Date: Sat, 09 Feb 2002 16:38:14 +0000 (GMT)
From: Chris Oliver
Subject: Norian in Calcaneal fractures
This was a calcaneal fx I operated on in 1999 in a 70 year old lady. I used Norian to support the fracture surface. Subsequent films in 2000, 2001 and 2002 at yearly intervals show virtually no resorption or significant change of the Norian.
This has been my experience with Norian in other fractures, it just does not resorb. May as well use bone cement! (cynical). Do others who have used Norian have similar experience?
Chris Oliver DM, FRCS (Tr & Orth), FRCP
Consultant Trauma & Orthopaedic Surgeon
Edinburgh Orthopaedic Trauma Unit
Date: Sun, 10 Feb 2002 20:44:53 +0100
From: Victor de Ridder
My experience with calcaneal fractures is the same, but also with tibia plateau or acetabular voids filled with Norian. It is great stuff as you can fill every weird void with it and patients can load it after 24 hours, but resorption or remodeling, no. But what the hell, why would you want that if it works the same like this?
Victor de Ridder MD PhD
St Franciscus Hospital, Rotterdam, Netherlands.
Date: Sun, 9 Mar 2003 16:18:16 -0600
From: Frederic B. Wilson, M.D.
This has also been our experience at Tulane. Several authors have suggested that it is unnecessary to fill the void left by reducing the subtalar joint. Having both filled and not filled the void, I lean towards filling with allograft cancellous chips and using 5cc of DBX to cover the chips as suggested by Larry Marsh. We also use the locking plates from Synthes for our fixation. I know your question is about a year old, but came across it while looking for something else and wanted to comment.
Date: Sun, 9 Mar 2003 21:29:32 EST
sorry but a locking plate IS rather bulky and you will have to explain to me how that narrows the calcaneus since the screws stop compressing once they hit the plate. Also unless you walk your calcaneal patients at one month, which you supposedly can do with Norion, adding graft is a waste of time and money as the void fills in within three months without graft. I also dont belive you can walk anyone on allograft chips and DBX having used this stuff over 500 times in other fracture cases (it is a regular adjunct in pilons, plateaus, and for fusions). It should be noted that unless it helps in maintaining an articular reduction it really has no use AS THE BODY FILLS the void within the 3 months it takes to heal the fracture.. Just one man's opinion.
Roy Sanders, MD,
Date: Sun, 9 Mar 2003 20:50:28 -0600
From: Frederic B. Wilson, M.D.
Greetings. We usually reduce the subtalar fragments with a combination of 3.0mm and 4.0mm cannulated screws, trying to fix the chondral fragments anatomically reduced and fixed to the constant (sustentacular) fragment. The locking plate does not seem to be much bulkier than the original Synthes plates and is better configured. The locking screws are not intended to compress the fragments but rather provide the scaffolding to maintain the height, length, and varus/valgus relationship. As for the bone graft/norian/ DBX issue, I suspect that you and several others may be right. That's why I refer to it as a "belt and suspenders" approach. We would probably be well served to look at a sufficient number with and without locking plates, and with and without bone graft to determine by outcomes whether it makes a difference. Probably would take several institutions to pool their data, and that would introduce differences in surgeon technique, experience, etc. I, for example, have done far fewer of these than you. Still, an interesting thought.
Date: Sun, 9 Mar 2003 22:19:21 EST
we wrote a paper on 200 fractures using my synthes plate. we had an 8% plate failure rate, so we then designed the ACE peri plate. Synthes has now connected the dots as well and so the plate wont break. We had originally designed the arms to move up and down, but that made them too weak. At any rate, Since I use a 1 mm thick titanium alloy new perimeter type plate, I have had the occasional broken screw, but absolutely no plate failures in over 210 cases. Locking and or grafting is just not a problem.
Roy Sanders, MD,
Date: Sun, 9 Mar 2003 22:56:27 -0500
From: Clifford Jones, M.D.
with your plate, do you fill all the holes or certain holes? Furthermore, do you change your screw configuration based on the fx pattern, i.e. tongue vs. depression? Also, do you initially place standard compression screws to reduce the tuber and joint width followed by sequential locking screws to lock in your reduction?
Date: Mon, 10 Mar 2003 09:20:56 -0500
yes, I fix the joint first, all with lag screws, and then place the plate. usually I fill the following screw-holes: the first one is the anterior-lateral by the calcaneal cuboid joint. i then fine tune the rotation and lock the plate with the anterior-inferior screw. next i place one or two screws into the posterior end of the plate all under power to get compression and pull the heel out of varus. The final screw, is a lag screw at the uppermost end of the plate to connect the posterior tuberosity to the body. In this way the anterior process, the posterior facet and the tuber are all locked together and the body is stable in height and length.I also never contour or cut the plate. Hope that helps.
Roy Sanders, M.D.