broken DHS Lag screw

[Ajmal Yasin]

70 yrs old patient with 11 months old Inter trochanteric fracture  fixed with DHS. Now severly painful with broken DHS screw. ESR and CRP normal. Plan to revise. How to remove the screw as dont have any fancy retrival instruments.In case cant remove the broken piece, what implant should be reinserted for fixation.
Dr.Ajmal Yasin

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[RS vashishta]

Dear,Dr.Ajmal,there are hollow mills avilable,to retrieve the broken
screws ask your local dealer,but remove if u can easily,do not try too
hard,u can leave it there and fix it with a rt. angle blade plate,can
use thick cancellous instead of the usal 4.5 cortical in the
proximal,region to get a solid fixation,or a pox.fem locking plate.do
a local Phemister type of grafting.
regards
Dr.R.S.VASHISHTA
www.vashishtaorthopaedcs.

--
VASHISHTA Clinics & Hospitals For Orthopaedics
www.vashishtaorthoilizarov.com

[Dr.Dhiren Faldu]

looking at the x ray i dont think that to difficulty in removing this screw occur.
if no fancy intruments then also try , on last try also stuck a thine ST pin in screw hole and then removed with  T handle.

--
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)

[Dino Aguilar]

I will try to get it with a ended mouth forcep
If that not posible whatever I do will destroy the head and will convert to a total hip
Regards

Dino

Correo electronico generado desde un BlackBerry de movistar Nicaragua

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From: Ajmal Yasin <ajma...@hotmail.com>

Date: Thu, 15 Oct 2009 05:47:56 +0000

To: <orth...@googlegroups.com>

Subject: [Orthopod] broken DHS Lag screw

[Myles Clough]

The critical point is not (IMO) that the screw is broken, but that the fracture is ununited. If the fracture had united the screw would not have broken. 

Reverse obliquity fractures are difficult (see JBJS paper 2001) and many fail with sliding nail fixation especially if the reduction is not anatomic. There is a considerable literature about this The consensus seems to be that reverse blade plates or intramedullary devices like a recon nail are the best initial option.

So, the focus of planning for this patient should be the treatment of the non-union not the hardware removal. If you are going to replace the sliding nail or use an IM device, then you have to remove the broken part of the screw. I would personally advise against this as I wonder how much hold you will have in the femoral head. To get the screw out I would take an olive tipped fine wire from the Ilizarov set, shorten it to just beyond the olive and pass it through the screw head. (test that it will go through and improvise if it doesn't). Then 'stack' another smooth wire or two into the hole to jam it. You should then be able to unscrew it.

 Like Dr Vashishta I would use a condylar blade plate + bone graft + reduction & interfragmental screws to treat the non-union. Hemiarthroplasty or Total hip replacement is an option but you would need a calcar replacement component as the fracture goes well down into the subtrochanteric region.

Myles Clough MD FRCSC

Orthopaedic Surgeon, Retired

Kamloops, BC

myles...@shaw.ca

Clinical Instructor, University of British Columbia

Associate Editor, Orthogate www.orthogate.org

Editor, Orthopaedic Web Links (OWL) www.orthopaedicweblinks.com

Myles Clough MD FRCSC

Orthopaedic Surgeon, Retired

Kamloops, BC

myles...@shaw.ca

Clinical Instructor, University of British Columbia

Associate Editor, Orthogate www.orthogate.org

Editor, Orthopaedic Web Links (OWL) www.orthopaedicweblinks.com

[prof eid]

Dear Myles
With respect, this is not a reverse obliquity fractures. See attached image from Campbell.
As for the current problem. I think attempting to remove the screw head may lead to more damage. Better to leave it alone and use a fixation device that avoids the broken part, e.g. blade plate as the pain probably comes from the nonunion.

Abdelsalam EID
Assistant Professor Orthopedic Surgery.
Zagazig University, EGYPT.

[Myles Clough]

Brain fart! My apologies

Myles

<Image006.jpg><Image007.jpg>

[Gaurav Bhalla]

I would like to see the X ray. However, if the broken piece of the screw is in the head or proximal neck a proximal femoral locking plate may be used for an inter troch #.

 

Dr.Gaurav N Bhalla
D'ortho; MS Ortho
Orthopaedic surgeon and traumatologist
++91-9935693677; ++91-9415406331

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From: Myles Clough <myles...@shaw.ca>
To: orth...@googlegroups.com
Sent: Tuesday, 20 October, 2009 11:46:07
Subject: [Orthopod] Re: broken DHS Lag screw