Surgical Treatment of an Infected Nonunion of the Middle Third of the Femur Associated with Femoral Shortening in a Hemophilia Patient

Three-stage total knee arthroplasty combined with deformity correction and leg lengthening using Taylor spatial frames and conversion to internal fixation for severe intra- and extra-articular deformities and hypoplasia in a patient with hemophilic knee arthropathy: A case report

BACKGROUND

Hemophilic arthropathy is a cause of severe knee deformity, because chronic synovitis due to repeated hemarthrosis affects the area of the epiphyseal plates in juvenile cases. Total knee arthroplasty (TKA) is the standard treatment for end-stage knee arthropathy. However, it is difficult to perform one-stage TKA in patients with severe intra- and extra-articular deformities.

CASE PRESENTATION

We reported a case of hemophilic arthropathy in a 55-year-old male with leg length discrepancy of 4 cm, limited range of knee motion (-40° extension and 85° flexion), intra-articular deformity (medial proximal tibial angle: 69°; mechanical lateral distal femoral angle: 79°), extra-articular deformity at the distal femoral metaphyseal (30° valgus and 45° flexion deformity), and varus malalignment (% mechanical axis: 33%). We planned a three-stage TKA. Firstly, we performed gradual correction and lengthening of the distal femur using Taylor spatial flame. Six months after surgery, we performed conversion surgery from external fixation to internal fixation. Finally, we performed TKA with rotating hinged type implant. Two years after surgery, physical examination showed a normal gait, leg length discrepancy of 2 cm (the right leg was shorter), improvement in the range of knee motion (0° extension and 100° flexion).

CONCLUSION

To the best of our knowledge, this presents the first combination of three-stage TKA with correction of femoral deformity and leg lengthening using a Taylor spatial frame and conversion to internal fixation in a patient with hemophilic knee arthropathy and severe intra- and extra-articular deformities.

Infected Nonunion of the Distal Femur in the Elderly with Bone Loss: Case Report and Treatment Options

The management of infected nonunion associated with bone loss in long bones is both a time-consuming and challenging procedure for the orthopedic and trauma surgeon. In this paper, we present the case of a 75-year-old woman with infected nonunion of the distal femur associated with bone loss after plate osteosynthesis for a distal femur fracture. The patient was referred for nonunion of the distal femur after plate fixation (nonlocking "classic" plate) and was treated with a locking compression plate (LCP) and autologous cancellous bone transplant. During the follow-up, the patient was ambulatory without pain; however, the nonunion failed to heal, therefore, the induced membrane technique (Masquelet procedure) was performed in two stages, tissue samples were taken and revealed a bacterial infection (S. epidermidis), and antibiotic treatment was started. Due to infection, fracture healing was slowed, but did commence. Unfortunately, the LC plate failed before union occurred, the nonunion was treated with a femoral nail and blocking (Poller) screws, and the bony defect was filled with Ca-P cement. The patient was operated one last time for cement dislocation when not only the dislocated cement was removed but also the femoral nail dynamized. After one year after treatment completion, the fracture healed, and leg length discrepancy was 1.5 cm shorter on the left side. The patient experienced significant pain relief and can walk with the help of crutches. Our paper demonstrates the application of different techniques in fracture surgery as they are required can result in fracture healing even in very adverse circumstances.