CT images below speak for themselves. Significant open fracture with gas around bone and soft tissue defect which required massive free flap.
Unfortunately bone became infected with patient becoming properly septic after second stage of Masquelet procedure has been done. Additional surgical debridement with removal of bone graft and VAC irrigation was used to clear the infection. All the metalwork was removed and replaced with circular frame. Patient was put on prophylactic antibiotics after discussion with microbiology consultant. Bone defect was again filled with the bone cement mixed with a bone substitute loaded with antibiotics. Non-union of proximal tibia was still present.
After the infection settled subtotal removal of bone cement was done, one broken olive wire was removed and replaced with two olive wires. Distal tibial corticotomy was done using a drill-bit and an osteotom (low energy corticotomy) and distraction osteogenesis will start next Wednesday, 9 days post corticotomy. "Clickers" which were already included in the original frame will be used to lengthen the leg back to the length after the docking of the proximal non-union will cause leg to shorten in my estimate for around 5 cm. Corticotomy will also increase the blood supply in the area.
Current plan is:
31 July 2015
Certain progress has been made. Distal tibia corticotomy has been done and lengthening started using Ilizarov apparatus. So far we reached around one cm of length with already visible regenerate. Also proximal fracture (non-union) has been disimpacted using TSF, lengthened and positioned (aligned) in preparation of docking of the proximal into medullary cavity of the distal fragment. On two X-rays below tip of the proximal fragment is marked with an yellow arrow and the medullary canal with white one. Hopefully docking will happen in next few weeks whilst lengthening will continue with the speed of 1mm/day.
Currently all pin sites are dry, no discharge, frame feels stable but weight bearing is a bit painful.
04 August 2015
One week after we started with the compression of the fracture site X-ray suggests that fragments are traveling in the planned direction. Speed of compression is 2mm per day, when distraction of distal corticotomy is 1mm per day. Leg is still shorter for around 1 inch but will get shorter in next few weeks for more than 2 inches altogether. This is my current estimate, but I don't know how far into the mid fragment we will be able to get the proximal fragment. More compression we can get, the better.
Corticotomy side is distracted for another 7mm (14mm altogether) and good bone regenerate is visible. All pin sites are dry including proximal half pin which is HA coated. Today we changed one strut, another one is due in next few days (as per TSF prescription).
Ap and lateral view X-rays are suggesting good apposition of the proximal fragments and good callus formation in the level of corticotomy.
11 August 2015
We are getting more problems (complications) recently but we are in the most crucial part of the job. This is certainly anticipated therefore follow ups in one week increments.
One of the slotted screws broke. doesn't happen very often but knowing that they are withholding 1000N force through the wire and compressing the wire (friction force between wire and the ring enables stability) to the ring to maintain the fixation is not a surprise. My estimate of torque required to fix a wire to the ring is in the range of 10-15Nm. It is certainly easier to mange than broken wire. Slotted bolt gets replaced with a new one and wire tension re-established the old fashion way - using spanners only.
Otherwise X-rays show progress as planned. Proximal fragment is moving into the mid fragment (yellow arrow) when distal corticotomy is getting bigger (another 7 mm since the last time, blue arrow). One of the expected complications (drawbacks) is tightening of the Achilles tendon due to the lengthening of the leg. Only physiotherapy can help at the moment but we will also slow down the distraction speed to 0.5mm per day as we have already reached 2cm of new bone and the risk of premature consolidation is smaller. But still can happen. Will keep an eye on it.
Plan for the next week:
18 August 2015
Everything is going well. Still pain at the level of the mid shaft tibia, not as much in the ankle joint. Pin sites dry and clean. On the X-rays below you can see that the proximal fragment is getting into the mid fragment as originally planned. Clinically it looks that we have achieved the "docking" point as majority of the struts are tight to the level where they cannot be turned anymore by bare hand. Another TSF prescription given to correct apex posterior deformity on the lateral view, but not compressed it anymore.
Due to the deformity, proximal ring is impinging on the skin. Skin is padded and protected, but further correction should remove ring from the skin. Hopefully. But it is difficult to predict due to the moving fragment around the place.
