Prior to the knee replacement procedure lower limb should be in a reasonable alignment. Mechanical axis of femur and tibia should fall inside the joint level. Otherwise joint replacement with soft tissue balancing to accommodate for bone deformity is technically demanding if not impossible.
I am presenting a patient with previous surgeries to his lower limb due to the trauma and subsequent correction of alignment at the level of the femur.
Mechanical axis of the tibia falls in the lateral side of the lateral compartment suggesting difficulties during primary total knee replacement. CT scan confirmed obliterated medullary canal with a reasonable doubt not to be able to open the canal with reamers without risking thermal damage to the tibia either for stemmed tibial component or during the deformity correction with a nail. And there is also apex anterior deformity of the tibia on the lateral view.
In my opinion the safest way forward to correct the tibia deformity using fine wire frame and than proceed with primary total knee replacement with minimal risk for using stemmed components.
TSF was applied two days ago and low energy corticotomy was performed using drill bit and osteotom.
Two X-ray images present construct of the frame with the level of corticotomy. During the procedure compression of the corticotomy site was established but is usually not enough. In my experiences it has to be done using TSF struts to the level that wires on the opposite sides of the corticotomy bow.
18 August 2015
Patient is doing well. Pin sites dry, clean. Compression with the struts worked well and confirmed with the X-rays. On the images below you can see much smaller corticotomy gap than on the previous images. Will have to hurry not to get it healed before we can correct it.
New prescriptions for TSF correction was given today with the aim to correct 6 deg varus to 2 deg of values (to off-load the medial compartment) and to correct apex anterior deformity (10 deg) of the tibia. Correction will happen in next 6 days. New X-rays in a week's time. It looks that deformity is already smaller than initial one. Interesting.
Clinically it looks that the leg is an inch shorter than the left one. There will be some lengthening due to the varus correction but leg equality in length can easily be achieved if patient wants it to happen.
15 September 2015
Unfortunately one of the proximal wires broke and was removed. It is quite unusual for proximal wires to break. Otherwise frame is stable and pin sites are dry.
Correction completed. As expected pain in the knee eased. When there is still a quite significant swelling at the level of the corticotomy. It is possible that the swelling is just a result of the difficult corticotomy as the inflammation markers are minimally raised. Will still have to keep an eye on it.
Patient is walking unaided and no major pin site problems. X-ray confirm good alignment in both views. We have entered consolidation period.
13 September 2015
Two days ago patient presented to A&E with redness and swelling at the level of the corticotomy site. Corticotomy wound healed but small area of leaking (doesn't look like proper sinus) medial to the healed wound. CRP was increased. Was put on oral antibiotics. Patient was well in himself.
On examination area still red, swollen. Redness not significantly smaller than 2 days ago (marker pen line). Walking with crutches partial weight bearing. Leg swollen. Still discharge from the medial side. X-rays showed good alignment.
Ultrasound did not show any collection. Blood tests done. Swab taken (not sure this will be relevant sample).
Decided not to wash out but to treat with antibiotics for osteomielytis. Presented to out OPAT team to commence treatment.
In my opinion there is cellulitis at the level of the corticotomy which can evolve into osteomielytis.
01 December 2015
Antibiotics stopped. Walking unaided. Clinically significant improvement. Leg less swollen and does not look infected.
09 February 2016
CT scan was completed at the end of December 2015 and showed certain callus formation but not enough to warrant a removal or even dynamisation of the frame.
Patient was still comfortable, walking unaided and no major pin site problems.
X-ray below was completed on the day and showed in my opinion good progress. Decision to dynamise the frame was made. Usually I disengage all struts and let patient walk on the leg for four weeks and than compare the X-rays with previous ones.
The latest X-rays are below.
08 March 2016
Four weeks of dynamited frame. No significant pain or pin sites problems. X-ray confirmed no changes in alignment. and further signs of healing.
10 May 2016
Frame has been removed 4 weeks ago. All pin sites healed. Patient walking unaided indoors and using a stick for outdoors. Can comfortable walk for 40 min. Leg is still swollen mainly towards the end of the day. Certainly does not look infected.
X-rays confirm that the corticotomy has healed. Alignment of the leg is improved.
At the moment patient does not want to proceed or even consider arthroplasty.
Mr Matija Krkovic, MD, PhD
I am Consultant Orthopaedic Trauma Surgeon with special interest in Limb reconstructions and bone infections.