SlideShare uma empresa Scribd logo
1 de 39
Case Study: Charlotte
Complex Lower Limb Deformity
Age Range During Treatment: 14 years to 16 years
David S. Feldman, MD
Chief of Pediatric Orthopedic Surgery
Professor of Orthopedic Surgery & Pediatrics
NYU Langone Medical Center & NYU Hospital for Joint Diseases
BACKGROUND
Charlotte has been my patient since she
was three years old. Over the years, I’ve
collaborated with other medical
professionals to treat her for various issues
with her right leg.
Her issues began with a hemangioma that
involved her entire right tibia. The
hemangioma damaged her knee, ankle, and
foot joints in addition to her growth plates
which inhibited the growth of new bone.
After several minimally invasive procedures,
the hemangioma was finally stabilized when
she was eight years old.
At the age of 11, Charlotte underwent
osteotomies and plates were put in place to
treat rotational and angular deformities that
had developed in her leg and foot.
Charlotte later suffered fractures in her fibula
and tibia and the rods from the osteotomies
had to be removed because the
hemangioma had caused her bones to shift
out of position and the rods to protrude
causing pain.
Delayed bone growth caused by the
hemangioma resulted in a large limb length
discrepancy (over three inches). At the age
of 13, we discussed the option of surgically
correcting her limb length discrepancy and
deformity with a Taylor Spatial Frame.
TREATMENT
Surgery #1
Removal of Lock Plate from the Proximal Tibia
An incision was made over the proximal tibia at which point the lock
plate was found and the plate along with all screws were removed.
Removal of Intramedullary (IM) Rod from Tibia
The IM rod was located within the tibia but could not be easily removed.
A surgical drill was used to cut the IM nail and to saw the rod into
pieces that could be more easily removed in parts.
Proximal & Distal Tibia Deformity
Correction & Lengthening w/
Application of Taylor Spatial Frame
A Taylor Spatial Frame was applied in a
bifocal manner with three rings and six struts.
The tibia was noted to be quite small and
abnormal due to distal deformities that
caused the bone to bend outwards (valgus)
and inwards (varus) along with a severe
proximal deformity where her knee bent
backwards (recurvatum). In a rather
complicated procedure, osteotomies were
performed both proximally and distally as I
tried to achieve approximately 5cm (2in) of
increased length.
Charlotte in the hospital after having
her Taylor Spatial Frame applied.
Post Op
Charlotte was given schedules for adjusting the struts of the frame to
create space and allow the bone to grow.
Charlotte’s mom inspects her Taylor Spatial Frame.
Observations
Two weeks after surgery, her sutures
were removed and all pin sites were
found to be clean. A week later, there was
good range of motion in her knee and
foot. X-rays revealed the tibia was
lengthening well and in proper alignment.
Over the next few weeks, various struts in the upper and
lower frames were changed to accommodate the new
length of the limb.
Four months after surgery, the
regenerated bone at the distal
tibia osteotomy site appeared to
have healed. However, the
union of the regenerated bone
at the proximal tibia osteotomy
site was delayed. Plans were
made to remove the distal
frame and inject the proximal
tibia site with bone marrow to
promote bone growth.
Surgery #2
Injection of Bone Marrow Aspirate, Demineralized Bone
Matrix into Delayed Union of Lengthening
A few struts were removed from the distal frame to allow for
examination of the osteotomy site to determine if it had healed. A
Jamshidi needle was used to draw 20cc of bone marrow from the right
iliac crest. The bone marrow was then mixed with demineralized bone
matrix and dye (Hypaque). 16cc of the bone marrow mixture was
injected into the proximal delayed nonunion site and 2cc were injected
into the distal site.
Removal of Wire From Proximal Tibia
The entire frame was left in place but some of the transfixion wires
were removed from the proximal tibia.
Observations
Two months after surgery, x-rays
revealed insufficient bone
formation. It was decided that a
bone graft would be performed.
Surgery #3
Iliac Crest Graft & Infusion of Bone
Morphogenetic Protein (BMP7)
The distal tibia osteotomy site was tested and
noted to be moving, indicating there was still a
nonunion. An incision was made over the
posterior iliac spine and a graft was taken from
the iliac crest. Another incision was made over
the nonunion distal site, the nonunion tissue
and bone was debrided, and the iliac crest graft
and BMP 7 were applied to the area. This
procedure was repeated at the proximal
nonunion site.
