These cases are are to get you to start thinking and questioning your knowledge ahead of the next webinar when bone goes bad: bone infection, defects and correction of deformity.

We are joined for this webinar by:

 introduction to limb reconstruction techniques for the general orthopaedic surgeon. This webinar – presented by:

Case 1

49 year old male who had an open fracture of the left femur in Morocco 20 years previously. Which was treated non-op.

Since then, he’s had on/off local drainage and periods of antibiotics

Current situation:

  • Foul smelling discharge
  • Dressing changes x5/ day
  • Requesting amputation (family can’t stand the smell)

Non smoker, no co-morbidities, quads adherent limiting knee flexion

Does this man need any additional imaging?

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If yes, what flavor of imaging would you like? (select the investigation you most fancy getting)

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The patient is keen for something to be done - says he can’t live like this. What’s your recommended treatment going to be?

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Case 2

32 yrs female, previous PFFD. She had 10cm of lengthening and multiple previous surgeries

Major problems:

  1. Lateral right knee pain
    • MRI and arthroscopy
      • Lateral compartment OA, grade-4
      • Tricompartmental OA changes
      • Valgus mal-alignment
  2. Right hip pain (she has OA hip on the same side)
  3. Valgus deformity of the leg
  • Minor problems

Minor problems

  1. Mild valgus of right tibia
  2. Valgus right ankle with lateral OA changes (secondary to the longstanding valgus leg)
  3. Stiff hindfoot and midfoot

As a general rule of thumb, which problems do you normally go after first when dealing with a combination of limb deformity and adjacent joint arthritis? (pick the best answer from those below)

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Where would you start with this lady, accepting her deformity is complex?

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Case 3

60 y.o. Male, falls from a ladder. Bilateral closed Pilons (this case concerns the right side). Placed into a spanning external fixator and achieved a nice reduction.

What is your normally preferred treatment for a closed Type-C pilon fracture like this (ignore how it was done in this case)?

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The patient got ORIF with plates.  The post-op reduction looked decent and no infection.  However, at 8-months the medial fixation started to fail.  The patient was weight bearing with discomfort, needing crutches and a boot still.

What now?

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Updated position:
The treating surgeons decided to revise the medial fixation and that worked nicely for a while, until the new medial plate/screws broke again!
At 29-months the pt was still on crutches and in pain, albeit a little improved (image A).
A CT seemed to show that the fracture was healed and so the hardware was taken out (image B).
1-week later, a wt-bearing x-ray clearly showed a varus non-union (image C).  See also CTSo, the situation is a varus non-union.  Reasonable soft tissues (will tolerate further open surgery).  Never been overtly infected.

What now?

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Please do post your thoughts about these cases in the comments section below.

For the answers to these questions and much more join our webinar this week, Wednesday at 8pm BST.

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