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
Good progress. No major pin sites issues. Bone transport as planned. Remained non weight bearing.
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.