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41 years ago, in 1980, in a small town in Macedonia, a 17-year-old young man crashed with his motorbike, resulting in fractures in the area of his left knee. In detail, the young man had fractures in the patella and in the lower third of the femur. The patient was treated surgically at the local hospital, where the broken patella was removed, and external osteosynthesis and fracture of the femur were treated with the IlIizarov method.
Unfortunately for the young man, 8 months later it was found radiologically that the fracture in the thigh had not stuck, which forced the treating physicians to remove the external osteosynthesis and proceed, with open osteosynthesis, to the placement of a plate with screws. This technique failed, as a few months later a radiological examination showed that the plate had broken before the fracture had closed. Any fracture that has not completed healing - plugging (6) six months after its occurrence is classified as a pseudo-fracture and is an absolute indication for surgery.
In the case of the young man, for the treatment of the pseudoarthrosis, the treating doctors decided to re-install a new plate with screws, after removing the broken plate. This operation failed again, as it broke a few months later, before the fracture had finished healing.
After the three failed attempts to close the fracture, the new technique to treat the pseudoarthrosis of the femur, after removing the broken plate again, was the placement of an intramedullary flap, which was fixed peripherally to the fracture with two screws. The intramedullary healing technique eventually helped to close the fracture, although the radiograph showed that the flap broke peripheral to the fracture at the level of the screws.
Eight-year review: The now 25 year old young man, 8 years after his initial injury and having undergone five (5) surgeries, has as clinical and radiological outcome:
1) Fracture of the thigh fracture
2) Fracture of the intramedullary tonsil at the level of the peripheral screws
3) Ankylosis with zero knee motion(Automatic clinical knee arthrodesis), due to the adhesions of the initial arthrodesis for the removal of the fractured patella, combined with months of immobility following the Illizarov external osteosynthesis, but also the adhesion of the quadriceps muscle over the entire extent of the femur, which is the result of the repeated approaches for the open osteosyntheses of the fracture.
After five operations, he is forced to settle for walking for the rest of his life with an outstretched knee, like a pirate who was amputated and given a wooden leg. A disappointing outcome for a young man who is beginning to face the challenges of a lifetime with an unsightly and non-functional lower limb. While at first the patient felt no pain, over time the knee became painful as the deterioration of the articular cartilage resulted in severe osteoarthritis of the knee. When the pain exceeded his endurance limits, the now 58-year-old man began looking for a solution to his problem.
It was obvious, from the first visit to the Clinic "Agios Loukas" to the Orthopaedic Surgeon Dr. Konstantinos Voukalis, that under other circumstances, despite his young age, the only solution to his problem would have been Total Knee Arthroplasty. In his case, however, there were serious problems that had to be overcome before total knee replacement could be attempted.
Dr. Voukalis explained the pre-operative plan, as the effort had to be done in three phases, emphasizing the fact that the positive or negative result of each phase would allow or not the next phase to take place.
In the first phase, the materials of the broken intramedullary tonsil had to be removed. In the second, perhaps the most difficult phase, the entire atrophic and adherent quadriceps had to be detached from the femur using the Thompson plasty technique, with the aim of making the quadriceps muscle functional again, which is necessary for the success of a possible total joint replacement.
In the third and final phase, despite the clinical arthrodesis of the knee and the lack of patella, a Total Knee Arthroplasty would be attempted on the patient's knee.
The fact that in November 2021, during the first phase, only the intramedullary screws were removed and not the broken part of the intramedullary tendon, was not an absolute contraindication to proceed with the second phase of the Thompson quadriceps plasty three weeks later, despite the difficulties due to the long delay. The wonderful result of the Thompson technique, in terms of mobilization of the quadriceps muscle, created the necessary conditions for the final phase of converting a clinically arthrodesis knee into a functional knee with Total Knee Arthroplasty.
The presence of the broken intramedullary tonsil in the knee area did not allow for a classical knee arthroplasty with intramedullary guides, so with the help of the Orthopaedic Surgeon Thomas Lakkos, who pioneered the technique of robotic surgery in knee replacement, the Total Knee Arthroplasty was successfully completed with remarkable results, not only for the patient, but also for the team of doctors, as the mobility of the knee exceeded their expectations.
Already, one month after the knee replacement and 41 years after the initial injury, the patient is living in a new reality, walking normally again, confirming the medical maxim "When the challenge is great, the satisfaction is greater".
Dr. K. Voukalis - Orthopaedic Surgeon
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