274
Letters to the Editor
Letters to the Editor Journal of Pediatric Orthopaedics B 2015, 24:274–276
Derotational osteotomies utilizing a trochanteric-start intramedullary nail Paul E. Matuszewskia and John E. Herzenbergb, aDepartment of Orthopaedics, University of Maryland and bInternational Center for Limb Lengthening, Rubin Institute for Advanced Orthopaedics, Sinai Hospital, Baltimore, Maryland, USA Correspondence to Paul E. Matuszewski, MD, 110 S. Paca St, 6th floor, Baltimore, MD 21201, USA Tel: + 1 410 328 6040; fax: + 1 410 328 0534; e-mail: [email protected]
In the November 2014 Journal of Pediatric Orthopaedics B, Pailhé et al. [1] outlined a technique for the surgical treatment of adolescent femoral antetorsion with an intramedullary nail. They specified a trochanteric-start nail to avoid avascular necrosis of the femoral head that could occur from a piriformis entry point. We applaud the efforts of the authors to avoid the devastating consequences of avascular necrosis of the femoral head. However, we have concerns that their technique, as described, could lead to potentially fatal fat embolism. In their technique, the authors describe reaming the femoral canal before performing the osteotomy. Intramedullary reaming is associated with marrow pressurization and its potential complications [2–4]. Reaming of an unfractured long bone is particularly problematic, as the high pressures generated are not relieved through a fracture site, causing injection of pressurized marrow contents into the circulation. This can lead to fat/air embolism, pulmonary embolism, hypotension, desaturation, and even death [2,3,5,6]. The marrow fat load in the circulatory system would be even higher in bilateral cases. Many authors have suggested the use of venting or a ‘reamer–irrigator–aspirator’ while reaming pathologic (or intact) bones [3,4,7–9]. This effectively reduces the degree of pressurization of the femoral canal, thus decreasing the quantity of emboli. We recommend predrilling the osteotomy site with a 4.8 mm drill bit before reaming [10,11]. These predrilled holes serve to vent the canal (decreasing the potential risk for fat embolism). Furthermore, some of the bone reamings will exit through the vent holes and accumulate around the osteotomy site as a cloud of bone graft, which may aid in osteotomy healing. The level recommended for the osteotomy by the authors is distal metaphysis–diaphysis. This is a relatively wide area of the canal relative to the 8.5 mm nails recommended, which may result in insufficient fixation, particularly in bilateral cases in which limited weight bearing is
difficult to enforce. This complication was demonstrated in patient #3, who had a loss of fixation that resulted in varus malalignment, requiring reoperation and renailing with a larger nail. The authors may wish to consider the addition of blocking or ‘Poller’ screws to help prevent this complication [12]. Alternatively, an osteotomy at a higher level in the diaphysis may be utilized, which is intrinsically more stable. The authors state that their metaphyseal level osteotomy may heal faster than a diaphyseal level osteotomy. However, this assumption is contradicted by their metaphyseal osteotomy healing times (3 months, range 2–6 months), which are greater than those reported for diaphyseal osteotomies by Gordon et al. [13] (average healing time of 6 weeks). The concern of altering the mechanical alignment as a result of rotating over a curved intramedullary nail is unlikely to be of clinical significance given the magnitude of correction reported (13–25°), especially with small diameter nails (8.5 mm). The choice of the osteotomy level (distal metaphysis vs. proximal diaphysis) is more influenced by the alignment of the patella. In cases of patella maltracking (i.e. an increased Q-angle), distal external derotation in the anteverted femur is indicated to help improve the Q-angle and thereby stabilize the patellofemoral joint. In the absence of patella lateral maltracking, one may choose either a proximal or distal osteotomy site [14].
Acknowledgements Dr Herzenberg receives research support from Elipse Technologies. Conflicts of interest
Dr Herzenberg is a consultant to OrthoPediatrics. For the remaining author there is no conflicts of interest.
References 1
2
3
4
Pailhé R, Bedes L, Sales de Gauzy J, Tran R, Cavaignac E, Accadbled F. Derotational femoral osteotomy technique with locking nail fixation for adolescent femoral antetorsion: surgical technique and preliminary study. J Pediatr Orthop B 2014; 23:523–528. Kröpfl A, Berger U, Neureiter H, Hertz H, Schlag G. Intramedullary pressure and bone marrow fat intravasation in unreamed femoral nailing. J Trauma 1997; 42:946–954. Roth SE, Rebello MM, Kreder H, Whyne CM. Pressurization of the metastatic femur during prophylactic intramedullary nail fixation. J Trauma 2004; 57:333–339. Pape HC, Regel G, Dwenger A, Krumm K, Schweitzer G, Krettek C, et al. Influences of different methods of intramedullary femoral nailing on lung function in patients with multiple trauma. J Trauma 1993; 35:709–716.
