Gerald Eliot Wozasek

Lifshin, Lyn

Diposit Digital de Documents de la UAB

80you put your quarter inand she spins you wildlybubbles, squeezes, grips. Her hipshave a motor, she turns you inside out in her frothy juicetakes what you wanted toget rid ofPEE WEE'S MADONNA: 1says he has everything in handPEE WEE’S MADONNA: 2says he brought it on himselfPEE WEE’S MADONNA: 3thinks he got a raw dealthinks everyone should be behind him(certainly not in front)LAUNDRY MADONNAdoesn’t loosen a few buttons when it’s hot, makes it hot by unloosening a few buttonsBAD GIRL MADONNA: 2doesn't wax floors just waxes her bikini lineBAD GIRL MADONNA: 3when she can't sleep, heats up some body instead of milkBAD GIRL MADONNA: 4doesn't blush at blue movies knows she could do it betterJULY MADONNAmakes you want to be nakedin her green she's hot andwet wraps your root in hermulch smells like whatshe isBAD GIRL MADONNA: 1

Bad Girl Madonna: 4

Bad Girl Madonna: 2

Crossref

Strategies in Trauma and Limb Reconstruction

Limb salvage in a partially amputated distal femur with extensive segmental bone loss using the nailing after lengthening technique: a case report

Springer - Publisher Connector

CASE REPORT
Limb salvage in a partially amputated distal femur with extensive
segmental bone loss using the nailing after lengthening technique:
a case report
Gerald Eliot Wozasek
Received: 1 February 2014 / Accepted: 14 February 2015 / Published online: 10 March 2015
 The Author(s) 2015. This article is published with open access at Springerlink.com
Abstract Segmental long bone defects resulting from
high-energy trauma with severe soft tissue loss are difficult
problems to manage. Amputation was for a long time the
primary mainstay of treatment. This is the report on a
15-year-old male patient who sustained a third-degree
open, traumatic fracture with partial amputation of the left
distal femur and extensive bone loss of 26 cm. Successful
limb salvage was performed after vascular repair, short-
ening of the bone defect, primary placement of an antibi-
otic cement spacer and simple external fixation. This was
followed by bifocal lengthening modifying the simple
frame until limb equality was achieved and secondary in-
tramedullary nailing 11 months after injury.
Keywords Subtotal amputation with segmental long
bone defect  Cement spacer  Bifocal lengthening 
Secondary nailing
Introduction
Limb salvage in severe open injuries remains a challenge to
orthopaedic surgeons. The decision for aggressive and
heroic salvage against primary amputation still presents
difficulty [1, 2]. When salvage is chosen, these injuries
require a multidisciplinary approach, such as vascular re-
construction, free flaps with microsurgical techniques, ad-
vanced skeletal fixation and wound care therapies. The
prolonged, demanding and controversial treatment may
cause considerable mental and physical stress for the
patient, and ‘‘successful’’ limb preservation can lead to
functional deficits and secondary amputation.
The author presents a case of an open Gustilo type 3B
fracture of the distal femur with an extensive segmental
bone defect. The extent of injury and bone loss amounted
to a near traumatic amputation. After vascular repair, the
26-cm bone defect was filled using a cement–Kirschner
wire spacer and the limb was stabilized with a spanning
external fixator. Restoration of anatomic integrity was
achieved by bifocal lengthening using external fixation
systems first and subsequently intramedullary (IM) nailing
of the regenerated bone when leg length equality was
achieved.
Materials and methods
A 15-year-old boy sustained injuries in a motor cycle ac-
cident and was intubated at the scene before transfer by
emergency helicopter to our Level I trauma centre. On
arrival in the emergency room (ER), he presented with
stable cardiopulmonary vital signs, normal pupil reaction
and no signs of injuries to the upper extremity, abdomen or
pelvis. Standard radiograph of the chest revealed a pneu-
mothorax of the right lung for which a chest tube was
placed. Clinical examination of the lower extremity
showed a subtotal amputation of the left distal femur (AO
43-C3) with extensive soft tissue loss and wound con-
tamination. The distal third of the femur was retrieved from
the scene of the accident and brought separately to the ER
(Fig. 1). Standard radiographs revealed in addition a dis-
location of the left hip. Broad-spectrum antibiotic treat-
ment was initiated immediately. The dorsalis pedis artery
could not be palpated; computed tomographic (CT) an-
giography revealed an extensive bone defect of
G. E. Wozasek (&)
