Gun shot fractures/non-unions are very difficult to manage.
Whenever approaching similar non-unions I have already a few conclusions already formed in my head:
I find it extremely difficult to adjust the fine wire frame in tibio-calcaneal fusion. Whilst I have gotten lucky quite a few times in the past, recently I failed twice. Dramatically. This kind of event puts me down quite badly and makes me feel rather incompetent but I cannot even imagine how patients feel. On top of the pain and discomfort, they are all faced with prolonged treatment - more time with a ****** cage on their leg.
Idea is to use TSF on the femur but leave the thigh outside the frame, attach the frame to half pins in the femur and than use it as a standard frame for deformity correction purposes. There are certain limitations:
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.
Mr Matija Krkovic, MD, PhD
I am Consultant Orthopaedic Trauma Surgeon with special interest in Limb reconstructions and bone infections.