REPLACEMENT OF THE LARGE KNEE JOINT BONE DEFECT USINGCOMBINATION OF EXTERNAL AND INTERNAL FIXATION (CASE REPORT)

Solomin L.N., Shchepkina E.A., Korchagin K.L., Sabirov F.K.

Vreden Russian Research Institute of Traumatology and Orthopedics,
St. Petersburg State University, Medical Faculty,
Pavlov First Saint Petersburg State Medical University,
St. Petersburg, Russia

REPLACEMENT OF THE LARGE KNEE JOINT BONE DEFECT USINGCOMBINATION OF EXTERNAL AND INTERNAL FIXATION (CASE REPORT)

Complex opened fractures of knee joint bones can lead to formation of extensive defects because of removal of non-vital fragments in primary surgical preparation of opened injuries or in radical surgical preparation of osteomyelitis focus. Usually, posttraumatic defects of knee joint bones combine with soft tissue defects, absence of the extensor mechanism and with the chronic infectious process that do not allow joint replacement. Therefore, the alternative for amputation for such patients is reconstructive surgery with defect replacement (Ilizarov’s method) [1-5] or with the combined techniques [6-8]. The combined treatment techniques for extensive long bone defects is bone transport over nail (BTON) [6, 8] and lengthening over nail (LON) [7]. The extracortical fixators are used for prevention of contact between the intramedullary nail and the transosseous elements [9, 10]. We present a clinical case with an extensive effect in knee joint bones treated with the combined techniques.
The patient gave the written consent for publishing the data. The study corresponded to the present standards of treatment and to the ethical norms. 

THE CLINICAL CASE

The patient D., female, 1993 year of birth, received an associated injury including an opened fracture of the left lower extremity. The recurrent surgical procedures caused a defect in the distal femoral bone and in the proximal part of the leg with the soft tissue defect.
In October 2012, the patient addressed to Vreden Russian Research Institute of Traumatology and Orthopedics. In the microsurgery unit, the plastic surgery for the soft tissue defects of the knee joint was conducted with the revascularized thoracic dorsal flap, external fixation of the extremity. In February 2013, the patient was admitted to the unit No.7 in Vreden Russian Research Institute of Traumatology and Orthopedics. The diagnosis was: “Posttraumatic defect of knee joint bones (14 cm), a shortening of the left lower extremity (11 cm)” (Fig. 1).

Figure 1. A photo and X-ray image of the patient with knee joint defect

On March 5, 2013, the surgery was carried out: the fixation apparatus demounting, modelling resection of the distal end of the femoral bone and the proximal end of the tibial bone, intramedullary fixation of the left lower extremity with the long nail (Central Institute of Traumatology and Orthopedics) with maximally possible approximation of the ends of bone fragments. The nail was blocked on both sides according to the static scheme. The transosseous apparatus with the extracortical fixators was applied over the nail. Osteotomy of the femoral and tibial bones was conducted for bilocal replacement of the knee joint defect. The wire tractions were used for transfer of the bone fragments (Fig. 2). The traction at the level of femoral and tibial osteotomy was initiated on the 7th day after surgery (0.75-1 mm/day, 4 times).

Figure 2. A photo and X-ray of the patient during the first stage of the treatment: a) the ends of fragments with placed wire, and the appearance of the extremity after wound suturing; b) a photo and X-ray images of the patient after surgery; c, d) a photo and X-ray images after connection of the transferable fragments. The arrow shows the extracortical fixator

       

On August 19, 2013, after achievement of contact between the transferred fragments of the femoral bone and the tibial bone, the opened adaptation of the bone fragments was conducted, as well as bone autoplasty of the contact zone of the iliac crest autograft and external osteosynthesis. Then the apparatus was dismounted. The period of transosseous osteosynthesis was 166 days at that moment; the distraction regenerates of the femoral bone (7 cm) and the tibial bone (5 cm) were formed. The residual shortening of the left lower extremity was 13 cm after completion of the first stage of the defect replacement (Fig. 3).

Figure 3. A photo and X-ray images of the patient after completion of the first stage of treatment: a) the photos of a place of open adaptation of bone fragments; b) a photo and X-ray images after surgery

   

On July 2, 2014, the next stage of the surgical treatment was performed for partial correction of shortening of the left lower extremity: removal of the distal locking screws, transosseous osteosynthesis of the left femoral bone and the leg, osteotomy of the left femoral bone with subsequent lengthening over the intramedullary nail. Distraction at the osteotomy level was initiated on the day 6 after the surgery (1 mm per day, 4 times). After achieving the size of the regenerate of 5 cm, the rate was decreased to 0.5 mm per day. As result, the distraction regenerate of the left femoral bone (7 cm) was formed. On November 5, 2014, the distal locking of the nail with the static scheme was conducted, and the external apparatus was dismounted. The period of transosseous osteosynthesis for this stage was 126 days. Residual shortening of the left lower extremity decreased to 6 cm (Fig. 4).