Department of Trauma Surgery, Medical University of Vienna,
Waehringerguertel 18-20, 1090 Vienna, Austria
e-mail: ordination@wozasek.at
123
Strat Traum Limb Recon (2015) 10:59–63
DOI 10.1007/s11751-015-0212-8
approximately 26 cm of the distal third of the left femur,
no injury to the femoral artery but an injury to the femoral
vein (Fig. 2). Clinical neurological examination was not
possible. A decision for attempted limb salvage was made
taking into consideration the patient’s age and the absence
of injury to the femoral artery. Within 1 h of ER admission,
the patient was brought to the operating theatre and the hip
dislocation reduced. A thorough debridement of all con-
taminated and necrotic soft tissue was then performed. The
popliteal area was explored confirming no damage to the
popliteal artery and nerve. Surgical repair of the femoral
vein was performed by a vascular surgeon. The distal part
of the femur and proximal part of the tibia were shortened
and connected with a k-wire and bone cement spacer
(Palacos, Zimmer) with gentamicin added, creating a
solid interposition construct (Fig. 3). A complete fas-
ciotomy was performed and a synthetic skin replacement
(Epigard, Consept GmbH) as temporary wound dressing
applied. In addition, a spanning external fixator was
mounted for skeletal stabilization of the limb.
Anteroposterior and lateral radiographs after surgery
revealed an appropriate position for the bone cement
spacer. The Epigard cover was changed every 2 days until
the wound was clean and able to be covered by meshed
skin grafting (Fig. 3). A long-cassette radiograph and
clinical evaluation revealed a limb length difference of
10 cm with the bone cement spacer in situ. Bifocal bone
lengthening of both the femur and tibia was planned due to
the total length of the bone defect. A mono-lateral external
fixator (MonotubeTM, Stryker) was assembled at the femur,
and an osteotomy of the proximal femoral bone was per-
formed. For the tibia, a Taylor Spatial Frame (TSF) (Smith
& Nephew, Inc., Memphis, TN) external ring fixator was
mounted followed by an osteotomy of the proximal tibia
and fibula for bifocal callus distraction at both the femoral
and tibial sides. Distraction was started on the sixth post-
operative day, and the rate of callus lengthening was in-
dividualized according to the regenerate appearance on
radiographs which were performed every 2 weeks during
the distraction period (Fig. 4). The patient was mobilized
with partial weight bearing permitted. At 3 months, the
bone cement spacer and k-wires were removed and a local
antibiotic chain (Septopal, Biomet, Warsaw, Indiana,
USA) with 30 beads implanted into the bone defect. The
chain was extracted percutaneously gradually over
10 days. After 8 months (250 days) and a total callus dis-
traction length of 16 cm at the femoral and 9.8 cm at the
tibial side, radiographs and clinical evaluation revealed
limb length equality (distraction index, 11.46 day/cm). The
Fig. 1 Third-degree open, subtotal amputation at the lower third of
the left femur with severe soft tissue contamination. The distal part of
the femoral bone was brought separately to the ER
Fig. 2 Computed tomography (CT) angiography demonstrates a
complete dislocation of the left hip, segmental bone defect of
approximately 26 cm of the distal femoral bone without signs of
injury to the popliteal artery
60 Strat Traum Limb Recon (2015) 10:59–63
123
external fixation system was removed, and a reamed knee
arthrodesis intramedullary nail (T2, Stryker) was inserted
aiming to stabilize the newly formed regenerate from
bending or re-fracture. At 4 months following IM nailing,
standard radiographs displayed a non-union at the docking
site of the distal part of the femoral segment. A decision to
bone-graft the non-union was taken and autologous bone
graft retrieved through the contralateral femur via the
greater trochanter, utilizing the Reamer–Irrigator–Aspira-
tor (RIA) device (Synthes, Pennsylvania, USA). The au-
tologous bone graft was combined with bone
morphogenetic protein 7 (BMP-7) (Osigraft, Stryker, UK)
and packed to fill the non-union. The subsequent recovery
was uneventful, and complete bone healing was achieved
after 2 years (Fig. 5). At the final clinical assessment of
4 years following the end of the limb reconstruction
treatment, the patient showed good functional results
(Fig. 6).
Discussion
The debate continues over to perform primary amputation
or limb salvage in a high-energy, complex open fracture
with extensive bone defect in the lower extremities [3].
Both strategies have advantages and disadvantages. Aside
