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Case Report: V. Z. John, M. Alagappan, S. Devadoss, and A. Devadoss A completely shattered tibia J Bone Joint Surg Br 2005; 87-B: 1556-1559 [Abstract] [Full text] [PDF]

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A completely shattered tibia - Complex case.

Helen Auchterlonie, Christopher L. Talbot, Ramesh Thalava   (9 January 2006)

Re: A Completely Shattered Tibia

A Devadoss, Vinith Zachariah John, Sathish Devadoss, and M. Alagappan.   (2 December 2005)

A Completely Shattered Tibia

Quamar Bismil, Christopher PJ Wood, David M Ricketts   (10 November 2005)

A completely shattered tibia - Complex case. 9 January 2006
Helen Auchterlonie, medical student Tameside General Hospital, Ashton-Under-Lyne., Christopher L. Talbot, Ramesh Thalava Send letter to journal: Re: A completely shattered tibia - Complex case. helen.auchterlonie{at}stud.man.ac.uk Helen Auchterlonie, et al.	Dear Sir, We read this case report with interest. It is surprising how nature can do wonders 'when everything else fails'. The case report suggests that the patient had a resistant non-union in the proximal tibia after 39 months despite prolonged treatment with multiple procedures. He was subsequently lost to follow-up for a further period of 29 months after his last operation, at which time he received no further treatment. We wonder how this resistant non-union progressed to union, when the patient actually defaulted from any further treatment? We would very much appreciate the author’s views on how this occurred. It would also be interesting to know the organisms that were cultured from the open wounds, and the antibiotic therapy used. We congratulate the authors on successfully treating such a challenging injury and achieving a good functional result. H. Auchterlonie, Medical student, C. Talbot, Medical student, R. Thalava, Consultant Orthopaedic Surgeon, Department of Orthopaedics, Tameside General Hospital, Ashton-Under-Lyne, UK.
Re: A Completely Shattered Tibia 2 December 2005
A Devadoss, Professor and Head of Orthopaedic Surgery Institute of Orthopaedic Research and Accident Surgery, Madurai, India., Vinith Zachariah John, Sathish Devadoss, and M. Alagappan. Send letter to journal: Re: Re: A Completely Shattered Tibia ioras{at}ioras.com A Devadoss, et al.	Sir, We thank Dr. Bismil and colleagues for their interest in our case report. As mentioned by them, any orthopaedic surgeon would treat such a fracture in his or her own way. The senior author (AD) was aware of the good results of nailing in similar comminuted fractures.1 We did have in mind the various treatment options, however, as mentioned in our report, we declined to use the option of calcaneal pin traction, as it would require additional posterior splinting and prolonged immobilisation. The interlocked nail, in the form of an internal splint, enabled non-weight bearing mobilisation of the patient once the initial pain subsided. It also avoided the possibility of additional complications associated with prolonged skeletal traction and hospitalisation. In such grossly comminuted fractures, delineating a proper cortex and medullary canal among the multiple fragments, and hence passing a nail through the centre of the entire shattered diaphysis is impossible. The purpose of the internal splint is to bring the bone and extremity back to length, achieve axial and rotational alignment, and provide stability. This purpose is served by ensuring that the nail is seated in the centre of the proximal and distal epiphyseo-metaphyseal blocks and subsequently locked. In such a case, the apparent position of the nail with respect to the individual comminuted fragments of the mid diaphysis need not be a concern. Regarding Dr. Bismil’s concerns of potential infection, we would like to state that during both instances of bone grafting, there were no external signs of infection. The possibility of future infection at a non-union site should not discourage the surgeon from undertaking bone grafting. In our country where there are no mandatory insurance policies in health care, the entire cost of treatment has to be borne by the patient. A significant number of people carry on their activities of daily living in the presence of stigmata of chronic osteomyelitis. They resort to hospital treatment only