AP. So now we're going to add 2.5 cm to the nail. Right. Right? And then compress it inside to while she's here by at least a centimeter, see it actual compress, see you get compression. And then if we're getting good compression, we don't have to compress any further. But I can keep compressing her in clinic, you know? Every third week she comes in I'll compress her a little bit more. Let's see how much bone graft came out this side. So now we're going to take the nail in halfway to the osteotomy site. Take the osteotome, redo your osteotomy. Make sure your rotation lines line up. So we don't derotate her by any means, okay? I'll take some irrigation from you, if you don't mind. So I think the key with these osteotomies, either lengthening or shortening, is to do them low-energy, like not use an operating saw, use an osteotome. Less chance of getting any kind of thermal damage.
CHAPTER 7
Yeah, that's correct. Okay, go for it. Yeah. It's working. So, usually how much is sticking out? Three centimeter sticks, yeah, we need to get to like, you know... Five. Five. Okay, keep going. 5.5 or whatever. It's going to take 7 mm per minute. It's the highest RPM drill. I don't know if yours is 750. And we can keep going. There's no reason to stop, right? Yes. Okay. So at end of the case we'll do some Judet decortication. Yep. Because she actually has a diaphyseal nonunion, which has almost no callous growth. So just upsizing this nail wouldn't work for her. Most nonunion needs stability if they're hypertrophic. So you can basically dynamize the nail, number one option. Number two option is upsize the nail, ream and upsize the nail. In both the options, if you're oligotrophic or atrophic, they won't work well. So what this wants is compression. So initial thought was bone graft and compression and that can be done with the plate, but the nail offers you a controlled compression. We can actually control how much we're compressing her and when we're compressing her. That is measuring about, that is exactly a 5.2. Is that good? Yeah, I think that's plenty. Okay, let's go with that. Five is good. So we can go down by two plus centimeters, right? Yeah. Okay. Let me try that one time. Let me see how it worked again. Where do you put it? Oh, wow. Put it right here. Yeah. But you could see that what it tells you, like the rotation. Yeah, so I can... Yeah. I got to hold these two together, right? Sometimes we shorten. Yeah. Use the opposite. That's it, go ahead. Where you see the direction... Yep, that should be enough, right? Okay. That was just for trial purposes, okay. Let's put it on the jig. And then once you get it all the way to the osteotomy site, let's go back to the lateral, then we'll complete the osteotomy. And then once you get it there, I'll mark my lines again. Make sure my lines are visible. It is down to the isthmus, so the nail should reduce everything the way it's supposed to be. X-Ray there. Go north. Shot there. A little bit more north, tiny bit. That's it, shot there. Tiny bit more. That's it, X-Ray, perfect. Okay, take the wire out On the medial side, yeah. Lap times two. So keep it from not bleeding in that site. Can we do screws or should we do pegs? No, no, pegs are definitely stronger. That's visible, one line. Another one here, suction here. So we have these three lines that we have that will help us with the rotation. Other option is to put an ex-fix on if you're worried about moving. Okay, we ready? Okay, get it in, all the way till the fracture site. X-Ray there. North a little bit. Little bit north, tiny bit. That's it. Push the boom in. All the way in. Yep. Okay, you're in. Go a little bit deeper. Is there a mallet? That's it, that's it. But, remember, hand anterior first. This way and then we'll bring it back. Shot there. Tony, do you have another mallet? That's it, shot there. Okay keep it there. No, no - pull it back a little bit. Just a little bit. Okay, shot. A little bit more in. In, in, not out, in. Shot. Okay, keep it there, yeah. Suction to me. So it will feel very unstable the moment I break the femur. Okay, Tony, we have those big bone holding forceps ready? Hold this guy. Let me go ahead, put this on just in case