the functional loss, body image and mental health issues
after primary amputation surgery, patients can be at risk for
Fig. 3 Clinical and radiological findings 6 weeks after injury
Fig. 4 Radiological findings 250 days after injury preoperatively
before nailing procedure
Fig. 5 Radiological findings after 2 years with solid bony union
Strat Traum Limb Recon (2015) 10:59–63 61
123
recurring stump problems, phantom pain and discomfort in
prosthesis [4, 5]. Limb salvage requires a multidisciplinary
approach including repeated surgeries from orthopaedic,
plastic and vascular surgeons, with long hospitalization and
recovery periods adding to high costs [4, 6].
The Ilizarov method of distraction osteogenesis has been
developed for the treatment of large segmental bone de-
fects and allows salvage of lower extremity injuries that
may otherwise have been amputated [7–9]. Despite the
potential for success, callus distraction is time consuming
and has a high complication rate such as pin tract infection,
pain and the personal discomfort associated with the ex-
ternal fixator system [10]. After removal of the external
frame during the consolidation phase, the newly regener-
ated soft callus is at increased risk of re-fracture and
bending due to the lack of sufficient strength. In order to
avoid these potential complications, the external frame was
removed and the limb and new regenerate stabilized with
an intramedullary nail as soon as limb length equality was
achieved, according to the nailing after lengthening (NAL)
procedure [11]. This treatment concept has the additional
advantage of reducing the period in the frame and returns
the patient’s mobility, comfort and activity level earlier.
The use of a cement spacer filled within the extensive
bone defect has been originally described by Masquelet
[12] in the context of the ‘‘induced membrane technique’’
for the treatment of bone defects. In this case, an antibiotic
cement cylinder was moulded around multiple interposed
k-wires within the defect. The spacer avoids soft tissue
collapse, creates a soft tissue tunnel for later reconstruc-
tion, and maintains the soft tissue anatomy whilst deliv-
ering a high local dose of antibiotic.
There were no signs of deep infection after 4 years of
follow-up. We used established principles of reconstruction
including initial thorough debridement, the antibiotic/ce-
ment spacer, delayed reconstruction using distraction os-
teogenesis and subsequent arthrodesis with an
intramedullary nail to success. Nevertheless, a 4-year fol-
low-up is limited in terms of declaration of being free of
infection and longer-term follow-up is needed.
A number of scoring systems (e.g. MASS—mangled
extremity severity score, LSI—limb salvage index) have
been utilized to make an objective assessment in the con-
text of limb salvage versus primary amputation in limb-
threatening injuries. For this case, there is little doubt that
early amputation would have allowed quicker recovery,
shorter hospitalization and possible lower costs in the
short-to-medium term. However, modern sophisticated
limb prostheses are expensive and require several re-
placements during the course of a patient’s lifetime. In our
Fig. 6 Clinical findings after 2 years shows good functional result
62 Strat Traum Limb Recon (2015) 10:59–63
123
opinion, immediate amputation is indicated as a means for
haemorrhage control or in cases of severe crush injuries.
The size of a bone defect, whilst important, is not an ab-
solute indication, and options for reconstruction of large
diaphyseal bone defects include biologic and non-biologic
materials. In younger patients, biologic reconstruction is
favoured and includes techniques such as vascularized
bone graft. This is demanding technically, and there are
potential complications including a high incidence of stress
fractures, malunion and donor-site morbidity. In our pa-
tient, it would be unlikely for a transplanted fibula to have
enlarged sufficiently in the width to equal the missing distal
femoral bone. In adolescent patients, limb salvage using a
staged treatment protocol is an appropriate alternative
strategy, but the decision is one of clinical judgment and
expertise of the orthopaedic surgeon and multidisciplinary
team.
The principles of limb salvage and reconstruction were
applied in this patient. The initial surgery was to set a
foundation for reconstruction: debridement, venous vas-
cular repair, shortening of the limb, placement of a wire
and bone cement spacer into the defect, synthetic skin graft
and temporary simple frame fixation. When wound closure
was achieved, leg length discrepancy was treated by bifocal