Observations
Charlotte made one emergency visit to the office due to swelling in her
right knee. The combination of having her leg extending for a long
period of time while being fitted for a new brace and then extensive
walking around school placed a lot of stress on her knee which
resulted in swelling. However, there was no need for intervention
beyond elevating and icing the leg while at rest.
Surgery #4
Hardware Removal
A check was performed to ensure that there was continuity of the bone
within the tibia. The Taylor Spatial Frame was then removed, all pin
sites were debrided, and Charlotte’s leg was placed in a short-leg cast.
The bone was thin but appeared intact and x-rays showed good
positioning.
Observations
One month after surgery, x-rays showed no major changes from
previous x-rays but a small area of buckling at the proximal tibia was of
some concern. Charlotte’s short leg casts were replaced with new
waterproof casts and she was able to place full weight on the leg.
Surgery #5
Open Reduction Internal Fixation (ORIF) with William’s
Nail & Synthes Locking Plate
An incision was made over the nonunion and proximal tibia. The bone
edges were aligned and a Williams rod and small plate were used to
hold the previous area of nonunion in place.
Infuse at the Tibial Nonunion Site
BMP7 was used at the nonunion site to stimulate healing of the bone.
Charlotte’s leg was then placed in a bivalved long-leg cast.
Surgery #6
Change of Plaster & Manipulation Right Foot
with Long Leg Casting
Charlotte was taken back into the operating room and her stitches and
cast were removed. The wound was clean and completely healed with
no signs of infection. The osteotomy, fracture, and nonunion sites
appeared to be in good position and healing/strengthening. Dressings
and a long leg cast were applied.
Observations
One week after surgery, Charlotte’s leg cast was shortened to below
her knee to allow for bearing weight on her right leg.
Four months after surgery, x-rays showed excellent bone formation in
the tibia and that all hardware was in place. Plans were made for
Charlotte to walk at home with her brace and no crutches and then
without braces or crutches.
Five months after surgery, x-rays revealed excellent bone formation
and a normal ankle. However, there was severe arthritis and a
deformity in the subtalar joint which caused severe pain when the joint
was moved.
It was decided that Charlotte would wear a Jobst stocking for support
and continue physical therapy. Her foot would be reevaluated in six
months at which point triple arthrodesis would be considered if there
was no improvement.
Surgery #7
An x-ray of Charlotte’s ankle five weeks before her seventh surgery.
Triple Arthrodesis of the Right Foot & Ankle Including
the Subtalar, Calcaneocuboid, & Talonavicular Joints
with Plates & Screws Utilized for Fixation
An incision was made over the joint between the ankle and heel (sinus
tarsi) and clear liquid flowed from the wound as a result of a
hemangioma on the foot; a tourniquet was applied. At this point,
cartilage was stripped (denuded) from the medial and posterior facets
of the joint (arthroplasty).
The talonavicular and calcaneocuboid joints were then opened with a
closing wedge osteotomy on the talonavicular joint. An opening wedge
osteotomy was performed at the calcaneocuboid joint. Arthroplasties
were performed on all of the joints. Next, a plate was inserted into the
talonavicular joint and screws were then applied to the calcaneocuboid
joint. A bone transplant (allograft) was then applied to the
calcaneocuboid joint and held in place with a plate and screws. Good
fixation was achieved and Charlotte’s foot and all hardware were in
proper position.
The wound was closed and
dressed, the tourniquet was
removed, an ankle block was put
in place, and a bivalved short-
cast was applied.
Surgery #8
Change of Plaster & Removal of Sutures
All wounds were found to be dry and clean and sutures were removed.
Dry sterile dressings were applied and short-leg casts were reapplied.
CONCLUSION
Charlotte is doing well overall and is actively involved with sports. I’ve
recommended a 1cm shoe lift for better balance and symmetry in
addition to ongoing physical therapy for strengthening which will allow
her to eventually walk without her crutch. While it’s possible that
Charlotte’s lower right limb may never be as strong as her left,
treatment has allowed her to avoid the need for an above knee
amputation and prosthesis. This case is an example of multiple
complex factors requiring an extended course of treatment that is now
concluding with a well functioning limb.
David S. Feldman, MD
Pediatric Orthopedic Surgeon
www.davidsfeldmanmd.com

