New insights in lower limb reconstruction strategies

Abstract

High Energy Musculoskeletal Traumas (HEMTs) represent a relevant problem for healthcare systems, considering the high social costs, and both the high morbidity and mortality. The poor outcomes associated with HEMT are related to the high incidence of complications, including bone infection, fracture malunion and non-union. The treatment of each of these complications could be extremely difficult. Limb reconstruction often needs multiple procedures, rising some questions on the opportunity in perseverate to try to save the affected limb. In fact, theoretically, amputation may guarantee better function and lower complications. However, amputation is not free of complication, and a high long-term social cost has been reported. A comprehensive literature review was performed to suggest possible ways to optimize the limb preservation surgeries of HEMT's complications in order to ameliorate their management.

Keywords: fracture-related infection; high energy musculoskeletal traumas; limb reconstruction; limb salvage; mal union; non-union; osteomyelitis.

Figure 1.

A clinical case of a 42 years old male with a middle shaft tibia septic non-union following an open fracture treated with intramedullary nailing (a). The patient was treated through septic bone resection and subsequent bone transport (b). In (c) non-union of the docking point, treated through a new bone resection and bone transport for definitive infection control (d). In (e) X-ray at 7 months suggestive of docking point union. In (f) recurrence of an aseptic atrophic non-union treated using the Huntington’s procedure (g). In (h) X-ray at 12 months after the procedure, note the full integration and partial hypertrophy of the fibula.

Figure 2.

A clinical case of a 38 years old male with a tibial varus malunion (a) after a road accident. Initially the malunion was treated using an exapodalic external fixator (b). In (c) the reoccurrence of varus deformity related to osteotomy partial non-union. In (d) intraoperative picture of the chipping osteotomy, leading to a good alignment and reliable healing; in (e) the post-operative X-ray; in (f) full length lower limb X-ray at 9 months after the surgery.

Figure 3.

A clinical case of a 61 years old female with a tibial chronic osteomyelitis following a road accident occurred 40 years before our observation. In (a) and (b) clinics and antero-posterior and latero-lateral X-rays at the time of our observation. The patient was treated through a sequestrectomy and application of an antibiotic-loaded bone substitute. In (c) the intraoperative fluoroscopy before (left) and after (right) the application of the bone substitute. In (d) antero-posterior and latero-lateral X-rays at 1 month after the surgery. Note the partial bone substitute reabsorption. In (e) and (f) X-rays and clinics at 4 months after the surgery.