now itself, instead of putting it later. Tony, can I get a freer or a lane or a joker. Put my bone holding forceps right there and right there. So, you can control the whole thing, right? Yep. Okay, suction. Osteotome. Got it up. I'll take the mallet. Shot there. Shot there. X-Ray. Shot. Need to do a couple more passes. Let me see if the rotation still looks good. Okay, so that was the posterior cortex gone. Now we got to get the anterior cortex. Shot there. Suction. So you can see the rotation moving a little bit, right? But I can fix that. Lines are good. One more pass. Shot there. Shot there. Okay, so now we just do a test. Yep. See that fully moves, mobile, fully, yep? Yep. Okay, X-Ray. All right, so we're ready for the nail to pass now. So this is how you want to do most of your osteotomies. Low-energy, no saw. Hold on. It's not reduced anymore, see that? Ball spike. Ball spike. Sorry, did you... No, no, no. X-Ray. Okay, so let's reduce that. Go ahead, pass the nail. Gentle. Now start turning it. Turn, turn, turn, turn, turn. Turn, yep. Okay, stop there. Shot there. Okay. Come distal a little bit. Shot there. Okay, it should correct. Keep going, gentle tap, suction. Hold on. The handle is way too posterior. So, this would be it. Not going? It's not going. If it's not going, check the lateral to make sure it's not... X-Ray, please. Okay, lateral, please. Let's just check it, the fracture site. That's where the reamers were getting stuck to. Okay, back to the AP. On the AP, look where it wants to go and where it's trying to push you. So just use your handle and redirect it. X-Ray there. I would push your hand in towards her. Okay, give me the ball spike back. Hold on. Rotate. Okay, gentle taps. Nice. So keep going a little bit more. Yeah. Suction for me. Look at the rotation. That's the line - lined up. Perfect, right? That line in the back lined up perfect? Yeah. All three lines are lined up. So gentle, gentle. I'm holding this guy, and this guy - don't move. Check it, X-Ray. How much more we got left? Two. Yeah. Okay, keep going. Going easy? Yeah. Okay. Suction again. We got plenty of bone graft there, see that? Keep going. Can I take an X-Ray, please? Go a little bit north. Okay, go ahead, hit it. Okay. I think that's enough, right? Is that second screw I got into the lesser... Doesn't matter. Yeah, the second screw is... In the lesser - that one's buried already, so we're good there. Come distal. Would that be easiest to see at the top? Yeah, that's it. X-Ray, come distal. Shot there. Yeah, X-Ray right there. That's great. Okay, back to the hip. Shot there. Other way, I don't want to rotate the whole thing. Maybe you can rotate with me. Hold this guy and we'll want to both go internal rotation, gently internal rotation. There's no way he can go. Come off your angle a little bit. That's it, shot there. Much better, right? I think we're in good position. Second one goes in the lesser, top one's fine. Okay, I'm happy with where it is. Let's lock it up, let's do it. Tony, ready? Knife. To Phil. Let's see if we can make one incision for both. Nope, two incisions. I'll take a 15 blade, please. I measured them already and they're... So just make two, two incisions. One there and then one right there. A little bigger, a little bigger. No, distal, let's go distal. Let's see if we can get 'em both in one. Go, go, go. Go - that's it. Okay, drill. Knife's coming back. Thank you. Drill. Thank you. These aren't calibrated but we have a dip stick if you... All right. Go all the way down. Let's see where you come out. Start. Perfect, we'll use this guy. So this is off. That's fine. Go for it. You're on bone now? Shot there. X-Ray. Don't push down. There you are. Don't push too hard. Shot there. Keep going. Take it out. Give me a saline, please. Can I have another liter of warm saline, please? Go for it. Don't spin with holding this guy, okay. It's going to spin. Better. Don't push too hard. X-Ray, take the whole thing out. No problem. Okay, go for it. Yeah. There we go. X-Ray. All right. Feel that side. Be careful, shot there. Feel that there? That's it there. That's some of it - 50, huh? Go again, go through. And stop. 35, X-Ray there. 