Spiral fractures of tibia are relatively difficult to nail in anatomical or close to anatomical position. The main reason very likely lies in fracture configuration itself. As the spiral fractures have only one degree of freedom, they will either reduce perfectly or will not reduce at all.
Nailing of spiral fracture requires at least one poller screw in the fragment with broader medullary canal. If we want to apply epicentric/non-epicentric concept, than we need at last two poller screws. One on the each side of the fracture, ideally more or less at the same distance from the fracture. Interestingly, epicentric concepts is in our practice related to a significant lower pain postoperatively, which we can only explain at the moment by lower shearing at the fracture side. Any other explanations are more than welcome.
Open tibial fractures are relatively difficult to manage. Segmental tibial fractures are more difficult to manage. Open, segmental tibial fractures are even more difficult to manage.
If the segmental fragment is avascular, question arrises whether is not better to remove it and proceed with bone transport or bone graft. I assume it depends amongst other factors, on the length of the segment.
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.
Mr Matija Krkovic, MD, PhD
I am Consultant Orthopaedic Trauma Surgeon with special interest in Limb reconstructions and bone infections.