Mais conteúdo relacionado

Mais procurados

Nathalie: Osteogenesis Imperfecta (Type IV) Case Study
Nathalie: Osteogenesis Imperfecta (Type IV) Case StudyNathalie: Osteogenesis Imperfecta (Type IV) Case Study
Nathalie: Osteogenesis Imperfecta (Type IV) Case StudyDavid S. Feldman, MD
 
David: Femoral Neck Fracture with Avascular Necrosis of the Hip Case Study
David: Femoral Neck Fracture with Avascular Necrosis of the Hip Case StudyDavid: Femoral Neck Fracture with Avascular Necrosis of the Hip Case Study
David: Femoral Neck Fracture with Avascular Necrosis of the Hip Case StudyDavid S. Feldman, MD
 
Grace: Varus Ankle & Medial Physeal Bar Case Study
Grace: Varus Ankle & Medial Physeal Bar Case StudyGrace: Varus Ankle & Medial Physeal Bar Case Study
Grace: Varus Ankle & Medial Physeal Bar Case StudyDavid S. Feldman, MD
 
A case presentation of acetabular fracture treated through crif
A case presentation of acetabular fracture treated through crifA case presentation of acetabular fracture treated through crif
A case presentation of acetabular fracture treated through crifAtanu Kayal
 
Arthroscopy of the Hip for Labral Pathology and FAI: Indications and Technique
Arthroscopy of the Hip for Labral Pathology and FAI: Indications and TechniqueArthroscopy of the Hip for Labral Pathology and FAI: Indications and Technique
Arthroscopy of the Hip for Labral Pathology and FAI: Indications and Techniquewashingtonortho
 
How to establish hip arthroskopy
How to establish hip arthroskopyHow to establish hip arthroskopy
How to establish hip arthroskopyTheRightDoctors
 
4.position of safe immobilisation
4.position of safe immobilisation4.position of safe immobilisation
4.position of safe immobilisationNgoc Quang
 
Hip Arthroscopy in 2013: Inova Annual Sports Medicine Program
Hip Arthroscopy in 2013: Inova Annual Sports Medicine ProgramHip Arthroscopy in 2013: Inova Annual Sports Medicine Program
Hip Arthroscopy in 2013: Inova Annual Sports Medicine Programwashingtonortho
 
A case presentation on infected non union
A case presentation on infected non unionA case presentation on infected non union
A case presentation on infected non unionAtanu Kayal
 
PostPolio Residual Paralysis part2 lower limb
PostPolio Residual Paralysis part2 lower limbPostPolio Residual Paralysis part2 lower limb
PostPolio Residual Paralysis part2 lower limbAnisuddin Bhatti
 
4 ddh principles & protocols 3 & above
4 ddh principles & protocols 3 & above4 ddh principles & protocols 3 & above
4 ddh principles & protocols 3 & aboveAnisuddin Bhatti
 
Anterior shoulder instability st4-6
Anterior shoulder instability   st4-6Anterior shoulder instability   st4-6
Anterior shoulder instability st4-6Lennard Funk
 
Patella fractures and extensor mechanism injuries
Patella fractures and extensor mechanism injuries Patella fractures and extensor mechanism injuries
Patella fractures and extensor mechanism injuries Hamid Hejrati
 
1 perthese diagnosis & classification
1 perthese diagnosis & classification1 perthese diagnosis & classification
1 perthese diagnosis & classificationAnisuddin Bhatti
 
Osteoarthritis and total joint replacement.ppt (1)
Osteoarthritis and total joint replacement.ppt (1)Osteoarthritis and total joint replacement.ppt (1)
Osteoarthritis and total joint replacement.ppt (1)Ali Ismail
 

Mais procurados (20)

Nathalie: Osteogenesis Imperfecta (Type IV) Case Study
Nathalie: Osteogenesis Imperfecta (Type IV) Case StudyNathalie: Osteogenesis Imperfecta (Type IV) Case Study
Nathalie: Osteogenesis Imperfecta (Type IV) Case Study
 
David: Femoral Neck Fracture with Avascular Necrosis of the Hip Case Study
David: Femoral Neck Fracture with Avascular Necrosis of the Hip Case StudyDavid: Femoral Neck Fracture with Avascular Necrosis of the Hip Case Study
David: Femoral Neck Fracture with Avascular Necrosis of the Hip Case Study
 
Nadine: Hip Dysplasia Case Study
Nadine: Hip Dysplasia Case StudyNadine: Hip Dysplasia Case Study
Nadine: Hip Dysplasia Case Study
 
Grace: Varus Ankle & Medial Physeal Bar Case Study
Grace: Varus Ankle & Medial Physeal Bar Case StudyGrace: Varus Ankle & Medial Physeal Bar Case Study
Grace: Varus Ankle & Medial Physeal Bar Case Study
 
