Abdominal flank bulge following intercostal neurectomy for symptomatic rib fracture nonunion

The gold standard for rib fracture nonunion management remains a matter of debate. Operative treatment of rib fracture nonunion has become increasingly popular. A 69-year-old man was operatively treated with intercostal neurectomy of the left eighth rib to resolve chronic thoracic pain following a rib fracture nonunion. After the intervention, the patient developed a flank bulge which was most likely due to the intercostal neurectomy, causing partial denervation of the abdominal musculature. Although the pain at the nonunion site decreased after the operative intervention, the patient still experienced severe pain during daily activities and reported poor quality of life due to the flank bulge. Physiotherapy and an abdominal belt did not improve this flank bulge. When considering operative neurectomy of the intercostal nerves of ribs 7–12 to resolve chronic pain due to rib fracture nonunion, the treating surgeon should be aware of this debilitating complication.

Endoscopic resection of scar tissues and bone graft with an intramedullary nail left in situ for distal femoral nonunion after nailing: A case report

Femoral shaft nonunion after the intramedullary nailing has been successfully treated with advances in surgical technique. Nonetheless, the techniques cause morbidity to periosteum at the fracture site. We report the case of a 67-year-old man who underwent endoscopic surgery for refractory nonunion following the fracture of the distal femoral shaft, despite two fixations using an interlocking nail. In addition, the patient had uncontrolled diabetic mellitus. Endoscopy allowed us to acquire a clear view of the nonunion site, in which the resection of scar tissues and the packing of the cancellous bone were performed. At the final follow-up, bone healing was observed, and the patient was able to return to normal daily and social activity.

Percutaneous, Transtrapezial Fixation without Bone Graft Leads to Consolidation in Selected Cases of Delayed Union of the Scaphoid Waist

Purpose We evaluated clinical and radiographic outcome of percutaneous transtrapezial fixation of the scaphoid delayed union or nonunion using a headless bone screw without bone grafting. Methods Sixteen patients with delayed union or nonunion of the scaphoid were included in this retrospective study between 2006 and 2011. All patients had a delayed presentation of scaphoid fracture, and none of them was treated conservatively elsewhere. Patients with bone graft, sclerotic bone debridement, or displacement of the fragment at the nonunion site were excluded. A percutaneous transtrapezial fixation technique was used in all cases. Patients were reviewed until clinical and radiographic union was observed. At the final follow-up, DASH (Disabilities of the Arm, Shoulder and Hand) and PRWHE (Patient-Rated Wrist and Hand Evaluation) outcome scores were completed. Results Radiographic union was obtained in 15 out of 16 patients (94%) at an average follow-up of 36 months (range: 12–98 months). No complications from the percutaneous technique were noted. The average DASH score was 6 (range: 0–39) and the average PRWHE score was 10 (range: 0–56). No statistical significant difference in range of motion and grip strength was found between the operated side and the contralateral side. Conclusion Percutaneous transtrapezial screw fixation for delayed or nonunion of selected scaphoid fractures without bone grafting is promising. At a mean of 4 months, 94% union was obtained with good functional results when there was no sclerosis, minimal osteolysis, and no displacement at the scaphoid nonunion site. Type of Study Therapeutic study. Level of Evidence IV.

Nonunion Paediatric Femoral Neck Fracture Treatment without Open Reduction

Objectives Fractures of the proximal femur account for less than 1% of all children's fractures. Because of this, most orthopaedic surgeons lack enough experience in treating them. This adds to the rather high incidence of complications especially nonunion. At the time of this review there is no consensus on which method of treatment of the nonunion is the best. The objective of this study is to present our method of treatment to correct the nonunion without open reduction of the nonunion sites. Method 9 children with nonunion of the proximal femur with an average age of 10.2 years (2-14 years old) were included in the study. There were 7 males and 2 females. All of them underwent at least 1 operation to treat the initial fractures and the nonunion. The nonunion in all these 9 cases was treated with valgus intertrochanteric osteotomy without open reduction of the nonunion site. The healing time of the nonunion, the postoperative neck-shaft angle and the functional outcome were evaluated. Results All the nonunion cases had coxa vara and had bone resorption of the femoral neck with x-ray evidences of avascular necrosis (AVN). Ratliff classification was used to classify the AVN, Ratliff type 3 was found in 4 cases, Ratliff 2 in 1 case and Ratliff 1 in 4 cases. Patients were followed for an average of 68 (range 36-156) months. All patients had x-ray evidence of solid union of the nonunion in an average time of 15.4 (range 13-18) weeks and union of the osteotomy sites within10.6 (range 9-12) weeks. The postoperative neck-shaft angle averaged 135° (range 125°-150°) compared to 98° before the surgery. The increase in the amount of neck-shaft angle was statistically significant (p<0.001). Using Harris Hip Score, 2 patients were graded as excellent, 3 patients were graded as good and 4 patients were graded as fair. Harris Hip Score was significantly improved compared to the preoperative status (p<0.001). Conclusions Nonunion paediatric femoral neck fracture treatment could be successfully treated without open reduction by using valgus intertrochanteric osteotomy. All patients obtained union of the nonunion site and the osteotomy site in this study. Harris Hip Score showed significant improvement. This technique can be used to treat nonunion with associated coxa vara, bone resorption and AVN with satisfactory results even in cases who had received several operations before.

Nonunion with Breakage of Gamma Nail and Subsequent Fracture in the Ipsilateral Femur

We describe a rare case with breakage of gamma nail accompanied by nonunion of the original fracture and a subsequent new fracture in the ipsilateral femur. A 73-year-old woman suffered a subtrochanteric fracture of the femur, and the fracture was fixed with gamma nail at a previous hospital. However, fracture reduction was not adequately achieved and a large gap remained between the fracture fragments. The fracture demonstrated atrophic nonunion 10 months after surgery, and autologous bone grafting was performed at the same hospital. Two months after the second surgery, a breakage of the nail at the distal screw hole was observed. Twenty-six months after the second surgery, the patient fell and a fracture occurred at the level of the nail breakage. The atrophic nonunion site and fresh fracture site were very close thus demonstrating a segmental fracture. We exchanged the original gamma nail with a long gamma nail and performed autologous bone grafting at the nonunion site. Both the fresh fracture site and the nonunion site obtained bony union. This tragic chain of events was caused by inappropriate initial treatment and replacing the nail to a longer nail and autologous bone grafting were effective as salvage surgery.

Salvage Technique for Treatment of Periplafond Tibial Fractures: The Modified Fibula-Pro-Tibia Procedure

We describe a technique of fixation for treatment of distal tibia periplafond fractures and nonunions that uses a modification of the principle of the fibula-pro-tibia procedure (fusing the tibia and fibula together to create a one-bone lower leg). The fibula is plated, and the screws are brought across to the medial tibial cortex. The procedure is accomplished with or without a tibial buttress plate and always includes iliac crest bone grafting of the nonunion site and synostosis. We have used this technique in five patients with satisfaction.