Distraction of the distal tibia is going well, good regenerate visible.
11 September 2015
I was on a holiday, therefore a bigger gap. But everything was under control.
Proximal fracture (yellow arrow) was translated and compressed further with some visual effect on the latest X-rays and corticotomy gained further length (blue arrow). Almost reached the length of the leg as per original plan. Another inch or so to go. Had to change clickers for longer ones (will be visible on the next X-ray next time) and longer threaded bars to allow further lengthening. No obvious infection around pin sites.
13 October 2015
Both legs have equal length. Distraction osteogenesis is completed. Patient is well in himself. Still pain in his leg and ankle, but less since stopped distraction. Pin sites are generally dry, clean, some discharge from few of them. Nothing to worry about at the moment. Ankle is still stiff but is improving slowly (close to neutral dorsiflexion). Knee movement is from 0-95 deg. I am very happy with it. Recent inflammation markers were normal. This is excellent news.
X-rays were impressive today with excellent regenerate in the distraction site (blue arrow) but even more surprisingly was new callus formation at the level of the compression site (yellow arrows). I certainly did not expect to see callus at this point. Expected few months later, if I am honest. I am very optimistic.
As I have only presented X-rays recently I asked the patient if I can take few pictures to better present the soft tissues. Images are below.
24 November 2015
No major problems. Majority of pin sites dry with no signs of infection. Patient still not walking comfortable with one crutch due to the limited ankle dorsiflexion. Can only manage shorter distances with one crutch. Around 10-15 degrees flexion contracture in the right knee. Swelling of the leg significantly improved.
X-rays confirmed that the proximal fracture is healing with good callus formation and the distal regenerate is gaining in quality. So far as planned. There is clinically some valgus in his knee and X-ray confirms it (around 8-10 degrees). Question is whether to accept it or not?
I am personally more inclined to correct the alignment at the level of corticotomy using struts. This would represent third level of struts on one leg. It does sound complicated but certainly doable. To increase the stability will add a blind ring to the construct (to keep struts short).
14 December 2015
Clickers replaced by struts. Prescription run. Leg alignment corrected. No problem with pin sites.
Gait pattern changed as expected. Can walk unaided on shorter distances, but knee certainly feels more stable. X-rays are below.
CT scan is booked in the next few days but images certainly look promising for the proximal fracture - in my opinion good callous formation.
05 January 2016
CT scan was done and showed very promising signs of healing. Not healed yet, but did not expect it anyway. I am very pleased with the results.
Otherwise pin sites still OK, no signs of infection. Walking slightly better but not as I would like it to be. Created an additional prescription for TSF to translate the distal tibia medially, but keep slight external rotation of the foot.
Below you can see sagittal and coronal reconstruction CT images, where good calus formation can be seen. Also you can see how we really managed to "shove" the proximal fragment into the mid fragment's medullary canal. It really worked. You can also see some cement left in the lateral condyle which we were aware of from the beginning.
19 January 2016
It looks that we have completed the last prescription. The patient followed the prescription until noticed that the foot position is what he wanted and than stopped. This is exactly the level of involvement I expect from the patients.
No problems with pin sites apart from occasionally appearing discharge in the mid fragment (described above) which in my opinion represents low grade infection, which we will keep an eye on. Does not look related to any pin site.
Patient can walk unaided for shorter distances but limited ankle dorsiflexion is still causing problems and forcing him to walk with more externally rotated right foot than he would like to.
1 March 2016
Walking with one stick. Knee feels more stable and reliable. Pin sites are still OK.
X-ray shows excellent consolidation of the regenerate (blue arrow) and further healing of the fracture (yellow arrow). Possible sinus mentioned previously has not reoccured.
11 April 2016
No major problems. All pin sites clean, no irritation. Possible sinus at the level of the middle third of the anterior tibia is still quiet. Inflammation markers still inside acceptable limits (CRP 5, ESR 20). At the moment no major concern.
Patient is walking with the crutches but get pain from the knee. I am certainly not surprised about his knee pain. interesting part is that the extensor mechanism is still intact and working, despite broken wire and not augmentation ever performed for the patellar tendon. Lesson to learn?