external callus distraction. In the last step, the arthrodesis
nail was implanted to reduce the duration of the frame and
to correct the limb alignment.
In conclusion, limb preservation in high-energy complex
fractures of the lower extremities with extensive bone loss
and soft tissue compromise is a costly and time-consuming
procedure that requires a multidisciplinary approach. The
limb should be considered for salvage, especially in young
and active patients who are mentally prepared and willing
to spend the time in the external fixator and undergo the
multiple surgeries. This particular case of 26 cm of trau-
matic bone loss is unusual but highlights how principles
including the Masquelet cement spacer, Ilizarov distraction
osteogenesis and the NAL can be made to work together
for successful limb salvage.
Conflict of interest The author declares that there is no conflict of
interest.
Ethical standards This study was approved by the institutional
review board and has been written according to the ethical standards
as laid down in the 1964 Declaration of Helsinki.
Research involving human participants The author confirms, that
all procedures followed were in accordance with the ethical standards
of the Institutional Review Board of the Medical University of Vienna
and with the Helsinki Declaration of 1975, as revised in 2009.
Informed consent An informed consent was not required.
Open Access This article is distributed under the terms of the
Creative Commons Attribution License which permits any use, dis-
tribution, and reproduction in any medium, provided the original
author(s) and the source are credited.
References
1. Busse JW, Jacobs CL, Swiontkowski MF, Bosse MJ, Bhandari M
(2007) Complex limb salvage or early amputation for severe
lower-limb injury: a meta-analysis of observational studies.
J Orthop Trauma 21(1):70–76
2. Chung KC, Saddawi-Konefka D, Haase SC, Kaul G (2009) A
cost-utility analysis of amputation versus salvage for Gustilo type
IIIB and IIIC open tibial fractures. Plast Reconstr Surg
124(6):1965–1973
3. Bosse MJ, Mackenzie EJ, Kellam JF, Burgess AR, Webb LX,
Swiontkowski MF et al (2002) An analysis of outcomes of re-
construction or amputation after leg-threatening injuries. N Engl J
Med 347(24):1924–1931
4. Pelissier P, Boireau P, Martin D, Baudet J (2003) Bone recon-
struction of the lower extremity: complications and outcomes.
Plast Reconstr Surg 111(7):2223–2229
5. Harris IE, Leff AR, Gitelis S, Simon MA (1990) Function after
amputation, arthrodesis, or arthroplasty for tumors about the
knee. J Bone Joint Surg Am 72(10):1477–1485
6. Demiralp B, Yildirim C, Yurttas Y, Cicek EI, Basbozkurt M
(2013) Lower limb salvage surgery using Ilizarov circular ex-
ternal frame for a landmine injury about the knee. Eklem Hastalik
Cerrahisi 24(1):41–45
7. Hollenbeck ST, Woo S, Ong S, Fitch RD, Erdmann D, Levin LS
(2009) The combined use of the Ilizarov method and microsur-
gical techniques for limb salvage. Ann Plast Surg 62(5):486–491
8. McKee MD, Yoo DJ, Zdero R, Dupere M, Wild L, Schemitsch
EH et al (2008) Combined single-stage osseous and soft tissue
reconstruction of the tibia with the Ilizarov method and tissue
transfer. J Orthop Trauma 22(3):183–189
9. Sen C, Kocaoglu M, Eralp L, Gulsen M, Cinar M (2004) Bifocal
compression-distraction in the acute treatment of grade III open
tibia fractures with bone and soft-tissue loss: a report of 24 cases.
J Orthop Trauma 18(3):150–157
10. Katsenis D, Bhave A, Paley D, Herzenberg JE (2005) Treatment
of malunion and nonunion at the site of an ankle fusion with the
Ilizarov apparatus. J Bone Joint Surg Am 87(2):302–309
11. Rozbruch SR, Kleinman D, Fragomen AT, Ilizarov S (2008)
Limb lengthening and then insertion of an intramedullary nail: a
case-matched comparison. Clin Orthop Relat Res
466(12):2923–2932
12. Masquelet AC (2003) Muscle reconstruction in reconstructive
surgery: soft tissue repair and long bone reconstruction. Lan-
genbecks Arch Surg 388(5):344–346
Strat Traum Limb Recon (2015) 10:59–63 63
123


Bad Girl Madonna: 1

Bad Girl Madonna: 3

file:///data/core-remote/dit/data/Springer-OA/pdf/dd4/aHR0cDovL2xpbmsuc3ByaW5nZXIuY29tLzEwLjEwMDcvczExNzUxLTAxNS0wMjEyLTgucGRm.pdf

Limb salvage in a partially amputated distal femur with extensive segmental bone loss using the nailing after lengthening technique: a case report

Abstract

Similar works

Full text

Available Versions

Diposit Digital de Documents de la UAB

Diposit Digital de Documents de la UAB

Crossref

Springer - Publisher Connector

Diposit Digital de Documents de la UAB

Diposit Digital de Documents de la UAB

Springer - Publisher Connector