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.
Soft tissue cover is done as per BOA/BAPRAS Guidelines. After the soft tissue cover is completed successfully, it is our internal policy to wait for 4 weeks for the free flap to mature and than apply a fine wire frame - my personal preference is TSF frame to Ilizarov frame due to the shorter operating time and lower complexity of the construct with more options for amendments without theatre visit.
04 August 2017
3 weeks post starting callus distraction. No major problems with the pin sites or frame. Swelling a bit of an issue, but still under control. 4 clicks per day per clicker and simultaneous compression of the defect using TSF struts and TSF prescription for the last 3 weeks.
18 August 2017
05 September 2017
Unfortunately swelling of the flap got bigger than anticipated. A ring just above the foot plate was together with some struts impinging into free flap. Therefore it was replaced for a bigger diameter ring. Patient will remain in hospital for elevation to reduce the swelling.
18 September 2017
Swelling decreased significantly. Knee range of movement has improved on CPM but there is still a lack of extension as a direct consequence of the bone transport.
Patient will be discharged today. There will be very likely further swelling of the leg and the flap but will deal with it when/if necessary.
29 September 2017
Bone transport is progressing really well. Good and strong regenerate. Swelling is still there but so far no impingement on the rings. The knee is still lacking 20-30 deg of extension. Docking is still not completed.
20 October 2017
No improvement in the knee flexion contracture. Regenerate progressing well - close to 10cm. The docking is still not completed. It looks as the TSF prescription for large rings and acute angles of struts does not work. When we tried to generate a new on for today, it reported error.
Plan is to bring the patient back on Friday and use standard threaded bars and plates to facilitate the docking.
01 December 2017
Knee extension remains the issue. Unfortunately we see it in every single patient with proximal corticotomy and bone transport for more than 5-7cm. Usually it improves more or less completely in time but it does require a hard work.
The free flap is still causing oozing and swelling with impingement to the foot plate. At the moment is still reasonable not to reposition the foot plate.
Regenerate's progress is very good. It certainly looks improving. Docking site looks compressed as well but to be certain, a CT scan was ordered.
22 December 2017
Swelling is still causing a lot of problems.
CT scan is booked.
Discussion with a previous patient (patient to patient) took place two weeks ago and was very helpful.
Regenerate is progressing well but the docking site is still under question.
Because the foot plate is "too small" will exchange it for a bigger one. Hopefully this will sort the swelling problem although this was usually not a permanent solution in the previous patients. Will hope for the best.
08 January 2018
CT scan was done and can be found below. It confirmed good regenerate but also healing in progress of the docking site (tibia-talus). A nice surprise.
Otherwise the foot plate was still causing the problems mainly by irritating the skin. Surprisingly it did not cause any ulceration.
As CT scan showed healing in the docking site, the foot plate was removed, and talar wires were repositioned on a bigger ring.
09 February 2018
Knee stiffness still remains a problem. My expectations are that it will improve but will need time. No major issues with pin sites. And regenerate looks really good.
Patient stopped with lengthening. Overall length of the regenerate is 21 cm. Quite a lot. Regenerate consolidation is as expected.
17 March 2018
Pin sites all well. Some minor discharge but nothing important. Flexion contracture in the knee is still persistent and will very likely remain for a quite some time. In my experience it will take some time to regain the knee extension but it will happen.
Regenerate looks fine, good progress. Also docking site is showing positive signs of progressive union.
29 May 2018
18 July 2018
CT scan has been done and confirms healing of the docking site and viable regenerate. Activity level is improving but slowly. No obvious sign of infection.
18 September 2018
A few weeks ago patient was admitted for pin sites infection and swelling. Improved on antibiotics and discharged.
Patient is now walking with a Zimmer frame/crutches, but short distances only. Clinically today the pin sites are fine.
Dynamisation of the lowest ring has proven for the tibio-talar fusion to be solid. The same can be confirmed on the X-ray below. Regenerate looks strong with good visible cortex on all sides.
Will continue with dynamization of the most distal ring. In six weeks will hopefully dynamize the whole frame.
26 October 2018
16 November 2018
19 November 2018
Frame removed. Fingers crossed.
14 December 2018
25 january 2019
Despite all previous CT scans and X-rays the latest CT scan confirms the tibio-talar non-union.
In my opinion no other option than to redo the fusion. My preferred choice is hind foot nail. Will have to sacrifice talo-calcaneal joint. Looking at the most recent CT scan, the joint has been affected already.
Flexion contracture in the knee is gradually improving.
31 JANUARY 2019
Fusing the "ankle" was quite difficult. One of the reasons was significant atrophy of the calcaneus, not as much of talus. Very difficult placement of the guide wire for hind foot fusion nail.
Correcting the deformity was another difficult job. Significant valgus with shortening/scarring of the lateral side tendons was not easy to overcome. Still left with some minor residual valgus and a bit of equinus as I did not want to shorten the leg even further - I believe I shortened it for about 1-1.5cm but certainly not more.
Whilst using a nail was difficult, using a nail would certainly fail due to the osteporosis.
Mr Matija Krkovic, MD, PhD
I am Consultant Orthopaedic Trauma Surgeon with special interest in Limb reconstructions and bone infections.