1060-152X Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
Letters to the Editor 275
5 Stürmer KM. Measurement of intramedullary pressure in an animal experiment and propositions to reduce the pressure increase. Injury 1993; 24 Suppl 3: (Suppl 3):S7–S21. 6 Leddy LR. Rationale for reduced pressure reaming when stabilizing actual or impending pathological femoral fractures: a review of the literature. Injury 2010; 41 Suppl 2 (Suppl 2):S48–S50. 7 Husebye EE, Lyberg T, Madsen JE, Eriksen M, Røise O. The influence of a one-step reamer-irrigator-aspirator technique on the intramedullary pressure in the pig femur. Injury 2006; 37:935–940. 8 Joist A, Schult M, Ortmann C, Frerichmann U, Frebel T, Spiegel HU, et al. Rinsing-suction reamer attenuates intramedullary pressure increase and fat intravasation in a sheep model. J Trauma 2004; 57:146–151. 9 Pape HC, Zelle BA, Hildebrand F, Giannoudis PV, Krettek C, van Griensven M. Reamed femoral nailing in sheep: does irrigation and aspiration of intramedullary contents alter the systemic response? J Bone Joint Surg Am 2005; 87:2515–2522. 10 Rozbruch SR, Birch JG, Dahl MT, Herzenberg JE. Motorized intramedullary nail for management of limb-length discrepancy and deformity. J Am Acad Orthop Surg 2014; 22:403–409. 11 Kogalgu M, Solomin LN, Chelneokov AN, Herzenberg JE, Kovar FM. Lengthening Over a Nail (LON): combined and consecutive use of external and internal fixation. In: Solomin LN, editor. The basic principles of external fixation using the Ilizarov and other devices. Milan: Springer; 2012. pp. 1309–1377. 12 Krettek C, Miclau T, Schandelmaier P, Stephan C, Möhlmann U, Tscherne H. The mechanical effect of blocking screws ("Poller screws") in stabilizing tibia fractures with short proximal or distal fragments after insertion of small-diameter intramedullary nails. J Orthop Trauma 1999; 13: 550–553. 13 Gordon JE, Pappademos PC, Schoenecker PL, Dobbs MB, Luhmann SJ. Diaphyseal derotational osteotomy with intramedullary fixation for correction of excessive femoral anteversion in children. J Pediatr Orthop 2005; 25:548–553. 14 Paley D, Herzenberg JE. Principles of deformity correction. New York, NY: Springer Verlag; 2005. pp. 243–245.
be it from a teen individual. We use narrow shaft diameter and deep-fluted new generation reamers also, so as to provide more relief space for medullary contents. We acknowledge that distal metaphyseal osteotomy does not provide as much stability as the proximal third of the shaft. We have not encountered any other instability issue in our experience of more than 50 cases to date. Blocking or ‘Poller’ screws allow indeed further stability of the distal segment if needed and can also help to achieve desired alignment. Bone healing was defined in our series by complete circumferential callus, which may explain the relatively longer time to union as compared with others. We persist there is a risk of altering mechanical alignment as a result of rotating a curved bone over a curved intramedullary nail, as demonstrated by the maths in the supplement of our paper and nicely depicted in Fig 9-2d p. 236 in Principles of deformity correction [5]. We believe it is hard to tell whether or not it is of clinical significance and what amount of correction is problematic, as it has never been investigated before, to the best of our knowledge. In-vitro trials (cadaver or saw bone) may provide some answers. We thank again Dr Matuszewski and Herzenberg for their very constructive comments [1].