Figure 4. A photo and X-ray images of the patient at 2nd stage of surgical treatment: a) after recurrent application of EFD, distal unlocking of the intramedullary nail and femoral bone osteotomy for lengthening over the nail; b) after elongation, distal bar blocking and EFD dismantling

   

In October 2016, the patient was admitted for correction of residual shortening of the left lower extremity. Two variants of surgical management were discussed with the patient: recurrent shortening of the left lower extremity over the intramedullary nail or shortening of the right leg with intramedullary fixation. The patient chose the second variant. On October 17, 2016, the bones of both legs were resected (4.5 cm), and intramedullary fixation was conducted (Fig. 5). The residual shortening (1.5 cm) was not corrected intentionally for improvement in gait [11].

Figure 5. A photo and X-ray images of the patient during 3rd stage of treatment: a) before surgery; b) after surgery

   

The total period of treatment was 42 months (3 years and 5 months). The total period of transosseous fixation was 292 day (9.7 months). The total hospital stay was 197 days (6.5 months).
There were two episodes of soft tissue inflammation near the transosseous elements. This type of complications was corrected with local administration of antibacterial agents (complications of category 1 according to Caton) [12, 13]. One time, the extracortical fixator was replaced owing to instability of evident osteoporosis (complications of category 2 according to Caton). These complications did not influence on the treatment result.
The long term result was estimated in August 2017, 10 months after the last surgery (Fig. 6). The patient could move without additional supporting. The support ability of the left lower extremity restored completely, without blood circulation and innervation disorders. The patient drives a car with automatic transmission and works as accountant.

Figure 6. A photo and X-ray images of the patient 10 months after treatment

     

 

DISCUSSION

It is known that the use of the combined techniques (BTON and LON) significantly decrease the period of transosseous fixation and associated complications [8]. As result, BTON and LON become more important for treating patients with shortening or defects of the long bones [6-8]. However the specificity and technical difficulties of use of the combined techniques in patients with knee joint defects limit their wide-spread use. So, the analysis of the literature relating to treatment of patients with knee joint defects show that most publications are dedicated to replacement of extensive defects with use of Ilizarov’s device [1-5, 14-16]. Rozbruch et al. (2005) report on 4 cases of replacement of posttraumatic bone defects of the knee joint with the mean size of 7.5 cm (4-14 cm). The period of transosseous fixation was from 6 to 17 months. All defects were replaced in bilocal manner. In two cases after knee joint arthrodesis, recurrent osteotomy was conducted for subsequent lengthening. The residual shortening was 1.8 cm (0.6-3.7 cm) after completion of the treatment. All patients had some complications, which were common for transosseous fixation: inflammation in site of exit points of transosseous elements. In one case, equine deformation of the foot was found. The patient refused from surgical correction and used only orthopedic footwear.
Barwick et al. (2013) also report on 4 cases with patients with extensive posttraumatic knee defects (6-10 cm). The period of transosseous fixation was 17 months (13-24 months). In two cases, the extremity lengthening was conducted after arthrodesis in 4-6 months due to necessity for healing of soft tissues. The average residual shortening was 3 cm after completion of treatment. All cases were associated with the complications of transosseous osteosynthesis: inflammation in the exit points of transosseous elements. Three cases included deep venous thrombosis in the lower extremity. Two patients received the surgical treatment of equine deformation of the foot.
Other publications on replacement of extensive knee joint defects are dedicated to replacement of defects after removal of oncologic prostheses [8, 15, 16] or after removal of revision endoprosthesis [1, 2, 17].
We found only one publication describing a case of over-nail technique for replacement of a defect (11 cm) in a patient after removal of oncologic prosthesis of the knee joint [8]. The defect was replaced within 4 months. Plate osteosynthesis was after achievement of contact between the ends of bone fragments. The residual shortening was 2 cm. There were not any described complications.
The described clinical case confirms the high potential of the combined use of external and internal fixation in treatment of such complex category of patients. The use of extracortical fixators as a part of configuration of the device and the cable technique for transfer of bone fragments allowed minimizing the possible complications. 

CONCLUSION

The categorical refusal from amputation in a patient with extensive defects of the knee joint, his/her active cooperation with a doctor and understanding of all difficulties relating to features of long term treatment are the basis for making a decision on reconstructive surgery. The use of techniques of lengthening over nail and bone transport over nail removes the problems of long term external fixation. The use of shortening the contralateral lower extremity is a substantiated technique for correction of length of extremities. 

 Information on financing and conflict of interests

The study was conducted without sponsorship.
The authors declare the absence of clear or potential conflicts of interests relating to publishing this article.

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