A case presentation of acetabular fracture treated through crif
A case presentation of acetabular fracture treated through crifA case presentation of acetabular fracture treated through crif
A case presentation of acetabular fracture treated through crif
 
Arthroscopy of the Hip for Labral Pathology and FAI: Indications and Technique
Arthroscopy of the Hip for Labral Pathology and FAI: Indications and TechniqueArthroscopy of the Hip for Labral Pathology and FAI: Indications and Technique
Arthroscopy of the Hip for Labral Pathology and FAI: Indications and Technique
 
How to establish hip arthroskopy
How to establish hip arthroskopyHow to establish hip arthroskopy
How to establish hip arthroskopy
 
4.position of safe immobilisation
4.position of safe immobilisation4.position of safe immobilisation
4.position of safe immobilisation
 
Hip Arthroscopy in 2013: Inova Annual Sports Medicine Program
Hip Arthroscopy in 2013: Inova Annual Sports Medicine ProgramHip Arthroscopy in 2013: Inova Annual Sports Medicine Program
Hip Arthroscopy in 2013: Inova Annual Sports Medicine Program
 
A case presentation on infected non union
A case presentation on infected non unionA case presentation on infected non union
A case presentation on infected non union
 
Approach knee pain
Approach knee painApproach knee pain
Approach knee pain
 
PostPolio Residual Paralysis part2 lower limb
PostPolio Residual Paralysis part2 lower limbPostPolio Residual Paralysis part2 lower limb
PostPolio Residual Paralysis part2 lower limb
 
Knee what's new - robots and more
Knee what's new - robots and moreKnee what's new - robots and more
Knee what's new - robots and more
 
4 ddh principles & protocols 3 & above
4 ddh principles & protocols 3 & above4 ddh principles & protocols 3 & above
4 ddh principles & protocols 3 & above
 
Anterior shoulder instability st4-6
Anterior shoulder instability   st4-6Anterior shoulder instability   st4-6
Anterior shoulder instability st4-6
 
Patella fractures and extensor mechanism injuries
Patella fractures and extensor mechanism injuries Patella fractures and extensor mechanism injuries
Patella fractures and extensor mechanism injuries
 
1 perthese diagnosis & classification
1 perthese diagnosis & classification1 perthese diagnosis & classification
1 perthese diagnosis & classification
 
Mystery of Knee pain Black Hole of Orthopedics- Patellofemoral joint dr.san...
Mystery of Knee pain  Black Hole of Orthopedics- Patellofemoral joint  dr.san...Mystery of Knee pain  Black Hole of Orthopedics- Patellofemoral joint  dr.san...
Mystery of Knee pain Black Hole of Orthopedics- Patellofemoral joint dr.san...
 
Total hip replacement
Total hip replacementTotal hip replacement
Total hip replacement
 
Osteoarthritis and total joint replacement.ppt (1)
Osteoarthritis and total joint replacement.ppt (1)Osteoarthritis and total joint replacement.ppt (1)
Osteoarthritis and total joint replacement.ppt (1)
 

Semelhante a Charlotte: Complex Lower Limb Deformity

comminuted fracture of left patellar with displacement case presentation
comminuted fracture of left patellar with displacement case presentationcomminuted fracture of left patellar with displacement case presentation
comminuted fracture of left patellar with displacement case presentationJOEL RAJAN U
 
TalipesEquinoVarus.pptx
TalipesEquinoVarus.pptxTalipesEquinoVarus.pptx
TalipesEquinoVarus.pptxOwen342285
 
Osteoarthritis of Knee Joint
Osteoarthritis of Knee JointOsteoarthritis of Knee Joint
Osteoarthritis of Knee JointDr.Anshu Sharma
 
One Time Stable below Knee Residual Limb in Pediatric Amputee-Crimson Publishers
One Time Stable below Knee Residual Limb in Pediatric Amputee-Crimson PublishersOne Time Stable below Knee Residual Limb in Pediatric Amputee-Crimson Publishers
One Time Stable below Knee Residual Limb in Pediatric Amputee-Crimson PublishersCrimsonPublishersOPROJ
 
Outpatient Clinic Case Summary
Outpatient Clinic Case SummaryOutpatient Clinic Case Summary
Outpatient Clinic Case SummaryMichelle Davis
 
Pentagon Intraarticular Osteotomy: A Novel Surgical Approach to Complex Defor...
Pentagon Intraarticular Osteotomy: A Novel Surgical Approach to Complex Defor...Pentagon Intraarticular Osteotomy: A Novel Surgical Approach to Complex Defor...
Pentagon Intraarticular Osteotomy: A Novel Surgical Approach to Complex Defor...skisnfeet
 
