King Fahd Hospital

No bright idea about the cause. Maybe AVN? Thermal lesion during
reaming? What to do - i'd leave it alone. Check x-rays every 6-12
month.

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Best regards,
Alexander N. Chelnokov
Ural Scientific Research Institute
of Traumatology and Orthopaedics
7, Bankovsky str. Ekaterinburg 620014 Russia

Reviewing all sets of x rays at your site , reflects possibility of low grade infection. His knee pain seems to be due to long nail distally which could be breaching the the articular surface of the troclea of the femur.
I would suggest removal of the nail and obtaining specimens for microbiological study and protective wt bearing in the initial few weeks post removal.He is young and his immune system could be suppressing his infection if it turn to be infection and his nail is not doing any good for him now , rather may be harbouring the organisms.

Dr SALEH WASLALLAH ALHARBY (FRCS)
Consultant and Associate Professor in Orthopaedics,
Department of Orthopaedic Surgery ,
Division of Sports Medicine and Reconstructive Surgery
King Khalid University Hospital and College of Medicine
King Saud University.
P.O.Box 87996, Riyadh 11652, Saudi Arabia.
E- mail alharbys@yahoo.com

http://faculty.ksu.edu.sa/DrSalehAlharby/default.aspx

patient require implant removal first and see weather infection is there or not? a s he might be having subclinicle infection and might not getting in routine investigation , and then do reming and renailing always use titanium nail with proper interlocking with bone grafting is better option for this candidate, by this he may relieved from knee pain also as k nail might irritation g distally due to long and anteriror wall of femur is irritating.

Dr Dhiren Faldu MS(orthopedic surgeon)
Consultant Joint replacement and truama surgeon
Fellow of Department of Adult Joint Reconstruction New York University Hospital for Joint Disease-USA
Rajkot(Gujarat State, India)

If the nail is removed it may refracture the femur. I see too much sclerosis in the distal end. I would do first a gammagram with cipro and run bacterial culture and antibiotic sensitivity. When I get a negative for infection I would the do bone grafting and partial removal of the sclerotic bone with the same nail or other nail

Dear all,
if you see all images in the site you can see patella too lateral: it is possible that pain is related to patellar subluxation (by trauma, congenital dysplasia or surgical approach). If patient has not pain on femur and has patellar pain, I suggest only arthroscopy and patellar realignment.
Best regards,

Sandro Reverberi
Arcispedale S. Maria Nuova
Reggio Emilia
Italy

This has been going on for the last 5 years. There is enough bridging on the posterolateral cortex. Since the cause of the knee pain may be due to the distal end of the nail, the nail can be removed safely. (Hope you can remove it easily!) Swab from the removed nail can rule out any persitant infection.

Dr Vishwanath M Iyer
B106, Kumaradhara, N G V, Bangalore. 560047
91 80 25712134 919742399481

103, Railway lines,Solapur.413001
91 217 2317597/2316783 919822394597

In case there is 70 % bone consolidation from the circumference of the fracture area, so we can safely remove the nail. He has well consolidation. If there is no problemn for him, so leave the nail inside as a support.

I seen this many times , it can be due to extensive dissection & devascularisation of this bone part
I would bone graft it with cancellous graft
thanks
Prof Dr Khaled Emara
Ain Shams Univ.

Most likely low grade infection, if you look carefully you will find there is periosteal reaction.
you need to do ESR, CBC, CRP,
You need to open laterally clean that area from soft tissue, send it for culture,then fill the gap by bone graft taken from iliac crest.
I hope this will do the job.
Let me know what have you done

For my this is a case of infected non union of the femur- the callus on the medial side is the peiosteal reaction for the chronic osteomylities(for 5years) –and this is the cause for lateral bone resorption. This patient if continues weight bearing very soon will get metal failure
I Suggest to remove the nail –bone debidement-then use the Ilizrov ring fixator.

Dr Salah Abouseif

Orthopedic Cosultant-new jeddah clinic hospital

Assalam O alikum wa rahmatullah wa barakatuhu,

Another interesting problem from King Fahd Hospital Madinah. He requirs FBC, ESR , CRP and Bone Scan. He may have a low grade infection. If the Bone Scan and Blood tests are normal, One can go ahead with exchange interlocking nail fixation of the fracture with bone grafting ( tissue culturs and swabs need to be taken to exclude infection).

If the tests suggest that he may have infection, then he requires debriedment and removal of the nail and application of the Illizarov fixator and bone grafting at suitable time till the fracture completely heals.

Dr Syed K I Shah Orthopaedic Surgeon

Preston Royal and Chorely District Hospitals

In My opinion as the pt is walking good with pain at the knee we can try for him something like bone marrow autologous transfusion to be injected at the site of weak callus formation and to keep the nail in its place to act as a buttress for the posterolateral cortex ( which is the same curve for the nail )as long as it is away from the intercondlar notch ( Xray knee is needed ) .
As regard the cause of resorption mostly the butterfly was devascularized from the injury itself or if open nailing done i.e opening on the fracture site at the time of reduction

Dear Dr magdy
Alsalam alycom
Still i think this is sort of low grade infection (was it open nailing ?)
but i will not do any thing now since patient is not symptomatic from mid thigh ,just follow him if xrays showed more resorbtion the plan might change
AYED

Prof. of Orthopaedic Surgery

Al-Azhar university . Cairo Egypt

I believe that the cause of knee pain is the irritation by the extralong nail, the bridging callus in the medial cortex is a real mature bridging bone healing and not a periosteal reaction due to osteomyeilitis! There a possibility of low grade infection which might be the cause of lateral cortical absorption, thermal effect is not possible because I believe manual reaming was used, I think now the nail is doing no good and must be removed, also the remaining circumferential bone is not adequate and not secure to permit safe full wt. bearing and resumption of activities! The best choice is to remove the nail, approach the fracture area and insure no infection, apply a new reamed nail +/- bone grafting if needed. If evidence of infection, I think Ilizarov or orthofix would be a better option.

Dear Dr.Vishwanath.

You wrote 8 мая 2009 г., 23:22:26:

DVI> knee pain may be due to the distal end of the nail, the nail can
DVI> be removed safely. (Hope you can remove it easily!) Swab from the
DVI> removed nail can rule out any persitant infection.

Asymptomatic bacterial coloization of implants is up to 50%,
so without clinical manifestation is is of no meaning.

--
Best regards,
Alexander N. Chelnokov
Ural Scientific Research Institute
of Traumatology and Orthopaedics
7, Bankovsky str. Ekaterinburg 620014 Russia