if there is any acute exacerbation. The time and money spent for evaluating and eradicating an apparently inactive focus of chronic osteomyelitis is unacceptable to them. Referring to the article2 quoted by Dr. Bismil, plain radiographs still provide the best screening for chronic osteomyelitis, as they are simple and economical. Although MRI and radionuclide scans can help to gauge the extent of bone and soft tissue infection, they are costly and should be requested only if the diagnosis is in doubt or a definitive debridement is to be undertaken.2 Our patient has not presented again with an acute exacerbation for the past 1½ years. He dresses his two sinuses daily. They were pinhead sized with no active discharge. The apparent large size is due to a depression in the surrounding skin following excision of a sequestrum. He also manages to earn his own livelihood using the reconstructed, well-aligned, sensate and functional extremity. Amputation in chronic osteomyelitis may be indicated only in patients with diabetes, a history of smoking, or advanced age, where preservation of the extremity becomes dangerous or a nuisance. Patients younger than 45 years of age tend to do well.3 Mere evidence of stigmata of chronic osteomyelitis in a sensate and functional limb would not always require surgery, let alone an amputation.4 V.Z. JOHN, DNB(Orth) M. ALAGAPPAN, D(Orth) S. DEVADOSS, MS(Orth), MCh(Orth) A. DEVADOSS, FRCS(Ed), FRCS(Glasg), MCh(Orth) Institute of Orthopaedic Research and Accident Surgery, Madurai, India. 1. Grosse A. Bilateral comminuted fractures of femur. In: Van Den Branden E, ed. Grosse and Kempf Locking nail system. Indications and clinical cases. Brussels: Howmedica, 1986:27–9. 2. Lazzarini L, Mader JT, Calhoun JH. Osteomyelitis in long bones. J Bone Joint Surg [Am] 2004;86-A:2305-18. 3. Siegel HJ, Patzakis MJ, Holtom PD, et al. Limb salvage for chronic tibial Osteomyelitis: an outcome study. J Trauma 2000;48(3):484-9. 4. Solomon L, Warwick D, Nayagam S. Chronic Osteomyelitis. In: Solomon L, Warwick D, Nayagam S, eds. Apley’s System of Orthopaedics and Fractures. Eighth ed. London: Arnold, Hodder Headline Group,2001:37-8.
A Completely Shattered Tibia 10 November 2005
Quamar Bismil, Specialist Registrar in Orthopaedics and Trauma Princess Royal Hospital, Christopher PJ Wood, David M Ricketts Send letter to journal: Re: A Completely Shattered Tibia quamar.bismil{at}btinternet.com Quamar Bismil, et al.	Sir, We read this article with interest. We note the outcome of treatment for the complex injury described. This case illustrates the difficulties of successfully treating severe IIIB tibial fractures. We would like to make the following points: 1. Presented with such an injury, nearly every orthopaedic surgeon would treat it in their own way. However, there are several options that the authors do not mention. Most involve traction to keep the tibia out to length, followed by external bracing once the fracture is ‘sticky’ enough (i.e. traction for several weeks followed by immobilisation in plaster, pins and plaster or a Sarmiento functional brace). This treatment is described in the literature for IIIB fractures of the tibia with good results.1 2. The authors' described treatment has actually followed a similar plan. We note that the intramedullary nail shown in Fig. 2 passes around the fracture fragments (not through them as described), and that the afflicted limb was immobilised in plaster for at least 8 months. 3. In Fig. 3 two large sinuses are visible on the patient's shin: the patient has chronic osteomyelitis and may yet require further procedures or amputation. One wonders if the use of bone graft in the presence of potentially infected non-union at two operations may have contributed to this. The literature describes the accuracy of MRI scans in determining the extent of osteomyelitis: such an investigation may help plan future treatment for the patient described.2 Q. Bismil, Specialist Registrar in Orthopaedics and Trauma C.P.J.Wood D.M. Ricketts Princess Royal Hospital 1. Korovessis P, Milis Z, Christodoulou G, et al. Open tibial shaft fractures: a comparative analysis of different methods of fixation in southwestern Greece. J Trauma 1992;32:77-81. 2. Lazzarini L, Mader JT, Calhoun JH. Osteomyelitis in Long Bones. J Bone Joint Surg [Am] 2004;86-A:2305-18.