23 y.o. male with posttraumatic knee varus, femur shortening. It is about 3 years after the accident. ROM: 5-45 deg. Knee is medially unstable. He walks without crutches, with moderate pain and severe limping. What kind of treatment can we propose to avoid further arthrosis and improve gait quality?
Loaded closed chain isometrics? Static bilateral and unilateral squats & calf raises in varying ranges;30, 45 & 90 degrees.
Dear Leszek
Thank you very much for the question. It would be most helpful if there will be on top of the AP radiograph you published if it was possible to have a lateral view. This will make the picture potentially clearer and help us to see the possible callus formation of the femur anteriorly and if this blocks the quadriceps. On the AP seems that there is bone loss medially and due to the distance not clear if the bone is fully united.
Grateful for your help
Dear Dr.Kuik,
Of course, the correction of the deformity, including LLD. CT of lower third of the bone is needed for better planning osteotomy. Recovery ROM - using higes or soft tissues mobilization (combination?) as the second stage - need to further discussion.
Best regards,
Leonid Solomin
i think this patient ultimately needed a osteotomy and correction of deformity to correct the femoral varus, The question is when to do it and how because the femur appear to be not fully united yet. if doing correction, it could be using internal or external fixator each with own advantages and disadvantages.
As i am very familial with correction using ring fixator so i would choose taylor spatial frame.
Dear Leszek,
This is very interesting and difficult case for definitive solving. CT scan is necessary to clear the situation. Medial cortex in the supracondylar region is very insuficient. Intercondylar line of fracture still is not disappear. Prearthrosis is present. Ring fixator may be a solution.
Dear Leszek,
Extension and traction restores tissue, muscle and cartilage to its locus .
Thank you for all your answers. The femoral cortex is indeed insufficient but fusion seems to be at least partially completed according to low pain. I wonder if anyone considers HTO? No CT scans are available for now.
With insufficient cortex I would prefer removal of metal work, refreshing of the area, osteotomy and application of a circular frame od Ilizarov type. If there is any bone loss toremove all "dead" bone and a corticotomy above with translation of the bone and compression. Personally I would not touch the tibia. All the deformity is at femur level so femur has to be corrected.
Dear Dr. Leszek Kuik,
HTO? No, never in such cases!
According to the 1st ostetomy rule - osteotomy at CORA level. But at poor quality of bone (therefore CT is very necessary!) - osteotomy can be done slightly higher, with the need of peripheral transklation (2nd osteotomy rule).
A little more information is available in the attached file.
Best regards,
LS
Very difficult case. HTO is not indicated at all because the problem is in the distal femur, and because of the frontal inclination of the joint ascending from lateral to medial (Boitzy rule, 1970 ). This means correction should be done on the distal femur.Otherwise biomechanics would get worse.
Probably, removal of osteosyhthesis, quadriceps release, supracondylar osteotomy of the femur with osteoplasty medially and new osteosynthesis (external or internal). One imporatnt point is the duration of the trauma. This makes things very difficult.
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