Gerald E. Wozasek

A treatment strategy for complex cases of osteomyelitis in children and its applicability on three exemplary cases.

The aim of this study was to carry out a two-step surgical approach for complex cases of pediatric osteomyelitis. The surgical technique used here involved initial bone debridement and stabilization by a customized spacer (intramedullary Kirschner wires mantled with refobacin-palacosa cement). After infection eradication, the spacer was removed and distraction osteogenesis performed. This study included one boy and two girls (aged 7–10 years) with severe osteomyelitis (tibia: two, femur: one). At least 50% of the bone was initially resected, and either a bifocal physeal distraction (tibia) or callus distraction (subtrochanteric osteotomy) was performed. At discharge they were able to walk without assistance. Complete infection eradication and load restraining reconstruction was achieved in all three children.

Pitfalls in automatic limb lengthening – First results with an intramedullary lengthening device

BACKGROUND The treatment of leg length discrepancy and deformities has become more common over the last few decades due to newly developed implants. Lengthening using fully implantable intramedullary nails provides many advantages; however, only little data is available. Therefore, we aimed to determine: (1) safety of the implant, (2) the complication rate and (3) functional outcome after magnetic driven intramedullary bone lengthening with a telescopic implant. HYPOTHESES Automatic bone lengthening with intramedullary nails provide good short-term outcome. PATIENTS AND METHODS Ten patients with limb length discrepancy of lower extremity, treated with an Ellipse PRECICE® nail, were included in this retrospective follow-up study. The mean limb length discrepancy was 4.7cm (range: 2.5-7.0cm). RESULTS In all patients, limb lengthening goals were reached within a range of ±0.5cm after a mean time of 53 days. However, in 2 patients, mechanical failures with unintended shortening were observed. In a further patient nail breakage occurred. Overall, 7 patients presented with complications during the follow-up period. DISCUSSION The PRECICE® nail represents a new, fully implantable, magnetically driven device for limb lengthening. However, due to a high rate of complications, a close follow-up is necessary to identify early implant failures and to avoid severe adverse outcomes. LEVEL OF EVIDENCE Retrospective follow-up study, case series, level IV.

Intramedullary magnetically actuated limb lengthening in a patient with congenital humeral limb shortening

The treatment of leg length discrepancy has become a common procedure in orthopaedic surgery. However, lengthening of humeral deformities is still infrequent. The purpose of this case report was to present humeral lengthening with a new intramedullary lengthening device (PRECICE® P2 for tibia) in a 32 year old female patient with congenital shortening. Hereby the telescopic device presents a promising tool for humeral limb lengthening with excellent outcome at short-term in this case.

Unusual complication with an intramedullary lengthening device 15 months after implantation

The treatment of leg length discrepancy and deformities has become more important over the last decades due to newly developed implants. Several different devices have been presented with various complications reported in literature. The purpose of this case report was to present an unusual complication 15 months after implantation of an intramedullary lengthening device (PRECICE(®)). An intramedullary lengthening device (PRECICE(®) P1 nail) was implanted in a 74 years old male patient with a congenital leg length discrepancy in January 2014. After bone lengthening of 6cm and obvious radiological callus formation a nail breakage with severe deformity occurred 15 months after implantation. Physicians have to be aware of the risk of such late complications regarding this device with serious implications for the patient.

Plate failure following plate osteosynthesis in periprosthetic femoral fractures.

SummaryBackgroundIncreasing numbers of total knee and hip arthroplasties result in a growing number of periprosthetic femoral fractures (PPFF). PPFF with a stable stem component are treated commonly with plate osteosynthesis. Therefore plate failure is seen as a major complication. The aim of this retrospective study was to investigate the patients’ outcome after plate failure.MethodsThe database of a Level 1 trauma center was searched for all patients treated for a PPFF with plate osteosynthesis. Patients with plate failure were investigated specifically. Standard demographic data, details on initial arthroplasty, trauma, and treatment were recorded for all patients. All fractures were classified and their outcome reviewed.ResultsSeven (8.8 %) out of 80 patients treated with plate osteosynthesis following PPFF met our inclusion criterion being plate failure. All these patients were female, with an average age at primary surgery of 74 ± 13 years and a mean follow-up of 885 days (range, 264–2549). Four patients suffered a PPFF after total hip arthroplasty (THA) (2 Vancouver Type B1 and 2 Type C) and three after total knee arthroplasty (TKA) (Lewis-Rorabeck Type II). Following plate failure, four patients healed uneventfully and three patients experienced complications such as pseudarthrosis, screw loosening, and further plate failure.ConclusionIn patients with poor bone quality, bone graft, bone cement, and bone biologics have to be considered in revision surgery. Furthermore, long-stem revision and tumor prosthesis are an additional solution.