DOI: 10.1097/BPB.0000000000000164
Reply to ‘Derotational osteotomies utilizing a trochanteric-start intramedullary nail’ Régis Pailhé, Etienne Cavaignac, Laurent Bedes, Jerôme Sales de Gauzy and Franck Accadbled, Orthopaedics Department, Universitary Children Hospital, Toulouse, France Correspondence to Régis Pailhé, MD, Service de Chirurgie Orthopédique, Hôpital Rangueil, 1, avenue du Pr Jean Poulhès, TSA 50032, 31059 Toulouse Cedex, France Tel: + 33 617 970 492; fax: + 33 561 322 232;
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1 2
e-mail: [email protected]
We thank Dr Matuszewski and Herzenberg for their plea for prevention of fat embolism in elective femoral intramedullary nailing [1]. Any effort is indeed welcome to prevent this dreadful and potentially lethal complication. As already replied to the letter from Vialle et al. [2,3], we failed to emphasize in our manuscript that we always perform staged bilateral osteotomy with at least 2 days’ interval between the two procedures and that oxygen saturation is carefully monitored by the anesthetist during reaming. We are all the more aware of this risk that we coauthored the paper from Blondel et al. [4] on this particular topic. We agree that reaming the femoral canal before the osteotomy increases marrow pressurization and its potential complications. It makes sense to perform the holes of the percutaneous poststamp osteotomy before reaming and then to complete the cut, as suggested in this same paper [4]. We insist we ream up to 9.5 mm diameter only, which is relatively low for a femur,
3
4
5
Matuszewski PE, Herzenberg JE. Derotational osteotomies utilizing a trochanteric-start intramedullary nail. J Pediatr Orthop B 2015; 24:274–275. Pailhé R, Bedes L, Sales de Gauzy J, Tran R, Cavaignac E, Accadbled F. Response to comment on the article ‘Derotational femoral osteotomy technique with locking nail fixation for adolescent femoral antetorsion: surgical technique and preliminary study’ by Pailhé et al. J Pediatr Orthop B 2015; 24:171. Vialle R, Bachy M, Ramanoudjame M. Comment on the article ‘Derotational femoral osteotomy technique with locking nail fixation for adolescent femoral antetorsion: surgical technique and preliminary study’ by Pailhé et al. J Pediatr Orthop B 2015; 24:170. Blondel B, Violas P, Launay F, Sales de Gauzy J, Kohler R, Jouve JL, Bollini G. Fat embolism during limb lengthening with a centromedullary nail: three cases. Rev Chir Orthop Reparatrice Appar Mot 2008; 94:510–514. Paley D. Principles of deformity correction. Paris, France: Springer; 2005. DOI: 10.1097/BPB.0000000000000172
Isolated medial humeral epicondyle fracture Viroj Wiwanitkit, Hainan Medical University, Haikou, China Correspondence to Viroj Wiwanitkit, MD, Wiwanitkit House, Bangkhae, Bangkok 10160, Thailand Tel: + 66 24132436; fax: + 66 24132436; e-mail: [email protected]
The recent report on ‘isolated medial humeral epicondyle fracture’ is very interesting [1]. Lim et al. [1] supported ‘the practice of treating significantly displaced medial
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
Letters to the Editor
Letters to the Editor Journal of Pediatric Orthopaedics B 2015, 24:274–276
Derotational osteotomies utilizing a trochanteric-start intramedullary nail Paul E. Matuszewskia and John E. Herzenbergb, aDepartment of Orthopaedics, University of Maryland and bInternational Center for Limb Lengthening, Rubin Institute for Advanced Orthopaedics, Sinai Hospital, Baltimore, Maryland, USA Correspondence to Paul E. Matuszewski, MD, 110 S. Paca St, 6th floor, Baltimore, MD 21201, USA Tel: + 1 410 328 6040; fax: + 1 410 328 0534; e-mail: [email protected]
In the November 2014 Journal of Pediatric Orthopaedics B, Pailhé et al. [1] outlined a technique for the surgical treatment of adolescent femoral antetorsion with an intramedullary nail. They specified a trochanteric-start nail to avoid avascular necrosis of the femoral head that could occur from a piriformis entry point. We applaud the efforts of the authors to avoid the devastating consequences of avascular necrosis of the femoral head. However, we have concerns that their technique, as described, could lead to potentially fatal fat embolism. In their technique, the authors describe reaming the femoral canal before performing the osteotomy. Intramedullary reaming is associated with marrow pressurization and its potential complications [2–4]. Reaming of an unfractured long bone is particularly problematic, as the high pressures generated are not relieved through a fracture site, causing injection of pressurized marrow contents into the circulation. This can lead to fat/air embolism, pulmonary embolism, hypotension, desaturation, and even death [2,3,5,6]. The marrow fat load in the circulatory system would be even higher in bilateral cases. Many authors have suggested the use of venting or a ‘reamer–irrigator–aspirator’ while reaming pathologic (or intact) bones [3,4,7–9]. This effectively reduces the degree of pressurization of the femoral canal, thus decreasing the quantity of emboli. We recommend predrilling the osteotomy site with a 4.8 mm drill bit before reaming [10,11]. These predrilled holes serve to vent the canal (decreasing the potential risk for fat embolism). Furthermore, some of the bone reamings will exit through the vent holes and accumulate around the osteotomy site as a cloud of bone graft, which may aid in osteotomy healing. The level recommended for the osteotomy by the authors is distal metaphysis–diaphysis. This is a relatively wide area of the canal relative to the 8.5 mm nails recommended, which may result in insufficient fixation, particularly in bilateral cases in which limited weight bearing is
difficult to enforce. This complication was demonstrated in patient #3, who had a loss of fixation that resulted in varus malalignment, requiring reoperation and renailing with a larger nail. The authors may wish to consider the addition of blocking or ‘Poller’ screws to help prevent this complication [12]. Alternatively, an osteotomy at a higher level in the diaphysis may be utilized, which is intrinsically more stable. The authors state that their metaphyseal level osteotomy may heal faster than a diaphyseal level osteotomy. However, this assumption is contradicted by their metaphyseal osteotomy healing times (3 months, range 2–6 months), which are greater than those reported for diaphyseal osteotomies by Gordon et al. [13] (average healing time of 6 weeks). The concern of altering the mechanical alignment as a result of rotating over a curved intramedullary nail is unlikely to be of clinical significance given the magnitude of correction reported (13–25°), especially with small diameter nails (8.5 mm). The choice of the osteotomy level (distal metaphysis vs. proximal diaphysis) is more influenced by the alignment of the patella. In cases of patella maltracking (i.e. an increased Q-angle), distal external derotation in the anteverted femur is indicated to help improve the Q-angle and thereby stabilize the patellofemoral joint. In the absence of patella lateral maltracking, one may choose either a proximal or distal osteotomy site [14].