55, probably, go. Stop, X-Ray. It's still not through. Either you go 60 or 55, keep going. Stop, shot there. That's measuring 60 on the dot. Should we go 60? We're off a little bit. So, let's see. Let's do 55, okay. 55? Yep. You can sink it a little bit too. Should go in. Is the cannula not correct? It's not going... You had your sleeve out. No, inner sleeve's out. The outer sleeve is not going through it. Okay, there we go. X-Ray, please. A little bit more. Shot. Wow, it's long, huh? That's okay, good bite? Do you want to remove it? No, shall we take it out for a 45? Okay, 45. Go ahead. This is a 45. No, you gave me a... 55. 55. So give me a 50. Yeah, keep going. Hopefully it's on it. Come on, oh, yeah. Yeah, boy. Okay. Is it locked on? Okay. This is the 55 I gave you, this is a 50. Okay. This is 50. 50. X-Ray. Better. Bite? No, X-Ray. That's fine, let me see. Shot there. Doesn't want to go in, huh? Give me a mallet. You just gentle tap on this guy. Very gentle. Okay. Shot there. No bite on the peg, huh? It's fine? Do you have a screw option on this? Except we drilled with a 5-0. Okay. Yeah. Because there's not a lot of bite. There's no bite. Okay, let's do the next one. How do you undo this, Tony? Give me the screwdriver. What size is the screw? 5-0? Yeah, 5-0. But we already drilled with a 5-0, huh? Just for the one though. So we can drill with the 4-3 and the next... Take this off. A 5-0 fully threaded. Yeah, we have 5-0 fully threaded. Drill. This one, right? Yeah. Shot. Okay, keep going. Stop. 60's coming up. X-Ray, please. Stop. X-Ray. Still going good. Shot there. We can do, this is measuring 65, should we just do 60 or 55? Let's do 60, 55 will be fine actually. Got it at 55? Yeah, I think 55, shot there. Take it out. Yeah, let's measure it. Give me that dip stick to measure or the actual depth gauge. The dip stick, that probably might not be long enough to get through. So let's just do... There's a little dipstick that... That's fine, 55, let's do it, 5-5. So the pegs are considered better than the screws? Stronger. Well, they have a bit more weight-bearing... Because it's a 5-0 core, right? Shot. Yeah, that would've been useful to have, like, threads on both sides. It gives you more bite. Yeah, hopefully. Shot. 55 was the right option. It's measuring off, huh? The thing is measuring really off. That's getting something. Just leave it there, yeah. Oh, yeah. I think it'll be okay. X-Ray. Shot there. X-Ray. It's just spinning there now. So, just leave it there. Shot there. Maybe I'm just losing strength or it's getting tighter. One of the two things is happening. Okay. Rotation is good. Now lock it up distally. Tightening it, why you tightening it? Loosen, loosen. That's it, keep going, keep going. That should be enough. Okay, suction . Just not on the, oh no, no, no. Not on the bone graft. That's our line right there, see that? Actually, give me a pickups. I'll just save this and move it there. Suction there. Yeah, I think our line's pretty good. We're good with the rotation. So, go ahead. Let's lock it up, perfect circles. The perfect circles, are they lateral-to-medial or A-to-P on this one? I think there's an AP option, but there's two mediolaterals. Lateral-to-medial, right? Yeah. Shot there. Can we call for our next one? Next patient, yeah. Shot there. Shot. Okay. Fall back on the C just a little bit, shot. Little more Shot there. Shot there. Shot there. Okay. Shot there. Suction, Tony, move the light, let me check the rotation again. Pull back for a second. Pull out, pull out. Pull back, please. And put an Ioban on this thing. I'll just save this and move it there. It locked, so it's already moving with this guy so I was able to move it, now it's lined up. Okay. Tony, don't move this leg at all, yeah? Because it's rotation. Okay, come on in now. Can I use Ioban for the... Ioban for this thing. I think the nailing landed exactly where we wanted it. Right, see the bow starting right underneath? Right. So had we gone longer, it would be a problem, right? It needs more tilt back and forth, okay? Shot. Shot there. Take the machine up all the way to the roof. Keep going. Shot there. I think it's still in rotation. Over the top. Over