Tibio-talo-calcaneal fusion after limb salvage procedures—A retrospective study

BACKGROUND The treatment of limb threatening trauma on the distal tibia or hindfoot often results in posttraumatic osteoarthritis requiring tibiotalocalcaneal (TTC) arthrodesis. The purpose of this study was to present a case series of patients undergoing various techniques of joint fusion after bone reconstruction and deformity correction as a salvage procedure. The study should help trauma surgeons making decisions in limb salvage and deformity correction in complex lower leg and foot injuries by presenting options and treatment strategies. PATIENTS AND METHODS Eight patients (4 male, 4 female) after TTC arthrodesis as a definitive procedure after polytrauma or monotrauma involving the distal tibia or hindfoot were the subject of this retrospective analysis. We included patients treated by external ring fixation (1 case), external fixation+wires (1 case), external fixation+screws (1 case) and intramedullary nailing (1 ante- and 5 retrograde; 1 bilateral, 4 unilateral). Initial trauma included open fractures, subtotal foot amputations and closed fractures with failed osteosynthesis and failed ankle joint replacement. Bone defects were treated with callus distraction or segment transport in 5 cases. Various angles were measured to assess foot deformities in the lateral radiographic view and clinical results were presented. RESULTS Independent, pain-free mobilisation with full weight bearing was achieved in all 8 patients. In terms of subjective outcome, all patients reported a highly satisfying result. Complete consolidation at the fusion site was achieved in 8 out of 9 cases with a high rate of adjacent joint arthritis. Angles measures in the lateral radiographs showed values typical for a pes cavus tendency. CONCLUSION Tibio-talo-calcaneal (TTC) arthrodesis is a viable treatment option for severe post traumatic arthritis and deformity of the ankle and subtalar joint. Despite bad bone quality retrograde intramedullary nailing does provide acceptable results providing stability, low invasiveness and low infection rate. Simultaneous TTC-fusion and tibial lengthening using the Ilizarov ring fixator may be necessary when the surgeon is confronted with large bone defects - often followed by a nailing after lengthening procedure. This study shows that limb preservation after limb threatening trauma with hindfoot injury and multiple fractures of the lower extremity is recommenced as the method of choice with reasonable clinical results. LEVEL OF EVIDENCE IV, Case series.

Knee Arthrodesis in Severe Injured Knee Joints

In this report we present our experiences with knee arthrodesis nails as a secondary salvage procedure after severe knee injuries at a level-one trauma centre. Exemplary two cases of subtotal amputation are discussed. Both cases, of totally destroyed knee joints, were treated with a unilateral external fixator, shortening and secondary bifocal distraction osteogenesis. In one case nailing after lengthening (NAL) was performed and in the second case nailing had to be performed as fracture treatment 20 years after bony consolidation at the docking site.

Limb Salvage: Lower Extremity

Extremity damage in disaster as well as combat situation, particularly of the lower limb, is typically a high-energy trauma with open injury [1, 2]. These dramatic conditions confront surgeons among others with significant human and ethical problems [3]. Hereby treatment of severely injured limbs challenges orthopedic surgeons [4]. It is important that in these extreme situations, only surgical specialists and senior trainees should be deployed and not be used as a training field for junior residents [5].

Case 38: Impaired Joint Motion During and After Callus Distraction

The temporary loss of motion of adjacent joints is a common complication after distraction osteogenesis of the lower limb. Various treatment options are available to address tendon shortening. Muscle imbalance, too rapid rate of distraction, intraoperative transfixation of tendons, fascia, and muscles must be avoided. Furthermore, fracture location, frame mounting location, arthrofibrosis, and damage to the joint cartilage can influence joint motion. The present case shows treatment strategies to manage joint contractures. 1 Brief Clinical History A 27 year old male was injured in a motor vehicle accident about 7 years prior to presentation. He presented to our outpatient clinic with 8 cm shortening of the right lower leg and malunion of an ankle arthrodesis. He was fused in equinus and adductus of his forefoot. He was only able to walk in a custommade orthopedic shoe. He stated that the sensation of his foot sole was normal. 2 Preoperative Clinical Photos and Radiographs See Figs. 1 and 2. 3 Preoperative Problem List 1. Posttraumatic shortening of the lower limb 2. Pes equinus deformity of the fused ankle joint and varus deformity of the forefoot 4 Treatment Strategy 1. Lengthening of the lower leg 2. Axis correction by osteodistraction, using a multiplanar ring fixator 3. Acute correction of the malaligned fused ankle joint *Email: gerald.wozasek@meduniwien.ac.at Limb Lengthening and Reconstruction Surgery Case Atlas DOI 10.1007/978-3-319-02767-8_155-1 # Springer International Publishing Switzerland (outside the USA) 2015