Acknowledgements Dr Herzenberg receives research support from Elipse Technologies. Conflicts of interest
Dr Herzenberg is a consultant to OrthoPediatrics. For the remaining author there is no conflicts of interest.
References 1
2
3
4
Pailhé R, Bedes L, Sales de Gauzy J, Tran R, Cavaignac E, Accadbled F. Derotational femoral osteotomy technique with locking nail fixation for adolescent femoral antetorsion: surgical technique and preliminary study. J Pediatr Orthop B 2014; 23:523–528. Kröpfl A, Berger U, Neureiter H, Hertz H, Schlag G. Intramedullary pressure and bone marrow fat intravasation in unreamed femoral nailing. J Trauma 1997; 42:946–954. Roth SE, Rebello MM, Kreder H, Whyne CM. Pressurization of the metastatic femur during prophylactic intramedullary nail fixation. J Trauma 2004; 57:333–339. Pape HC, Regel G, Dwenger A, Krumm K, Schweitzer G, Krettek C, et al. Influences of different methods of intramedullary femoral nailing on lung function in patients with multiple trauma. J Trauma 1993; 35:709–716.
1060-152X Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
Letters to the Editor 275
5 Stürmer KM. Measurement of intramedullary pressure in an animal experiment and propositions to reduce the pressure increase. Injury 1993; 24 Suppl 3: (Suppl 3):S7–S21. 6 Leddy LR. Rationale for reduced pressure reaming when stabilizing actual or impending pathological femoral fractures: a review of the literature. Injury 2010; 41 Suppl 2 (Suppl 2):S48–S50. 7 Husebye EE, Lyberg T, Madsen JE, Eriksen M, Røise O. The influence of a one-step reamer-irrigator-aspirator technique on the intramedullary pressure in the pig femur. Injury 2006; 37:935–940. 8 Joist A, Schult M, Ortmann C, Frerichmann U, Frebel T, Spiegel HU, et al. Rinsing-suction reamer attenuates intramedullary pressure increase and fat intravasation in a sheep model. J Trauma 2004; 57:146–151. 9 Pape HC, Zelle BA, Hildebrand F, Giannoudis PV, Krettek C, van Griensven M. Reamed femoral nailing in sheep: does irrigation and aspiration of intramedullary contents alter the systemic response? J Bone Joint Surg Am 2005; 87:2515–2522. 10 Rozbruch SR, Birch JG, Dahl MT, Herzenberg JE. Motorized intramedullary nail for management of limb-length discrepancy and deformity. J Am Acad Orthop Surg 2014; 22:403–409. 11 Kogalgu M, Solomin LN, Chelneokov AN, Herzenberg JE, Kovar FM. Lengthening Over a Nail (LON): combined and consecutive use of external and internal fixation. In: Solomin LN, editor. The basic principles of external fixation using the Ilizarov and other devices. Milan: Springer; 2012. pp. 1309–1377. 12 Krettek C, Miclau T, Schandelmaier P, Stephan C, Möhlmann U, Tscherne H. The mechanical effect of blocking screws ("Poller screws") in stabilizing tibia fractures with short proximal or distal fragments after insertion of small-diameter intramedullary nails. J Orthop Trauma 1999; 13: 550–553. 13 Gordon JE, Pappademos PC, Schoenecker PL, Dobbs MB, Luhmann SJ. Diaphyseal derotational osteotomy with intramedullary fixation for correction of excessive femoral anteversion in children. J Pediatr Orthop 2005; 25:548–553. 14 Paley D, Herzenberg JE. Principles of deformity correction. New York, NY: Springer Verlag; 2005. pp. 243–245.