the top. Shot there. Shot there. Just a little bit more. Shot there. Boom. Okay. Can you raise the machine up more? You can take the knife. No, other way, flip it 90 degrees. Like have it pointing up like this. X-Ray there, X-Ray there, X-Ray there. X-Ray there, X-Ray, X-Ray. Rodney, can I have your screen? X-Ray there. X-Ray there. Pull back. I like to see only the tip of the knife. Keep going, finish it, in the center of the hole. That way you know you're not going anywhere. You're not going to stress out your drill bit. If your incision in the skin is off anterior or posterior, you're fighting the soft tissue, then especially in a bigger person, when you're not going distal enough, you're going middle of the thigh. Knife's on your Mayo. I'll take the drill, please. Does he have the drill? 5-0, yeah. Same pegs, similar pegs. X-Ray, please. X-Ray. X-Ray. No, no. I think I should do one just for, you know. Keep going. See the tip in the center of the hole first. Just the tip in the center of the hole. X-Ray. X-Ray. X-Ray. X-Ray. X-Ray. That's actually fine. Now bring your hand over. Shot there. Bring your hand towards you, shot. Little more towards you. That's it, perfect, go for it. So, 5-0 drill, right? Yes, it's a 5-0. Disconnect. Schnidt, please. Right here. There's a drill bit measuring gauge if you want it. Use this, on the top, right there. Yep. No, open it. Control over this guy. There's a flat surface on it, right? Yeah, there you go. X-Ray there. All right, that's good. Go for it, hit it. It's probably going in. Take a look, shot there. Okay, go ahead. X-Ray. Let's get it up and down. Actually, I don't want to rotate it yet. So go ahead. Next one. Okay, let me try one. We have a depth gauge for this? A regular depth gauge? AP, please. Actually, you know what, leave it. Finish it, you good? The battery is dead? Battery is dead. New battery. Yes. Okay, my turn. Oh now I have to go this way. You should always do the distal one first. Why is that? Because it's looking my way now and I'm ready, you know? Shot there. Shot there. X-Ray, it's all good. Shot there. X-Ray. Shot there. Shot. X-Ray. X-Ray. Shot. X-Ray. Shot there. Shot there. X-Ray. Shot. X-Ray. Shot there. Shot there. Yeah, they both look pretty good. X-Ray. Shot there. Mallet. Shot there. Shot there. I'll just finish it. Hm? I'll finish it. That's fine. X-Ray. Shot there. Shot there. X-Ray. Depth gauge. I have it here. X-Ray there. Shot. Shot there. These go by fives as well? Fives, yeah. 25. You got it? Yeah. Shot there. Probably get a better bite there. Yeah, diaphyseal bone. Shot there. Yep. Just take over. Shot there. Yeah, another 25 is correct. Shot there. So that sounds pretty well there. Yeah, nothing more, right? Yeah. X-Ray. It's just going to spin now if I keep going, I think. Okay. Loosener. Shot there. Okay. 25, ready? Yep. Just want to check it. You can just detach the handle. Just detach it, pull it back and then you can get ready. Hey, we broke up the whole pieces for you. Oh, you're the best, thanks. Puzzle, there you go. I think we just measure it again. Measuring over 25, huh? Over 30. It'll look weird but go for 30, I guess. 30. Okay, ready? Ready. X-Ray. X-Ray. You got bite? Yeah. X-Ray. Very thick diaphyseal bone there. So do you want to leave this? Because it seems like if we go a little bit, it might loosen a little bit. You won't loosen here. Your diaphyseal is much thicker. Distal one was very, very thin diaphysis. Shot. That's it. Let me feel it, you can leave it there. Oh, yeah, this is solid, right? Okay What was the last one? 25 or... 35. 30. 3-0. Okay. All right, ready? ERC machine. Do you want to put your graft in first or? No, we'll put the ERC first, compress her, and then put the graft on. There's enough graft that was there already that came out. So what we're going to do is we're going to mark the magnet. Yeah. Shot there. Okay, come out, a AP and out. Actually, just go north. That's it. Push in now, all the way. Need a needle driver or chubby. Let's see where the bone graft is. Yep, rotation's perfect. Looks great. Okay, we're ready. We're going to go from here, right? In the front? I can visually see the site. Okay. It's open. Yeah.
