Nonunion of the Long Bones
Diagnosis and treatment with compression-distraction techniques
13
Redento Mora (Ed.)
Nonunion
of the Long Bones
Diagnosis and treatment with
compression-distraction techniques
Foreword by Dror Paley
REDENTOMORA
Department of Orthopaedics and Traumatology
University of Pavia Città di Pavia Institute Pavia, Italy
Library of Congress Control Number: 2005936344
ISBN 10 88-470-0408-X Springer Milan Berlin Heidelberg New York ISBN 13 978-88-470-0408-5 Springer Milan Berlin Heidelberg New York
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Foreword
Professor Mora’s book on pseudoarthrosis is a comprehensive text, based on his carrer’s interest and expertise in this field. While previous texts have focused on internal fixation methods, this new one also details the use of external fixation methods, in particular those introduced by Professor Gavril Abramovitch Ilizarov. Methods of compression, distraction, and bone transport of the pseudoarthrosis have added to the armamentarium and success of treatment of this frequently unsolved orthopaedic problem. These newer methods have great- ly reduced the need for amputation as the final solution for this disease.
This text has three parts. The first part deals with present-day knowledge of the mechanisms of fracture healing and the features and diagnosis of nonunions.
The second presents indications, surgical methods, and technical details for treatment of noninfected and infected nonunions. In the third part, the first chapters discuss several important subjects connected with the nonunion prob- lem, and the final chapters, dedicated to computer-assisted surgery and docu- mentation systems, explore future perspectives of compression-distraction tech- niques in the management of nonunions.
With a wide range of diagrams, x-rays, and photogaphs, Professor Mora’s book guides the reader through the classification, strategy of treatment and methodology. Throughout twenty-two chapters, this new publication, offers the most exhaustive overview on this subject since Weber and Cech brought out their research three decades ago.
Dror Paley Director, Rubin Institute for Advanced Orthopaedics Co-Director, International Center for Limb Lengthening Sinai Hospital of Baltimore
Preface
Expressions such as “compression-distraction techniques”, “transosseous osteosynthesis methods”, and “circular external fixation”, born in past decades in the former Soviet Union, are interchangeable and will be used in this book without distinguishing between them. Moreover, the term “screw” is used throughout this volume instead of “fiche”, as established in the Instructional Courses “External Fixation in Italy” which took place in the 1990s.
These methods, almost unknown in Western countries until 30 years ago, have a very ancient past. Indeed, the description of a circular external fixation system for the purpose of reducing and immobilizing leg fractures dates back to Hippocrates, about 2,400 years ago. It was not until the twentieth century, howev- er, that both the theory and practice of circular external fixation was further developed to a greater extent. The American surgeon Bittner, in 1934, had the idea of a circular external fixation system so perfect that it can be considered the real precursor of today’s systems. At the same time the Italian surgeon Della Mano, in 1938, described a ring apparatus which he successfully used to treat leg fractures. However, the German surgeon Wittmoser was credited with recogniz- ing the advantages of external circular fixation based on two or more crossed wires on a single ring plane.
Unfortunately, these systems only met with little success in Western countries.
The concepts, devices, and applications for circular external fixation were highly developed in the former Soviet Union, though, mainly thanks to the work and colloboration of G.A. Ilizarov in Kurgan, M. Volkov and O. Oganesian in Moscow, and V. Kalnberz in Riga. From there, these methods gradually began to spread to Western Europe and America in the 1980s. This somewhat disordered and uncontrolled diffusion produced two unfavorable consequences: the conviction that these techniques were “miraculous” (being the remedy for all problems, that is, any orthopaedic and traumatological pathology) and “easy”, and that a rapid and superficial knowledge of wire and screw application sites was sufficient to employ the technique. That inevitably produced treatment indication errors (first an excess of indications and then in the kinds of defects) and insufficient treat- ment (mainly postoperative), and led many specialists away from this area of orthopaedics and traumatology.
In the orthopaedic literature, many good treatises on fracture nonunions and excellent texts on compression-distraction systems have been published, but sci- entific papers concerning the treatment of nonunions with external fixation techniques are poorly represented, and most of all, they rarely address the main problem: specify the indications. That is the aim of the present work.
It must be undercored that all the photographs refer to clinical and radi- ographic features of patients treated in the Orthopaedic Department of the University of Pavia – “Città di Pavia” Institute, and that all the preparations and microphotographs of biological specimens were performed at the research labo- ratories of the same department.
This text is based on knowledge gained over almost 30 years, starting with a long stay in the former Soviet Union in 1978 and 1979 and extended by an ever- increasing intensive collaboration with the Central Institute of Orthopaedics and Traumatology of Moscow and with the Latvian Institute of Traumatology and Orthopaedics of Riga, and on the continuous practice and development of the devices and the operative techniques of compression-distraction. This has result- ed in about 3,000 patients personally treated both in the former Soviet Union and in Italy for orthopaedic and traumatological pathologies.
This work aims to debunk many still existing myths concerning circular external fixation methods, to specify the indications, and to show exactly the lim- itations of these techniques.
