Limits...
Treatment of shepherd ’ s crook deformity in patients with polyostotic fibrous dysplasia using a new type of custom made retrograde intramedullary nail: a technical note

View Article: PubMed Central - PubMed

ABSTRACT

Aims: The severe form of coxa vara, the ‘shepherd’s crook deformity’, is always a consequence of a locally extensive form of polyostotic fibrous dysplasia (or McCune-Albright syndrome). Treatment of this deformity is a challenge. The soft bone does not tolerate any implant that depends on the stability of the cortical bone (like plates or external fixators). Intramedullary nails are the most appropriate implants for stabilisation, but if they are inserted from the greater trochanter, they cannot correct the varus deformity enough.

Patients and methods: We have developed a special intramedullary nail that can be inserted from the osteotomy site and can be driven retrograde into the femoral neck in an appropriate valgus position. We have operated 15 legs in 13 patients. The average age at surgery was 14 years and 5 months (6 to 28.9). In all, 11 femora had been operated before (unsuccessfully) with various implants.

Results: The average follow-up was 54.2 months (7 to 132). The average correction of the neck/(distal) shaft angle was 57.5° (10° to 80°) ( = 72.8%). While pre-operatively none of the patients was able to walk without aid, at follow-up only one patient was unable to walk, three used the aid of crutches because of tibial lesions and one patient had an increased external rotation of the leg. At follow-up, most patients were free of pain. One implant broke and had to be replaced.

Conclusion: This new operative method offers the possibility of efficient correction and stabilisation of this severe and difficult deformation.

No MeSH data available.


Related in: MedlinePlus

Principle of the retrograde intramedullary nail. Step 1) Pre-operative situation. 2) As the first step, an osteotomy in the trochanteric area with resection of a lateral wedge in the scheduled angle is carried out. Step 3) With adduction of the leg, the reamer is inserted from the osteotomy site. Step 4) The custom-made nail is pushed down until the epiphyseal plate. Step 5) The central pin is pushed down through the nail and is locked through the epiphysis with a screw inserted from the lateral condyle. Step 6) From the osteotomy site a hole is reamed into the femoral neck in the scheduled direction. Penetration of the cranial cortex should be avoided. Step 7) In the middle of the femoral shaft a window is created. The leg is then abducted and the nail that has circular bulging rings can be pushed into the bore hole with the help of a pestle and a hammer. Step 8) Situation with the nail in situ, two femoral neck screws are inserted through the predrilled holes in the nail.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC5382339&req=5

Figure 2: Principle of the retrograde intramedullary nail. Step 1) Pre-operative situation. 2) As the first step, an osteotomy in the trochanteric area with resection of a lateral wedge in the scheduled angle is carried out. Step 3) With adduction of the leg, the reamer is inserted from the osteotomy site. Step 4) The custom-made nail is pushed down until the epiphyseal plate. Step 5) The central pin is pushed down through the nail and is locked through the epiphysis with a screw inserted from the lateral condyle. Step 6) From the osteotomy site a hole is reamed into the femoral neck in the scheduled direction. Penetration of the cranial cortex should be avoided. Step 7) In the middle of the femoral shaft a window is created. The leg is then abducted and the nail that has circular bulging rings can be pushed into the bore hole with the help of a pestle and a hammer. Step 8) Situation with the nail in situ, two femoral neck screws are inserted through the predrilled holes in the nail.

Mentions: The principle of the retrograde intramedullary nail is illustrated in Figure 2.


Treatment of shepherd ’ s crook deformity in patients with polyostotic fibrous dysplasia using a new type of custom made retrograde intramedullary nail: a technical note
Principle of the retrograde intramedullary nail. Step 1) Pre-operative situation. 2) As the first step, an osteotomy in the trochanteric area with resection of a lateral wedge in the scheduled angle is carried out. Step 3) With adduction of the leg, the reamer is inserted from the osteotomy site. Step 4) The custom-made nail is pushed down until the epiphyseal plate. Step 5) The central pin is pushed down through the nail and is locked through the epiphysis with a screw inserted from the lateral condyle. Step 6) From the osteotomy site a hole is reamed into the femoral neck in the scheduled direction. Penetration of the cranial cortex should be avoided. Step 7) In the middle of the femoral shaft a window is created. The leg is then abducted and the nail that has circular bulging rings can be pushed into the bore hole with the help of a pestle and a hammer. Step 8) Situation with the nail in situ, two femoral neck screws are inserted through the predrilled holes in the nail.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC5382339&req=5

Figure 2: Principle of the retrograde intramedullary nail. Step 1) Pre-operative situation. 2) As the first step, an osteotomy in the trochanteric area with resection of a lateral wedge in the scheduled angle is carried out. Step 3) With adduction of the leg, the reamer is inserted from the osteotomy site. Step 4) The custom-made nail is pushed down until the epiphyseal plate. Step 5) The central pin is pushed down through the nail and is locked through the epiphysis with a screw inserted from the lateral condyle. Step 6) From the osteotomy site a hole is reamed into the femoral neck in the scheduled direction. Penetration of the cranial cortex should be avoided. Step 7) In the middle of the femoral shaft a window is created. The leg is then abducted and the nail that has circular bulging rings can be pushed into the bore hole with the help of a pestle and a hammer. Step 8) Situation with the nail in situ, two femoral neck screws are inserted through the predrilled holes in the nail.
Mentions: The principle of the retrograde intramedullary nail is illustrated in Figure 2.

View Article: PubMed Central - PubMed

ABSTRACT

Aims: The severe form of coxa vara, the ‘shepherd’s crook deformity’, is always a consequence of a locally extensive form of polyostotic fibrous dysplasia (or McCune-Albright syndrome). Treatment of this deformity is a challenge. The soft bone does not tolerate any implant that depends on the stability of the cortical bone (like plates or external fixators). Intramedullary nails are the most appropriate implants for stabilisation, but if they are inserted from the greater trochanter, they cannot correct the varus deformity enough.

Patients and methods: We have developed a special intramedullary nail that can be inserted from the osteotomy site and can be driven retrograde into the femoral neck in an appropriate valgus position. We have operated 15 legs in 13 patients. The average age at surgery was 14 years and 5 months (6 to 28.9). In all, 11 femora had been operated before (unsuccessfully) with various implants.

Results: The average follow-up was 54.2 months (7 to 132). The average correction of the neck/(distal) shaft angle was 57.5° (10° to 80°) ( = 72.8%). While pre-operatively none of the patients was able to walk without aid, at follow-up only one patient was unable to walk, three used the aid of crutches because of tibial lesions and one patient had an increased external rotation of the leg. At follow-up, most patients were free of pain. One implant broke and had to be replaced.

Conclusion: This new operative method offers the possibility of efficient correction and stabilisation of this severe and difficult deformation.

No MeSH data available.


Related in: MedlinePlus