Open fractures of the lower limb are still posing a significant problem. If not in acute management, certainly longterm management is still an issue. How to manage these patients in a timely manner with as low complication rate as possible remains open for discussion.
I will be presenting our management of a patient with open fractures of distal femur and tibia together with the destruction of the medial femoral condyle beyond reconstruction. Whilst an amputation is certainly the quickest solution, it is not as good on a long term. Reconstruction again seems expensive and time consuming, but it looks that it is cheeper on a long run and offers better life quality.
There is no clear or good evidence how to manage severely injured limb in patients who are already retired. As the amputation brings significantly increased energy demand, on the other hand reconstruction exposes them to significantly increased risk of surgical and non surgical complications.
Two questions remain:
In this blog I will be presenting a treatment of a retired patient with a significant soft tissue injury and critical bone defect with the destruction of distal tibial articular surface.
14 May 2017
Severe lower leg injury which required immediate below knee amputation due to the vascular compromise at the level of lower leg. Despite severe comminution and soft tissue defect, parts of the femur and thigh have been saved. There were other concomitant injuries but not life threatening.
Chronic Osteomyelitis post knee fusion and revision fusion following multi ligamentous knee injury and repair
Chronic Osteomyelitis still represents difficult problem in a day-to-day practice of an orthopaedic surgeon. Closer to the centre of body we come, more difficult it gets to eradicate the infection in a bone.
It is well accepted that the most reliable way of eradicating a bone infection is to remove the infected bone. Unfortunately this is not always possible. Even if it is, it comes with a price and limitations.
Growing new bone does not represent a significant challenge any more in current orthopaedic practice. In Chronic Osteomyelitis management, growing new bone using callus distraction methods remains reliable and predictable tasks. Soft tissue management unfortunately is not.
Quite often femoral fractures (particularly open ones) do not want to heal despite "dynamisation", bone graft, compression, exchange nailing,... One of the explanations is probably in "not neutralising" shear forces. There are a few examples on this website as to how I tackle "shear" forces and fracture/non-union healing.
I present a 2 year and 4 months old femoral non-union after an open femoral fracture which was previously treated with multiple procedures as mentioned above. Despite all the effort the non-union persisted and caused significant pain with leg shortening of 3-4 cm.
Due to previous failed attempts we decided to resect the non-union and start bone transport together with limb lengthening. For this purpose we exchanged the existing nail for a thinner one and applied a Modular Rail System from S&N.
X rays and a scanogram below show the nonunion.
Current strategy for femoral/tibial non-unions is:
Open tibia fractures have a high risk of infection.
It is well accepted that soft tissue injuries in open fractures should be debrided agressively, while bone should be preserved as much as possible. Is bone not a tissue or does it responds better to infection?
I am presenting a case of an open tibia fracture (high energy injury looking from the X-rays and CT scan) and the way we are managing it.
At the time of starting this blog we have completed or almost completed 20 patients with similar injuries. Results are encouraging and pending definitive review and publications.
Distal femoral fractures are complex injuries which do not tend to heal quickly. For closed injuries I tend to tell my patients that it will take at least 12 - 18 months for the fracture to heal. Open fractures with bone defects take even longer to heal and require special limb reconstruction techniques. Preventing complications, predominantly infection is of a paramount importance.
Comminuted distal femoral fractures are not easy fractures to treat and heal. If they are open fractures the problem is even bigger. Those fractures are usually seen in the young, active male population, but can happen in the senior age group as well.
I am presenting a case of an open comminuted distal femoral fracture with a bone defect in the region between 8-10 cm (it depends on how it is measured and if you accept any leg shortening as a result of it). Injury happened as a result of an RTA.