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.
276 Journal of Pediatric Orthopaedics B 2015, Vol 24 No 3
epicondyle fractures nonoperatively’. Indeed, nonoperative management of medial humeral epicondyle fracture is an interesting issue for discussion. Farsetti et al. [2] reported a similar finding that ‘nonsurgical treatment of isolated fractures of the medial humeral epicondyle with 5–15 mm of displacement yielded good long-term results similar to those obtained with open reduction and internal fixation’. The nonunion outcome is possible, but it does not affect the function [2]. However, there are many issues to be discussed. First, it should be noted that the distance of displacement is an important factor to determine the success of nonoperative management [3]. Second, the type of fracture has to be carefully considered. If the fracture is type 4, operative management is recommended [4]. Second, management in the pediatric population is totally different from that in the adult population. For adults, operative management is suggested [4].
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1
2
3
4
Lim KB, Woo CY, Chong XL, Ul-Alam S, Allen JC Jr. The isolated medial humeral epicondyle fracture treated nonoperatively: does fracture displacement change over time? J Pediatr Orthop B 2015; 24: 184–190. Farsetti P, Potenza V, Caterini R, Ippolito E. Long-term results of treatment of fractures of the medial humeral epicondyle in children. J Bone Joint Surg Am 2001; 83-A:1299–1305. Louahem DM, Bourelle S, Buscayret F, Mazeau P, Kelly P, Dimeglio A, Cottalorda J. Displaced medial epicondyle fractures of the humerus: surgical treatment and results. A report of 139 cases. Arch Orthop Trauma Surg 2010; 130:649–655. Pimpalnerkar AL, Balasubramaniam G, Young SK, Read L. Type four fracture of the medial epicondyle: a true indication for surgical intervention. Injury 1998; 29:751–756. DOI: 10.1097/BPB.0000000000000171
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
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.
276 Journal of Pediatric Orthopaedics B 2015, Vol 24 No 3
epicondyle fractures nonoperatively’. Indeed, nonoperative management of medial humeral epicondyle fracture is an interesting issue for discussion. Farsetti et al. [2] reported a similar finding that ‘nonsurgical treatment of isolated fractures of the medial humeral epicondyle with 5–15 mm of displacement yielded good long-term results similar to those obtained with open reduction and internal fixation’. The nonunion outcome is possible, but it does not affect the function [2]. However, there are many issues to be discussed. First, it should be noted that the distance of displacement is an important factor to determine the success of nonoperative management [3]. Second, the type of fracture has to be carefully considered. If the fracture is type 4, operative management is recommended [4]. Second, management in the pediatric population is totally different from that in the adult population. For adults, operative management is suggested [4].
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1
2
3
4
Lim KB, Woo CY, Chong XL, Ul-Alam S, Allen JC Jr. The isolated medial humeral epicondyle fracture treated nonoperatively: does fracture displacement change over time? J Pediatr Orthop B 2015; 24: 184–190. Farsetti P, Potenza V, Caterini R, Ippolito E. Long-term results of treatment of fractures of the medial humeral epicondyle in children. J Bone Joint Surg Am 2001; 83-A:1299–1305. Louahem DM, Bourelle S, Buscayret F, Mazeau P, Kelly P, Dimeglio A, Cottalorda J. Displaced medial epicondyle fractures of the humerus: surgical treatment and results. A report of 139 cases. Arch Orthop Trauma Surg 2010; 130:649–655. Pimpalnerkar AL, Balasubramaniam G, Young SK, Read L. Type four fracture of the medial epicondyle: a true indication for surgical intervention. Injury 1998; 29:751–756. DOI: 10.1097/BPB.0000000000000171
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
