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.
12 October 2017
After the initial debridement it became apparent that the segmental fragment is avascular. Spaning external fixator was applied to facilitate soft tissue closure.
06 November 2017
After soft tissue cover was completed and matured, the spanning exernal fixator was replaced by TSF.
09 November 2017
TSF construct can be seen below. For the segmental fragment was decided to put all the efforts it to try and heal it back using standard Ilizarov techniques.
01 December 2017
Pin sites are OK including foot plate. X-rays suggest to correct the alignment further. Still non weight bearing due to the foot plate.
12 January 2018
Foot plate has been removed. Pin sites have healed. There is two small wounds which have not healed, one on the proximal tibia and on on the foot but there are no obvious signs of infection.
X-rays shows that there is still some varus as before which is over the mid and distal tibia.
He can start walking with crutches weight bearing on the left leg as pain allows.
23 February 2018
Foot is still stiff and restricting weight bearing/walking. Pin sites are OK. Alignment on X-ray improved and I suspect I can see some calus formation on the proximal fracture site.
10 April 2018
Patient came earlier as the foot is getting more painful.
Clinically the foot is not tender on palpation, slightly swollen. Doesn't look infected. Main pain comes on passive plantiflexion.
X-ray of the foot suggest disuse osteopenia. Fractures healed.
X-ray of the tibia shows further improvement in alignment but prescription is not completed yet.
15 May 2018
Waling is still a problem mainly because of the equinuus deformity of the foot. Pin sites OK, frame is stable.
29 June 2018
Doesn't get much better than this.
10 August 2018
Walking is improving. Still a lot to do.
19 October 2018
Bone graft done. And decortication of the proximal fracture fragments.
25 January 2019
No major changes.
26 April 2019
In the meantime the frame was removed. Fractures were not healed. Why we removed the frame when fractures were not healed?
One month after the removal a nail was inserted. It is understatement to say that the nailing was difficult. Despite using poller screws we encountered a lot of problems getting the non-unions reduced and compressed by the nail.
In the last follow up appointment patient was happy with the progress he was making and said that the leg felt very strong.
Have a look at the X-rays and decide for yourself.
Mr Matija Krkovic, MD, PhD
I am Consultant Orthopaedic Trauma Surgeon with special interest in Limb reconstructions and bone infections.