CHAPTER 8
So now we're going to compress the nail as much as we can under X-Ray. Rodney, X-Ray there. Okay, we see the nonunion site, now compress it. Can you angle in? More. Okay, now go north. Okay, X-Ray there. Even more angle, slightly more angle. Pull back, shorter now by at least half a centimeter. Okay, so I'll do five. Five mm, yeah. Shot there. I want the bones touching each other, right? So if I want to do five more, we can just repeat the whole thing again? Yeah. Okay. Let's do five then five more. So all you need to do is, you know, line up that line on the side where the magnet is. So, the magnet's right there, right? Can you increase the brightness, Rodney? Now we can see the magnet better. Which one's the magnet? This one. The top one, okay. And it won't work if it's not communicating with the magnet, so if it's a green flashing light in the screen... It'll tell us, yeah. It takes a good three and a half minutes per millimeter. Whoa. The screen goes towards the... Three and a half minutes per millimeter? Because normally we're only doing a millimeter in the OR. Yeah. Intraoperatively we're only usually extracting, so we're compressing, you know... So, you said three and a half minutes per millimeter. That means about 20 minutes, huh? For the whole thing? Yep. Can we not use the fast one? We can, right? Yeah. But it's uncontrolled. Yeah. It's not controlled. Yeah, you can, right? So let's just try this for like 10 seconds, see how it works, we'll go to the fast one. Yeah. Okay. That's quite the drape. I can get the bone touching and then I can go one millimeter on this guy. Because right now we can see there's a gap between the bones. I can get that to compress with the fast guy. Yeah. Okay, let's start with this one. So... Aim towards the feet. I just cut off. Here. You can do this in the lateral position too, as long as you're on... Point towards the feet. And then I'll take this guy out, I guess, right? You don't need this guy. Okay, and magnet's above the thing. So it's about here. Yep. We can take all this off, right? Yeah. Let's take everything off. The T-handle on the Mayo stand. Yeah, I'll hold that. You okay? I just want to get another lap, if that's okay? We're good? Yeah, we're good. There you go. Okay, lap, please. Come on. So this part is the magnet? Yep. Yep. See that line where the white is? Yeah. That line's up to where... So right about there should be... And it will not function. It'll shut off if it's not lined up. It's not lined up. So, you see the flashing green light? It says use lengthening session. I don't want to do that. Nope, nope, let me see? Did it reprogram? Shorten. Shorten, yeah. Yep. Green light is flashing. You want to take a look? Pull says minus 5.55 mm. Okay. Shorten, sensor on. Okay. So, shorten, yeah? Yep. It's on. It's asking - when I press shorten it says... Just leave it as shorten, I guess. I press the green button or? Yep. Yep. Is it flashing? It was, it is now. It's running now. Okay. And it'll show you your progress. Save that. I mean, swap that. Okay, X-Ray. Oh, wow. So it won't show us anything while we're doing it? You just have to take it away to look at it. Okay. It says we're at half a millimeter now. 0.025. Yeah. It's moving fast, it's moving. This is doable. This is coming up on- It's coming on one already. No, no, no. Oh, 0.1. It takes three and a half minutes... Yeah, let's get the other one ready. Let's do it. Okay, take it away. Let's see if anything happened. So that one you're going to hold, put that right over the skin, right over the magnet. Yep. Can we take an X-Ray? Yep, shot there. You might want to mark where the magnet exactly is. The middle of the magnet, if you get a marker or something. You can see the medial side probably compressed a little bit. X-Ray. Right there, huh? Shot there. Hold your hand right over that. Like this? Yeah, put your palm right over it and start slow and then crank it. Yep, shot there. Okay, give me a Schnidt again. Make sure it's in line. Schnidt. I'll put the Schnidt right here and see. Oh, wow. Get the Schnit away from me. Get it away, there you go. Okay, shot there. X-Ray. Shot. X-Ray. Shot there. X-Ray. Shot there. Right there, huh? Okay, shot there. Okay, that should do it. The other thing you can look at besides the osteotomy side is the gearbox below it. That's the lead screw. Yeah, so we'll it exact, shot there. I'm on the magnet. This is better than anything else. It's right on there. Yeah. Okay, so let's go. Do I have to hold it or can I let it turn? Yeah, you have to hold it because it'll turn. Okay. Shot there. It did work. A little. So let's keep going. Shot there. It's trying. The lateral side is not but the medial side is trying. See that? Yeah. Shot there? Come distal. No, it's the... X-Ray. Oh, yeah, yeah, yeah. But the screw's not bending. I want to make sure the screw's bending. Yeah, on that last picture, the whole... Magnet was running. Yeah, okay, go to that one. Go proximal screws, shot there. The proximal screws are not bending either, so we can keep going right now, right? It's deflecting, Smith talked about this actually. Shot there. Shot there. Okay, that should be good. X-Ray. Is there any change at all? Can you tell if the gear's doing anything? I can't tell. Doesn't look like from the last time, no. Didn't look like it moved much. It's moving on a scale of millimeters, so... No, this thing moves fast. So, shot there. It's a fast millimeter. Shot there. It moved for sure that time. It did? You can look at the gears moving? Looking at the picture on the left and right, I think it's moved a little bit. Shot there. X-Ray. X-Ray. Look at the screws. Let's go distal, look at the screws. Shot there. A little bend in the screw. Go back up. Let's try a little bit longer, shot there, again. X-Ray. Shot there. On the magnet now. Shot there. You look like you're touching down medially. Yeah, and the lateral also came closer. Yeah, it did. Let's go distal, look at the screws again. Those look bent. The up ones look bent, huh? Top ones will go other way, though. Okay, let's do one more time and we're done. Shot there. Shot there. Shot there. That's significant. Okay, give me - actually a Weitlaner for a second. Or a Norfolk is good. You can see the compression of the nonunion site. Okay, let's do one last lap. Oh, yeah. X-Ray. Shot there. Okay, come distal, shot there. There's still no bend in the nail actually, right? No bend in the screws. Shot there. X-Ray there. X-Ray. X-Ray there. X-Ray. Go distal. Go back up north. Definitely closed down significantly. Yeah. The question is do we keep going or leave it there? One last round, 20 seconds. You do it, come. Try it. I'll get the bone graft ready for us. And a little osteotome. I'll do some decortication of the cortex. Take a look. X-Ray. Yep, good. 20 seconds or 30 seconds and that's enough. I just need a small osteotome first. Curved one, yep, perfect. After he's done. 30 seconds? 20. 30 seconds. 10 more seconds and that's it. X-Ray there. Okay, call it. X-Ray there, please. All right, let's get our Norfolk. We'll do some Judet decortication. I'll take the osteotome, please. Do we want to wash? There's still a chance to wash. Give me a Schnidt, please. I found one. Can I also get a new Yankauer?
