Date: Fri, 21 Jun 2002 18:30:15 +0530

Subject: Late reconstruction of intra-articular fracture tibia

Dear all,

I would appreciate inputs on this case of mine.

This 16 year old boy, sustained an injury to his knee one year ago. The exact mechanism of injury is not known, but he sustained a glancing hit by a passing train, while attempting to save another person who was on the tracks.

He had a laceration on the medial aspect of the tibia at its upper and mid third junction. There was no other external injury. Xrays at the time of injury show avulsion fractures of the medial tibial rim, and possibly the posterolateral area of the tibial condyle. He was treated in plaster cast immobilisation for 6 weeks, and then began physio for range of motion and muscle strenghtening.

His complaints today are of pain after he has walked for 10 minutes or so, and a lack of confidence in the knee. He is unable to run. He is able to demonstrate a voluntary side to side mobility of the upper tibia when standing.

On examination, the lachman test is postitive, clinically he seems to have a varus instability. I was unable to demonstrate any rotary subluxation. There is no effusion in the knee, and the active and passive range is lacking only in terminal flexion. On standing, the limb is in a varus alignment, but I cannot appreciate a definite lateral thrust when he walks.

His MRI shows no injuries to the menisci or the collateral ligaments. The posterior cruciate is normal, but the anterior cruciate is not visualised.

Xrays and a ct scan show a depressed fracture of the posterior portion of the medial tibial condyle, and a ? Ossification of the attachment of the posterior cruciate.

I have attached a composite image to this mail. A higher quality copy of the same image can be seen at http://www.sendpix.com/albums/020621/053933000000363fe678374db67fd0/

I think that his instability is due to the femur rolling back into the postero-medial depression of the femur

Considering his age, I wonder whether any kind of reconstructive procedure along the lines of an intra-articular osteotomy with elevation of the depressed fragment, would help him.

I did a medline search, but was unable to come up with anything

Would appreciate any inputs....

If anyone has seen/done something similar, or any articles about similar problems/procedures

Would a valgus osteotomy help in any way?

Anything else that I can look for?

Regards

Mangal Parihar
Orthopedic surgeon, Mumbai

Date: Fri, 21 Jun 2002 14:14:26 +0000

From: b.meinhard

A valgus osteotomy would not help. A posterior approach,infra-articular window and elevation of the depressed surface and iliac bone graft would restore the joint. Arthroscopic assistance may be of value. Also diagnostic arthroscopy would confirm your MRI findings. It would be important to examine the patient under anesthesia to be certain that the instability is related to the bone defect with or without a contribution from the ACL injury. At 16 I would doubt he has much more growth and a bone-tendon-bone ACL reconstruction could be done as the tunnels would not seem to interfere with your articular restoration. Reluctance to proceed with ACL reconstruction due to open epipyhses would then require a later procedure after epiphyseal closure.

bpm

Date: Sat, 22 Jun 2002 09:59:29 +0530

From: Dr Mangal Parihar

I have done that sort of an approach for fresh fractures, but in an old, united fracture, how does one ensure that only the depressed fragment would be lifted up. I would think that the fracture would need to be recreated, but is that possible thru an infra-articular window?

He doesn't have any growth left as his epiphyses are closed now.

Mangal parihar