be it from a teen individual. We use narrow shaft diameter and deep-fluted new generation reamers also, so as to provide more relief space for medullary contents. We acknowledge that distal metaphyseal osteotomy does not provide as much stability as the proximal third of the shaft. We have not encountered any other instability issue in our experience of more than 50 cases to date. Blocking or ‘Poller’ screws allow indeed further stability of the distal segment if needed and can also help to achieve desired alignment. Bone healing was defined in our series by complete circumferential callus, which may explain the relatively longer time to union as compared with others. We persist there is a risk of altering mechanical alignment as a result of rotating a curved bone over a curved intramedullary nail, as demonstrated by the maths in the supplement of our paper and nicely depicted in Fig 9-2d p. 236 in Principles of deformity correction [5]. We believe it is hard to tell whether or not it is of clinical significance and what amount of correction is problematic, as it has never been investigated before, to the best of our knowledge. In-vitro trials (cadaver or saw bone) may provide some answers. We thank again Dr Matuszewski and Herzenberg for their very constructive comments [1].
DOI: 10.1097/BPB.0000000000000164
Reply to ‘Derotational osteotomies utilizing a trochanteric-start intramedullary nail’ Régis Pailhé, Etienne Cavaignac, Laurent Bedes, Jerôme Sales de Gauzy and Franck Accadbled, Orthopaedics Department, Universitary Children Hospital, Toulouse, France Correspondence to Régis Pailhé, MD, Service de Chirurgie Orthopédique, Hôpital Rangueil, 1, avenue du Pr Jean Poulhès, TSA 50032, 31059 Toulouse Cedex, France Tel: + 33 617 970 492; fax: + 33 561 322 232;
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1 2
e-mail: [email protected]
We thank Dr Matuszewski and Herzenberg for their plea for prevention of fat embolism in elective femoral intramedullary nailing [1]. Any effort is indeed welcome to prevent this dreadful and potentially lethal complication. As already replied to the letter from Vialle et al. [2,3], we failed to emphasize in our manuscript that we always perform staged bilateral osteotomy with at least 2 days’ interval between the two procedures and that oxygen saturation is carefully monitored by the anesthetist during reaming. We are all the more aware of this risk that we coauthored the paper from Blondel et al. [4] on this particular topic. We agree that reaming the femoral canal before the osteotomy increases marrow pressurization and its potential complications. It makes sense to perform the holes of the percutaneous poststamp osteotomy before reaming and then to complete the cut, as suggested in this same paper [4]. We insist we ream up to 9.5 mm diameter only, which is relatively low for a femur,
3
4
5
Matuszewski PE, Herzenberg JE. Derotational osteotomies utilizing a trochanteric-start intramedullary nail. J Pediatr Orthop B 2015; 24:274–275. Pailhé R, Bedes L, Sales de Gauzy J, Tran R, Cavaignac E, Accadbled F. Response to comment on the article ‘Derotational femoral osteotomy technique with locking nail fixation for adolescent femoral antetorsion: surgical technique and preliminary study’ by Pailhé et al. J Pediatr Orthop B 2015; 24:171. Vialle R, Bachy M, Ramanoudjame M. Comment on the article ‘Derotational femoral osteotomy technique with locking nail fixation for adolescent femoral antetorsion: surgical technique and preliminary study’ by Pailhé et al. J Pediatr Orthop B 2015; 24:170. Blondel B, Violas P, Launay F, Sales de Gauzy J, Kohler R, Jouve JL, Bollini G. Fat embolism during limb lengthening with a centromedullary nail: three cases. Rev Chir Orthop Reparatrice Appar Mot 2008; 94:510–514. Paley D. Principles of deformity correction. Paris, France: Springer; 2005. DOI: 10.1097/BPB.0000000000000172
Isolated medial humeral epicondyle fracture Viroj Wiwanitkit, Hainan Medical University, Haikou, China Correspondence to Viroj Wiwanitkit, MD, Wiwanitkit House, Bangkhae, Bangkok 10160, Thailand Tel: + 66 24132436; fax: + 66 24132436; e-mail: [email protected]
The recent report on ‘isolated medial humeral epicondyle fracture’ is very interesting [1]. Lim et al. [1] supported ‘the practice of treating significantly displaced medial
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