CHAPTER 9
So you're taking like a rose petal off? Yeah, exactly. In that area, in the lateral cortex. So I got to X-Ray, both proximal and distal. Mainly distal side, so it's awakened. Some good compression there. Hopefully that heals. So, right there. Shot there. Okay. I think I took her side. I think so, yeah. Shot there. You can now put the bone graft in there. Can I have the bone graft, please? That's fine, yeah. Thank you. Everything must go here. It's pretty easy. Everything must go. Smells good. Okay. That should do it. Just get some finals.
CHAPTER 10
Okay, shot there. Okay, save that. Give me some internal rotation, because we moved the table up. So I just rotate the leg up. That's it. That's it, that's it right there. Shot there. Save that. Come distal. Shot there. Save that. X-Ray there. Go more distal. Me? Yeah. Stop moving. Are you taking a moving X-Ray or something? Go down, right there. Yep. Okay. Hold on. Internally rotate more. X-Ray, please. Okay. North, north, north, yep, right there. Rotate more, internally. Shot there. Yeah, that side looks very compressed. That's good. Go north. Shot. Okay, perfect, all done.
CHAPTER 11
I will take sutures. Actually, give me irrigation first, Tony, in a little basin. Should we tack this down at all? The Vastus? Like, just to cover the bone graft. Usually we don't close the vastus site, but I'm closing it just because I want to make sure the bone graft actually stays where I put it. As we move her and reposition her, it doesn't move. One more, Tony, last one. Gelpie. Do you have questions, Phil? No, it was good. I haven't seen any of that before. There's different ways to handle nonunion. You let her walk on this afterwards? Huh? You let her walk on this afterwards? No, it depends on the nail. They used to have a different nail that has a weight-bearing nail. Got it. So this nail is not a weight-bearing nail. It's not strong enough to accommodate her body weight. But they are making one that can accommodate body weight. So the maximum one on this nail is about 25 pounds I believe. Actually, no, more. Because it's a 12.5 nail, right. So 50 pounds on this nail. Wow. Yeah. Partial or? Touchdown. Touchdown. They did have that nail, which allowed weight-bearing but they took it off the market for some reason. So she'll stay in hospital for one night. Yep. Or longer if she needs to. That's her? I think so. That makes sense. Especially a nonunion. Yeah. See, like this to this here. Do you have another number one, Tony? I will get you one. So this is IT right here. See this thing? That's IT. So can we tuck this underneath? Here, I'll give you a hand. See if I can dunk it as I... Yes, I'll see what I do with this. Give me a Kocher, please, real quick. Times two, there's a suture back to you. So here's the IT. Okay. So go ahead. Pull this out, take it out. This is IT, right. Take it out for a second. Let's go with this guy and then pack it down here. Go from here or whatever is easier for you. May I have two more number one lightweights? Yep, and then maybe tack it somewhere there. See that right there? This muscle right here. Yeah, sure. Supine? Supine. X-Ray on the same side as the fracture. Just tack there. Okay, hold this. I'll do one from my side. Some triangle for the next piece? No triangle. No. Bone form. Bone form. Can you go back? Phil will take another number one. You're taking another number one? Phil is. I'll take it, yeah. Scissors, please. You have another one? I do. I'll take staples if you have it after this. I'll take 2-0 again. You probably will need one more stapler. Well, that's it, right? Locked? Oops, sorry. That's good. You want one more here, probably. We'll take a another one, please. Thanks. I can dress this wound while he's closing. Give me a wet and dry Xeroform. Or we can do Aquacel, whatever we have. Okay, I think I'll just put the Aquacel. No Xeroform required. You can reach the whole thing. We can remove some of that stuff. Yeah, you're right. It'll reach. Let's do it. Some of that here, you can remove it. Let's do it. That's the perfect size, it's good. Do you want me to do the same thing for these here? Well, that one we can use a small Aquacel if they have one, right? Yeah. Okay. 2-0 for me. Once you run, I'll start closing on this side. EBL 500. This is a cool way of doing it, you know. I was also thinking that sometimes you don't even have to open the osteotomy site. But if it's a