We do not dwell on preconstituted and, in general, hardly useful assembly schemes (also because the choice of the best assembly always depends on the orthopaedic surgeon), and instead focus on and describe the technical details that experience makes more important and interesting.
I extend warm thanks to the international and Italian colleagues who, with some fundamental chapters, collaborated with me and gave of their precious experience to write this book.
I sincerely thank all my assistants, who patiently and competently helped me prepare texts and images for each chapter.
Finally, I would like to thank our publisher Springer-Verlag for the competent collaboration to achieve the best presentation of this work.
Redento Mora
VIII Preface
Contents
Section I Fracture Healing
Diaphyseal Fracture Repair
R. MORA, L. PEDROTTI, G. TUVO . . . . 3
Assessment of Fracture Healing
L. PEDROTTI, B. BERTANI, R. MORA . . . . 15
Section II Nonunions: General Features
Failure of Union
R. MORA, L. PEDROTTI, G.B. GALLI . . . . 27
Section III Nonunions: Diagnosis
Diagnosis
R. MORA, L. PEDROTTI, G. TUVO, S. GILI . . . . 41
Diagnosis of Infection
A. MACCABRUNI, R. MORA . . . . 47
Section IV Nonunions: Treatment
Prevention
R. MORA, L. PEDROTTI, G.B. GALLI, S. GILI, A. MACCABRUNI . . . . 57
Nonunions: Treatment Objectives and Options
R. MORA, G. TUVO, S. GILI, M. MICELI . . . . 69 Compression-Distraction Systems
R. MORA, B. BERTANI, G. TUVO, G.B. GALLI . . . . 77
Compression-Distraction Methods
R. MORA, B. BERTANI, L. PEDROTTI, G. TUVO, S. GILI . . . . 89
Treatment of Noninfected Nonunions:
Techniques Other Than Compression-Distraction Methods
L. PEDROTTI, R. MORA, B. BERTANI . . . . 119
Treatment of Infected Nonunions:
Techniques Other Than Compression-Distraction Methods
R. MORA, G. TUVO, M. MICELI, S. GILI . . . . 137
Treatment of Noninfected Nonunions: Hypertrophic Nonunions
R. MORA, L. PEDROTTI, B. BERTANI, G. TUVO . . . . 147
Treatment of Noninfected Nonunions: Normotrophic Nonunions
G. TUVO, R. MORA, G.B. GALLI . . . . 173
Treatment of Noninfected Nonunions: Atrophic Nonunions
R. MORA, L. PEDROTTI, B. BERTANI, M. MICELI . . . . 177
Treatment of Noninfected Nonunions: Parafocal Osteotomy
B. BERTANI, L. PEDROTTI, S. GILI, G.B. GALLI, R. MORA . . . . 189
Treatment of Infected Nonunions
R. MORA, L. PEDROTTI, B. BERTANI, F. QUATTRINI . . . . 199
Amputations and Prosthetic Fitting
R. MORA, B. BERTANI, L. PEDROTTI . . . . 225
Antibiotic Therapy
A. MACCABRUNI, R. MORA . . . . 231
Rehabilitation
L. PEDROTTI, G. TUVO, B. BERTANI, R. MORA . . . . 241
Prevention of Venous Thromboembolism
L. PEDROTTI, R. MORA, G.B. GALLI, G. TUVO . . . . 247
X Contents
Section V Future Directions
Future Perspectives: Computer-Assisted Surgery
P.P. RAGUZZI, R. MORA . . . . 259
Method of Unified Designation of External Fixation
L.N. SOLOMIN . . . . 269 Subject Index . . . . 283 XI Contents
BARBARABERTANI
Assistant Surgeon
Department of Orthopaedics and Traumatology
of the University of Pavia Città di Pavia Institute Pavia, Italy
GIOVANNIBATTISTAGALLI
Orthopaedic Fellow University of Pavia School of Medicine Pavia, Italy
STEFANOGILI
Orthopaedic Fellow
University of Pavia School of Medicine Pavia, Italy
ANNAMACCABRUNI
Professor of Infectious Diseases University of Pavia School of Medicine Department of Infectious Diseases of the University of Pavia
Policlinico San Matteo Pavia, Italy
MILENAMICELI Orthopaedic Fellow
University of Pavia School of Medicine Pavia, Italy
REDENTOMORA
Professor of Orthopaedic Surgery University of Pavia
School of Medicine
Director of the Department of
Orthopaedics and Traumatology of the University of Pavia
Città di Pavia Institute Pavia, Italy
LUISELLAPEDROTTI
Chief Assistant Surgeon Department of Orthopaedics
and Traumatology of the University of Pavia, Città di Pavia Institute
Pavia, Italy
FABRIZIOQUATTRINI
University of Pavia School of Medicine Pavia, Italy
PIERPAOLORAGUZZI
Sales and Applications Engineer BrainLAB AG
Munich, Germany
LEONIDN. SOLOMIN
Head of External Fixation Department R.R. Vreden Russian Research Institute of Traumatology and Orthopaedics St. Petersburg, Russia
Contributors
XIV
GABRIELLATUVO
Assistant Surgeon
Department of Orthopaedics and Traumatology
of the University of Pavia Città di Pavia Institute Pavia, Italy
Contributors
