Open fractures of the lower limb are still posing a significant problem. If not in acute management, certainly longterm management is still an issue. How to manage these patients in a timely manner with as low complication rate as possible remains open for discussion.
I will be presenting our management of a patient with open fractures of distal femur and tibia together with the destruction of the medial femoral condyle beyond reconstruction. Whilst an amputation is certainly the quickest solution, it is not as good on a long term. Reconstruction again seems expensive and time consuming, but it looks that it is cheeper on a long run and offers better life quality.
Initial radiographs are below. Both fractures were open, grade 3B on Gustilo-Andersen classification. There was a direct communication with the knee joint as well.
After initial debridement of bone and soft tissues temporary stabilisation was completed followed by soft tissue cover of the open fractures.
29 July 2017
All wounds looked healing well. decision was made to proceed with a circular frame on the lower leg. In the same session TSF frame for the distal femur, Ilizarov frame for the knee fusion, Ilizirav frame for the proximal tibia corticotomy and TSF frame for distal tibia fracture with a defect were constructed. Bone fragments were additionally debrided and Stimulan beads inserted in all defects.
23 August 2017
All going well. Pain is still and issue but under control with pain killers. Patient is still wheel chair bound.
X-rays show good regenerate in the proximal tibia and improved position of the distal femur and the distal tibia. So far everything as planned.
12 September 2017
No major changes. Alignment of the proximal femur almost perfect. Alignment of the distal tibia needs further attention. Position of the knee fusion is acceptable. No major problems with pin sites although most proximal full ring is touching the skin. So far the skin is OK but will have to keep an eye on it. Regenerate certainly looks very good.
26 September 2017
Femoral TSF prescription completed, tibial not yet as the patient felt that the bone is going in the wrong direction. Possible. Otherwise no changes since the last appointment. Most proximal ring is impinging less on the skin - it looks that the swelling is coming down.
Regenerate in the tibia is what was expected. Distal femoral fracture is nicely aligned. I compressed further the knee fusion and prepared a new TSF prescription for the distal tibia.
Patient is still in a wheelchair. Suggested to start walking and weight bearing as tolerated.
10 October 2017
Patient started weight bearing. TSF for tibia completed but fracture not reduced yet. Knee fusion in varus. All wounds healed. All pin sites OK. No massive swelling. Regenerate doing well. The leg is still bit short. Distal femur is healing as well as the knee fusion.
Frame was adjusted to partially correct the varus in the knee. The rest will be corrected next time.
Clickers were adjusted and a new TSF prescription given.
24 Octoberber 2017
All wounds healed. No sign of infection. Pin sites OK.
As you can see below patient started weight bearing under physiotherapist's supervision.
Lower leg still looks deformed clinically but not on the X-ray. Distal tibia almost aligned when the regenerate looks great. Distal femur is also healing and the knee fusion as well. Unfortunately the knee fusion is in varus and the adjustment of the frame last time did not make any significant difference to overall alignment.
We decided not to try and realign the leg through the knee but to realign it later at the level of regenerate using TSF struts instead. When the lengthening will be completed.
Nothing without a hard work in physiotherapy. Both, patient and physiotherapist.
31 October 2017
Patient was admitted because of the cellulitis around the knee with significant swelling with one of the rings impinging on the skin.
After a course of antibiotics and elevation swelling subsided and the leg is again back to the shape where it was.
X-ray did not reveal anything untowards.
19 December 2017
No major problems with the pin sites. CT scan confirmed union in progress in the distal femur and knee fusion. Not healed yet but in my opinion enough evidence for callus formation to allow to observe and wait.
Regenerate in tibia is progressing well. Slight valgus in the distal tibia but will correct it with another TSF prescription.
Long leg alignment film was not possible to obtain as patient is not able to stand up comfortably. Will decide on the length clinically. At the moment right leg is still shorter but not significantly more than our target length which is 2-3 cm less than the other leg.
CT scan reconstructions:
02 February 2018
At the moment patient can only mobilise with a wheelchair due to the treatment of his other leg.
Otherwise the frame is stable, no significant pin site problems. Distal femur fracture is healing but slowly. Knee has fused and regenerate is good in quality. Distal tibia docking also completed. Slight translation on the lateral view but good position in the ap view. Accepted.
Will compress the proximal femur a bit more to enhance the healing. Otherwise more or less as planned and expected.
13 March 2018
Struts tight. Lengthening completed. Pin sites are fine. Pain under control. Whilst the knee fusion and regenerate are progressing as planned, the supracondylar fracture is not.Not sure about the progress to union.
27 April 2018
Patient started walking again after the other leg has been stabilised.
PIn sites re fine, struts tight.
Lower leg still in varus and will correct it now replacing clickers by struts and running a TSF prescription. Around 10 deg varus measuring at the level of the corticotomy. When leg length more or less the same.
25 May 2018
For the first time patient walked in the clinic on crutches. Great success.
TSF prescription completed. HOW COOL IS THAT!!!! I mean, comparing the long leg alignment films before and after.
17 July 2018
CT scan done and confirmed union on all three sites including good regenerate.
19 October 2018
We were able to dynamise the all three levels of struts today. No significant pain.
Patient is booked in 4 weeks for removal of the frame. Fingers crossed.
19 November 2018
X-rays today show healed fractures. At least I cannot see any obvious signs of non-union. From what I have learnt so far, this does not mean much.
And what is the value of "dynamization".
From what we have learnt so far not really much. Or nothing. Not even one patient who later failed after removal of the frame has shown any signs of instability during 4 weeks of so called "dynamization". I am not sure we will continue using it. Very likely not. It appears that it is only causing discomfort to patients (unstable rings) for last 4 weeks, without any added value.
21 December 2018
4 weeks post removal of the frame. Patient walking with crutches. All pin sites healed.
23 December 2018
Unfortunately a dog fell on the leg whilst sitting in a chair. It looks that the lower part of the leg was hinged at the level of the fracture/docking site at the time of the accident. X-rays on the day were unremarkable.
28 December 2018
Pain did not subside. In fact it increased. X-ray again not completely conclusive but clinical examination confirmed re-fracture. Very depressing even for me. And I try to distance myself not to cloud my judgment.
08 March 2019
Not clear from the X-rays that the distal tibia refracture is actually healing.
We replaced the plaster and will organise a CT scan.
26 April 2019
Clinically and radiologically fracture looks healed. Will start with weight bearing.
07 June 2019
Clinically the fracture united. Plaster removed. Pain improved.
Mr Matija Krkovic, MD, PhD
I am Consultant Orthopaedic Trauma Surgeon with special interest in Limb reconstructions and bone infections.