hypertrophic nonunion, I feel very comfortable because I know just adding some more stability to the fracture will solve the problem. Because it's a mechanical issue, not a biology issue. For her, she had all the stability. It was a nine nail, I understand that, but it was mainly biology for her, because the saw basically causes thermal injury, right? Yep. So that's one. Other thing was she was statically locked, not dynamized. Technically, she should have been dynamized. Because if she was dynamized, there would've been, you know, compression, not consistent compression or not controlled compression, but she would've had compression, that would've helped her heal. At this stage we could have done multiple things for her. We could have started off by just dynamizing the nail, but she doesn't have any callous to show me that that would heal. So that would be too little. So I didn't do that. That was an option. That would be just taking off one screw from the bottom. Other option, again, is just going, upsizing the nail and revision nailing. And that has varied results and it's debatable. But that would increase her stability. It would ream the canal as well. Right. Would that be enough for somebody who has an oligotrophic or atrophic nonunion? I don't think so. So nonunion is like... A paper just came out talking about, you know, revision nailing like works pretty well, but I think they included, like, if you had to go back and do it again as still working. I have revision nailed people multiple times and they've worked really well. There was one lady who came with a tibia fracture. She had been nailed three times already and she had a nonunion and I decided to nail her one more time and it worked. And she healed. More 2-0. Just depends if you address all the factors. In this case, I think more stability was added because we went to a 12 nail, right? It was a 12-5 nail. Reamed it, 12-5, yeah. Gave a significant amount of bone graft And gave her compression. So kind of addressed all the parameters here. So, hopefully it works. What is working against her is her medication and her medical status. If she was not compromised, she would've healed for sure, being young and healthy. You could trim, let me know. I'll give you a scissor. Yeah. I think we need one more small one.
CHAPTER 12
So, overall our surgery went pretty much as planned. We positioned the patient lateral decubitus. Initial surgery when we had done it was supine on a fracture table, but since we wanted better exposure to her thigh and her nonunion site, lateral decubitus was a good decision in this case. We took out the nail. There was no incidents, no problems there. We examined the nonunion site. There was a fibrous union that we could visually see, but there was mobility at the fracture site. So we took out the rod, we put in a new guidewire, reamed up to a 14 for a 12-5 Precice nail. Before we reamed for the nail, we drilled with the 3-5 drill and made several holes with the drill bit medially, but only one hole laterally. What this did was it helped us with collecting the bone graft medially. This would help her heal better in the future. So, while reaming, we could see some bone graft coming out laterally from the hole that we made, and that bone graft we collected. But medially, the several holes, the bone graft that came out stayed in the patient. So that will act as an autograft for her when she's healing. We reamed her, we cleared the osteotomy again using an osteotome, and then placed the Precice nail, maintain the rotation by making Bovie marks in the bone, so we don't lose our rotation during the surgery. One thing that surprised me or that we weren't unaware of, is how long it would take to shorten the nail when it's already in the patient's body. So instead of using an ERC device that's traditionally used and it's more controlled in how much compression we can do, we used a drill bit to spin a magnet right next to the nail to compress it more quickly. And we were able to get significant compression compared on X-Ray after the magnet was rolled. And then we will continue post-op, you know, getting her into clinic repeatedly every three weeks. And if we want to compress more, we can do it externally using the ERC device. Until she's healed, she'll be nonweight-bearing on this leg and once she's healed she can start weight-bearing on her extremity. And the nail will come out at about one year.