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.
At this stage we became involved. Thorough discussion about different treatment options was carried out and finally agreed to proceed with limb salvage using limb reconstruction techniques. The plan was divided into stages:
1. Resection of the infected bone with insertion of a cement spacer and temporary stabilisation of the leg if possible internal fixation but not a nail
After 4-6 weeks we planned to proceed to:
2. Application of external fixator and filling the bone defect using callus distraction techniques providing that soft tissue recovered and infection settled
It was completed relatively uneventful. Infection settled. Sinuses dried up. Decision was made to continue with Stage 2.
Initial plan was to perform corticotomies in the proximal femur and the distal tibia. This was abandoned due to an unpredictable nature of the problem. Only distal tibia corticotomy was planned to allow exit option in case of failure in the form of an above knee amputation.
From the previous case we have learned that "double pulley" system is just about "strong" enough. Hence "tripple pulley" system was created.
27 February 2017
Calus distraction started really well. Good regenerate. No clinical sign of infection. Also seroma is currently under control.
Two half pins were removed and callus distraction will continue using cable - 3 clicks 4 times per day (triple pulley).
10 March 2017
Excellent progress. Infection so far under control. Patient very happy and progressing well. as you can see on the X/rays below there is an excellent regenerate. So far we have grown 3.5cm of bone. 18.5cm to go. Pulleys are working brilliantly so far.
27 March 2017
Patient was admitted with signs of infection, possible sepsis. Swelling formed at the from of the leg, at the level of the previous knee joint. Unfortunately it bursted before we took him to theatre where we debrided it, washed it out thoroughly and inserted an Irrigation VAC. Samples were taken as well and antibiotics were adjusted as per Infectious Diseases Consultant advice.
On the X-ray I can see very good regenerate for now. It was not obvious during the surgery that the infection has propagated down the leg, but clinically it certainly did not look like it.
19 April 2017
Irrigation VAC has been changed three times. It looks that the infection is under control. The cavity is shrinking in volume.
Regenerate continues to grow despite everything.
22 April 2017
Irrigation VAC has been removed. Wound clean. Leg shortened at the level of the defect to allow tension free wound closure over a Redivac drain. Proximal edge of the transported fragment was chamfered to allow easier future passage underneath the scar. For now will use clickers again to distract the corticotomy and transport the fragment, when cable and pulleys will maintain fragment's proximal position until it gets safe to dock the fragment.
09 May 2017
Infection is again under control. Patient feels really good. The skin and the wound healed and healthy looking. The same with all pin sites. So far we have reached 9.5cm of regenerate and it looks good as you can see on the X-rays below. There are calcifications at the knee level but also still some remnants from Stimulan. No fluid level at the level of previous abscess treated with Irrigation VAC what is encouraging.