Ortho

1. Duane Anderson, MD

3.  Knee stiffness
 Shortening
 Possible peroneal nerve injury with lengthening
 Length of the distal fragment
 Stability of fixation related to above statement
 Which approach(es)
 What implant(s)

4.  Peroneal nerve release imperative
 Femoral shortening imperative
 Lateral approach therefore a necessity
 Which implant(s), could be medial and lateral plates
 Doubt IM nail or one plate enough even with a locking plate
 Either an IM nail and Lateral T plate or Medial and Lateral T or L plates would be my choice
 These plates are cheap and readily available in most places and allow multiple screw angles and
lengths along with use of 6.5 screws
 Use the longest fully threaded or partially threaded 6.5
 If you find difficulty with trajectory with fully threaded 6.5 then switch to partially threaded 6.5
as you can direct them easier in the distal fragment
 4.5 for the shaft and make sure they engage the far cortex

5.  Be prepared to stepwise address this difficult constellation of problems
 1. address the malunion with correction, shortening and rigid fixation, union in
good position without nerve injury is the first goal
 2. judge if your fixation is solid enough to move, if not sure address stiffness as a
secondary issue
 3. save any bone you remove and use as graft
 Use Vit D and calcium
 Cast if needed to gain union.
 Address the knee stiffness later after union is achieved with another procedure
 Lysis of intra articular adhesions and quadriceps plasty as a secondary procedure
 Avoid infection by avoiding multiple surgeries in short intervals!!!!

9. ADD A LATERAL PLATE 6.5
PARTIALLY THREADED
DISTAL SCREWS AND 4.5
PROXIMAL SCREWS, SCREWS
AROUND THE ROD

13.  If your fixation fails because you try to attack all problems at once you likely
completely and permanently fail in helping this unfortunate young man
 Get a union first before moving unless you are sure your fixation is solid
 Avoid repeated failed operations, they end in disaster for your reputation and the
patients benefit
 Cus be cus, enkale be igur
 Little by little the egg walks