07 May 2016
Patient walking with a stick. Main problem is still knee pain. Unfortunately this was expected from the beginning. No major pin site problems. Clinically everything looks well and progressing toward the union. Bone regenerate is also maturing satisfactorily.
From the regenerate perspective we can remove the frame, but not completely convinced that the proximal fracture has united.
05 June 2016
One of the proximal wires broke and was removed today. The rest of the wires still solid and pin sites clean. Knee started to grind and made noises. Unfortunately something we expected.
CT scan confirmed good biological response on the fracture side but no clear union as yet. Regenerate is almost completely ossified. No other untoward signs.
CT scan - Coronal reconstruction
CT scan - Coronal reconstruction
23 July 2016
Patient able to walk unaided on shorter distances. During the appointment all pins its were clean, but few days later one pin site became infected. Infection resolved on conservative measures.
X-rays in my opinion confirm further union but there is a possibility that the leg gained 1-2 degrees of extra valgus. Do not know how to explain.
04 October 2016
Pt is still walking with crutches, shorter distances unaided. No further changes in lower leg alignment. At the moment there is 10-14 deg of valgus. Borderline deformity but we will accept it for now.
Pin sites still clean, no sign of instability.
X-rays show further progress towards union in the proximal fracture when regenerate is well matured.
X-rays also show that fibula has been left in place and did not travel together with the distal tibia. I don't know why I did not spot it earlier. Surprisingly there is no instability of the ankle joint neither any pain coming from the ankle joint.
15 November 2016
CT scan confirmed additional callus formation but full union is yet to happen. It looks that the struts, even the short ones, do not offer enough stability for the fracture to unite. Therefore we changed the struts for threaded bars with hinges with a plan to correct the valgus deformity. I should have changed it earlier but was not expecting that.
CT scan - Coronal reconstruction
CT scan - Coronal reconstruction
25 November 2016
Leg alignment almost normal. Corrected 7 degrees of valgus. Unfortunately the pain has increased in the knee itself.
Will continue with the correction until some varus is achieved whilst observing the knee function. Hopefully we will get mechanical axis to the medial side and minimise the pain.
06 December 2016
Furthet improvement in alignement. No significant increase in pain. Pin sites OK, frame stable.
03 January 2017
The knee feels much more stable. Pain improving as well.
Pin sites are OK, no major issue.
X-tays suggest further progress towards union.
14 March 2017
Activity level has improved significantly. No major pin sites or pin issues apart from one broken pin which was removed in the clinic.
CT scan confirmed further progress towards union.
CT scan - Coronal reconstruction
CT scan - Saggital reconstruction
02 May 2017
Level of activity is increasing. Still using crutches for mobilising. All pin sites are OK.
Dynamised frame to allow vertical movements (mainly) and review in 4 weeks. Hopefully there will be no changes in alignment.
X-rays will be taken next time - 4 weeks time.
30 May 2017
As you can see from the comments patient has removed all the connectors (threaded bars) in-between second and third ring. He was able to walk without any additional pain. Clinically the fracture has united. It took 27 months. Very long time but I believe it was worth it.
11 July 2017
Frame was removed 4 weeks ago. Walking is still slow and with a limp but the fractures are united. There is a possible "collapse" in the lateral tibial condyle. "Neofibula" is being formed.
29 January 2018
Cement spacer war removed around 8 weeks ago and RIA bone graft from the right femur was used. As the micro samples showed bacterial growth patient was put on antibiotics for 6 weeks.
X-rays today show good progression although it is still a bit early.
Patient is mobilising unaided on shorter distanced with a stick for longer distances.
Leg looks clinically OK, no sign of infection.
17 July 2018
Three years post injury. All wounds and fractures healed. No clinical sign of infection. The knee will cause pain on any longer walking or cycling as well as will the ankle, mainly because of the equinus deformity. No medial/lateral instability in the ankle.
Further Follow up in one year.
Mr Matija Krkovic, MD, PhD
I am Consultant Orthopaedic Trauma Surgeon with special interest in Limb reconstructions and bone infections.