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Re: Несостятельность фиксации
Tom DeCoster 05 Август 2003, 13:26
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This is a BIG problem, that fortunately is somewhat less common now than 10 years ago. The fibula and a large piece of distal lateral tibia are now displaced laterally about 1 cm. It is difficult to assess how well reduced the tibia articular surface was and is. You might consider:
1. What is the status of the soft tissues? Range from grossly infected with tissue loss to healing OK with surgical scars. Many somewhere in between but the soft tissue slough is a common and BIG problem. You haven't mentioned much about this.
2. What is the status of the patient? Diabetic?, compliant?, smoking? etc.
3. What is the status of the fixation? Is it solid or grossly loose? This appears somewhere in between with perhaps syndesmosis instability but the other fixation (fibula, tibia articular surface, tibia meta-diaphysis ?OK)
4. What is the status of the reduction. Again, syndesmosis very wide but other (fibular length, tibia articular surface, tibia alignment, talus beneath plafond) seems OK.
5. What is your risk tolerance? Individualized to patient and surgeon. How much risk of BKA are you willing to take to try to get somewhat improved ankle function.
I believe this may be salvage mode and a good ultimate result will be a preserved foot and ankle fusion. So be careful about doing too much that might result in infection, multiple operations and BKA. If soft tissue OK, patient
OK, reduction and fixation failure limited to sydesmosis etc then you could try repeat syndesmosis reduction and new fixation. Perhaps 2 screws with bicortical tibia and fibula purchase supplemented by enforced NWB (bent knee LLC vs other).
TD
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Re: Несостятельность фиксации
Alexander Chelnokov 05 Август 2003, 15:31
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TAC> 1. What is the status of the soft tissues? Range from grossly
No problem.
TAC> 2. What is the status of the patient? Diabetic?, compliant?, smoking? etc.
He is smoker, non-diabetic, but with cystostoma and a lot of WBC in urine. Now looks compliant, at least doesn't weight-bear the leg.
TAC> 3. What is the status of the fixation? Is it solid or grossly
TAC> loose? This appears somewhere in between with perhaps syndesmosis
TAC> instability
Exactly.
TAC> but the other fixation (fibula, tibia articular surface, tibia
TAC> meta-diaphysis ?OK)
At least he is now without external immobilization, moves to/from bed/wheelchair without sense of instability.
TAC> 4. What is the status of the reduction. Again, syndesmosis very wide but
TAC> other (fibular length, tibia articular surface, tibia alignment, talus beneath
TAC> plafond) seems OK.
Yes. Looks like pure depression of the grafted metaphyseal part. Of course along with separation of the lateral aspect (plus syndesmosis and tibia).
TAC> 5. What is your risk tolerance? Individualized to patient and surgeon. How
TAC> much risk of BKA are you willing to take to try to get somewhat improved
I suppose here to avoid procedures where the risk can't be so small to be neglected.
TAC> OK, reduction and fixation failure limited to sydesmosis etc then
TAC> you could try repeat syndesmosis reduction and new fixation.
It seems to me the articular tilt should be restored.
TAC> Perhaps 2 screws with bicortical tibia and fibula purchase
TAC> supplemented by enforced NWB (bent knee LLC vs other).
Yes, the screws can be inserted through stab wounds. My concern is what to do if closed foot distraction wouldn't provide "elevation" of the
articular surface.
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Re: Несостятельность фиксации
Отправитель: Tom DeCoster 06 Август 2003, 14:38
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It sounds like we are of similar opinion on this case. I didn't notice the collapse of the metaphyseal bone graft and talar tilt but upon re-review of the radiograph I see what you mean. I haven't had ANY luck successfully repairing this situation. Half the time it still doesn't look right on the post op x-rays (?perhaps inadequate surgeon-me). Half the time it collapses later and the other half (sic) it doesn't matter because they develop some other greater problem like totally degenerative joint.
After looking at these fragments in acutely operatively treated distal tibia fractures and seeing no soft tissue attachment (all the depressed articular pieces are clearly without soft tissue attachment and many of the cortical
pieces are quite alone) I wonder if a big part of the problem isn't avascularity of the fragments. When I have gone back in late, the pieces often look like unincorporated bone graft, just sitting there. Even if I restore some semblance of a normal plafond the fragments seem to behave like femoral head grafts I
once used to supplement deficient acetabulae for total hips- it looks OK for a while but eventually melts away.
I'm not saying it's impossible to restore the joint and obtain a good result at this point, but I've never been successful once it gets to this stage.
There is no situation so bad that it can't be made worse by a well-meaning orthopedist.
TD
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