Mikhail Samchukov

Case 9: Adolescent with Segmental Bone Defect Secondary to Grade IIIB Open Tibial Fracture Treated by Oblique Wire Bone Transport

Thirteen-year-old male sustained multiple fractures in a rollover bus accident including GustiloAnderson grade IIIB open right tibial fracture as well as severe traumatic brain injury necessitating a prolonged ICU stay. Initial treatment consisted of repeated irrigation and debridement, followed by insertion of flexible stainless steel Ender’s nails. Ten days postoperatively, infection necessitated aggressive bony debridement which resulted in a 10-cm bone defect and placement of a temporary spanning frame. Later, pin-to-bar external fixator was converted to TrueLok circular external fixator followed by proximal tibial osteotomy and 10-cm oblique wire bone transport. 1 Brief Clinical History The patient is a 13-year-old male who was a passenger in a rollover bus accident and sustained multiple fractures including Gustilo-Anderson grade IIIB open right distal tibial/fibular segmental fracture and closed fractures of the left femoral shaft, distal tibia and fibula, and distal radius, as well as none-displaced fracture of the pelvis, T11 compression fracture, mandibular fracture, and severe brain injury, requiring intracranial pressure monitoring. He was treated initially with intramedullary fixation of the femoral fracture and irrigation and debridement (I&D) of the open tibial fracture. Four days following injury, patient underwent I&D and insertion of two Ender’s flexible stainless steel nails for stabilization of his open tibia fracture. Six days later, the edges of the overlying wound were necrotic; repeated I&D revealed gross purulence and necrosis within the segmental tibia fracture (Fig. 1). The implants were removed, and eventually a bridging pin-to-bar frame was applied with an antibiotic methyl methacrylate spacer spanning 10 cm (Fig. 2). In addition, a rectus abdominus free flap was performed 20 days after injury and patient was transferred to a rehabilitation facility for further treatment of his brain injury (Fig. 3). The patient remained nonambulatory 3.5 months following injury and dependent for all care. 2 Preoperative Clinical Photos and Radiographs See Figs. 1, 2, and 3. *Email: Lori.Karol@tsrh.org Limb Lengthening and Reconstruction Surgery Case Atlas DOI 10.1007/978-3-319-02767-8_79-1 # Springer International Publishing Switzerland 2014

Case 7: Cable Bone Transport for Segmental Bone Loss Secondary to Grade IIIB Open Tibial Fracture

Thirteen year old male sustained a grade IIIB open tibial/fibular fracture with segmental bone loss and large soft tissue defect. He was initially treated with ankle spanning external fixation, multiple irrigation and debridement procedures, and an eventual vastus lateralis vascularized free flap. Following flap coverage, stabilization was converted to a circular external fixator to allow for proximal tibial osteotomy and an 8-cm cable bone transport. 1 Brief Clinical History The patient is a 13 year old male who was an unrestrained driver in an all-terrain vehicle (ATV) rollover accident. He sustained a comminuted distal tibial Salter-Harris type II fracture and GustiloAnderson Grade IIIB open tibial/fibular shaft fractures with segmental bone loss and large soft tissue defect (Figs. 1, 2, and 3). At presentation, he had intact sensation to both the plantar and dorsal aspects of the foot, which was well perfused. The patient underwent urgent irrigation and debridement (I&D) of his grossly contaminated fracture. Numerous devitalized bony fragments without soft tissue attachment were identified and removed. Fracture stabilization was obtained with an ankle spanning external fixator (Fig. 4). The tibia was brought to length using the fixator, but due to the bone loss incurred, a 4-cm segmental defect was present. No internal fixation of the distal tibial fracture was performed due to comminution present and acceptable alignment obtained. Ultimate soft tissue coverage was achieved with a vascularized vastus lateralis free flap and split-thickness skin grafts 7 days from the time of injury. Definitive treatment was deferred until 3 months from the time of injury to allow for maturation of the free flap (Fig. 5). The patient had remained non-weightbearing during this time. He was also noted to have developed diminished sensation on the plantar aspect of the foot with hyperesthesias along the medial longitudinal arch following his free flap coverage procedure. 2 Preoperative Clinical Photos and Radiographs See Figs. 1, 2, 3, 4, and 5. *Email: Mikhail.Samchukov@tsrh.org *Email: MikeSamchukov@gmail.com Limb Lengthening and Reconstruction Surgery Case Atlas DOI 10.1007/978-3-319-02767-8_89-1 # Springer International Publishing Switzerland 2014

Case 18: Adolescent with 7-cm Femoral Shortening due to Physeal Growth Deceleration: Femoral Lengthening with PRECICE Retrograde Intramedullary Nail

A twelve-year-old male with 10 distal femoral varus and 7.5 cm of leg length discrepancy of unknown cause underwent distal femoral osteotomy followed by acute angular deformity correction and femoral lengthening using PRECICE retrograde intramedullary nail. 1 Brief Clinical History The patient is a 12-year-old male with 10 distal femoral varus and 7.5 cm of leg length discrepancy of unknown cause. There was no history of trauma or infection. The patient was otherwise clinically well. Radiographic evaluation revealed irregular idiopathic asymmetric physeal growth deceleration of the right distal femur, proximal tibia, distal tibia, and left distal femur (Fig. 1). MRI and CT scans confirmed the plain radiographic findings but without identifying etiology. There is a rare disorder of cutis dysplasia congenita characterized by scalp lesions at birth and similarly appearing spontaneous physeal growth disturbance, but this patient had no history for skin abnormality. He had full range of motion of all lower extremity joints and was neurovascularly intact. 2 Preoperative Clinical Photos and Radiographs See Fig. 1. 3 Preoperative Problem List • Limb length inequality (7.5 cm) with right leg shorter than the left (6.8 cm in the femur and 0.7 mm in the tibia) • Mild (10 ) varus deformity of the right distal femur • Complete destruction of the right distal femoral physis • Multilevel asymmetric physeal growth deceleration (right tibia and probably left femur), etiology indeterminate • Progressive leg length discrepancy with future growth potentially requiring contralateral epiphysiodesis and/or repeated limb lengthening *Email: John.Birch@trsrh.org Limb Lengthening and Reconstruction Surgery Case Atlas DOI 10.1007/978-3-319-02767-8_88-1 # Springer International Publishing Switzerland 2014