Date: Wed, 2 Feb 2005 19:04:12 -0800

From: Dr. Carla Smith

Subject: Subtroch Fracture Nonunion

62 y/o female, otherwise healthy, 10 months out from open reduction of this subtrochanteric fracture with continued pain, LLD 3 cm.

Although her original xrays from elsewhere appeared accurately reduced she is now in significant varus. I templated placing a blade plate inferiorly in the head and tilting the proximal fragment about 14 degrees to match the other side using an osteotomy blade plate and moving through the fracture nonunion. Would anyone attempt to use another spiral blade with the blade better placed inferiorly and, if so, how would you hold the proximal fragment while doing so? Would everyone bone graft? If so, use autograft and would anyone graft the nail tract? Use BMPs if available? I think the blade track is pristine (at least the place I would put the new blade) but the lateral cortex is largely gone (confirmed by CT a month ago). The AP pelvis and lateral are current (10 months out) and the right hand image is three months after injury.

Thanks in advance for your ideas.

Carla Smith
Bend, OR

Date: Thu, 3 Feb 2005 08:23:00 -0800

From: Solberg, Brian, M.D.

Carla:

I had a number of these, they collapsed the same way into varus. I would take the nail and wires out, perform a valgus osteotomy at the level of the lesser troch per Jeff Mast. I use a 110 or 120 angled blade, I wouldn't use a 95 degree plate. Forget putting in another nail. I error on the side of over correction of the valgus, think the most common technical error is under correction which will lead to another nonunion. Make sure you resect bone at the osteotomy site to good bleeding bone...I suspect some of the bone around the wires is dead. Bone graft yes, BMP no, make sure you compress the osteotomy. Good luck.

Brian Solberg
Los Angeles