Revision surgery fracture: non-union distal femur with stiff knee
23 yr old male farmer presented
with history of road traffic accident one year back. He suffered compound
fracture distal femur inter-condylar super-condylar femur. The fracture was
managed outside with articular reduction maintained with screws, supported by a
trans-articular spanning external fixator. The fixator was removed at 6 months
and the patient was allowed partial weight bearing. He progressed on to bear
full weight on right leg, but he had minimal movement in knee and the leg
gradually deformed into valgus. Upon presentation, the range of motion in knee
was 0 to 5 degrees. There was well healed scar over anterolateral aspect of
knee approx. 12 cm in length. The limb was in approx. 7 degrees valgus. X rays
were done. Intra-articular reduction was acceptable with screws and k wire in
situ. There was metaphyseal non-union and overall valgus at fracture site. The
patient was taken to operation theatre and distal femur was exposed laterally.
Three screws and k wire were removed. Most medial screw was left as it was not
coming in field of surgery and fixation. Medial incison was given to release
the patellar retinaculum medially. The patella was found adherent to distal
femur and was released with osteotome, carefully preserving as much bone as
possible. The nonunion site was exposed and the distal condylar area freed of
adherent soft tissue. The bone ends were freshened and acceptable alignment
achieved. The construct was fixed with distal femur locking plate and screws.
The range of motion achieved after this step was upto 15 degrees. All
intra-articular adhesions were removed with shard dissection using blade. After
this maneuver, the knee was bend upto 60 degrees. Quadricepsplasty was done
wherein vastus intermedius was separated; L plasty of vastus intermedius was
done; and pie crusting of rectus femoris was done. The iliotibial band was
sectioned at two places. The vastus medialis and vastus lateralis were
separated from quadriceps tendon. The range of motion was now upto 100 degrees.
The wound was washed. Non-union was bone grafted. Wound closed in layers over drain
and knee brace was given.