Total joint replacement surgeries
Total joint replacement surgeriesTotal joint replacement surgeries
Total joint replacement surgeriessaheli chakraborty
 
Cervical Hybrid Arthroplasty by Pablo Pazmino MD
Cervical Hybrid Arthroplasty by Pablo Pazmino MDCervical Hybrid Arthroplasty by Pablo Pazmino MD
Cervical Hybrid Arthroplasty by Pablo Pazmino MDPablo Pazmino
 
Bone and joint care
Bone and joint careBone and joint care
Bone and joint careArman Care
 
Case discussion dr leal
Case discussion dr  lealCase discussion dr  leal
Case discussion dr lealChaz Leal
 

Semelhante a Charlotte: Complex Lower Limb Deformity (20)

Technology4
Technology4Technology4
Technology4
 
comminuted fracture of left patellar with displacement case presentation
comminuted fracture of left patellar with displacement case presentationcomminuted fracture of left patellar with displacement case presentation
comminuted fracture of left patellar with displacement case presentation
 
Knee
KneeKnee
Knee
 
Hip
HipHip
Hip
 
TalipesEquinoVarus.pptx
TalipesEquinoVarus.pptxTalipesEquinoVarus.pptx
TalipesEquinoVarus.pptx
 
Osteoarthritis of Knee Joint
Osteoarthritis of Knee JointOsteoarthritis of Knee Joint
Osteoarthritis of Knee Joint
 
One Time Stable below Knee Residual Limb in Pediatric Amputee-Crimson Publishers
One Time Stable below Knee Residual Limb in Pediatric Amputee-Crimson PublishersOne Time Stable below Knee Residual Limb in Pediatric Amputee-Crimson Publishers
One Time Stable below Knee Residual Limb in Pediatric Amputee-Crimson Publishers
 
Outpatient Clinic Case Summary
Outpatient Clinic Case SummaryOutpatient Clinic Case Summary
Outpatient Clinic Case Summary
 
Ankle and foot arthrodesis
Ankle and foot arthrodesisAnkle and foot arthrodesis
Ankle and foot arthrodesis
 
Pentagon Intraarticular Osteotomy: A Novel Surgical Approach to Complex Defor...
Pentagon Intraarticular Osteotomy: A Novel Surgical Approach to Complex Defor...Pentagon Intraarticular Osteotomy: A Novel Surgical Approach to Complex Defor...
Pentagon Intraarticular Osteotomy: A Novel Surgical Approach to Complex Defor...
 
Foot and ankle
Foot and ankleFoot and ankle
Foot and ankle
 
Ankle arthrodesis
Ankle arthrodesisAnkle arthrodesis
Ankle arthrodesis
 
Total joint replacement surgeries
Total joint replacement surgeriesTotal joint replacement surgeries
Total joint replacement surgeries
 
Cervical Hybrid Arthroplasty by Pablo Pazmino MD
Cervical Hybrid Arthroplasty by Pablo Pazmino MDCervical Hybrid Arthroplasty by Pablo Pazmino MD
Cervical Hybrid Arthroplasty by Pablo Pazmino MD
 
Osteoarthritis
OsteoarthritisOsteoarthritis
Osteoarthritis
 
Bone and joint care
Bone and joint careBone and joint care
Bone and joint care
 
Distraction
Distraction Distraction
Distraction
 
Knee cap (Patella) fractures
Knee cap (Patella) fracturesKnee cap (Patella) fractures
Knee cap (Patella) fractures
 
Case discussion dr leal
Case discussion dr  lealCase discussion dr  leal
Case discussion dr leal
 
Club foot
Club footClub foot
Club foot
 

Último

AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsMedicoseAcademics
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptPradnya Wadekar
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Peter Embi
 
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptxORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptxNIKITA BHUTE
 
AORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectionAORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectiondrhanifmohdali
 
Unit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptUnit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptPradnya Wadekar
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfHongBiThi1
 
blood bank management system project report
blood bank management system project reportblood bank management system project report
blood bank management system project reportNARMADAPETROLEUMGAS
 
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationPhysiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationMedicoseAcademics
 
Adenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisAdenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisSujoy Dasgupta
 
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptxANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptxWINCY THIRUMURUGAN
 
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdfSGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdfHongBiThi1
 
power point presentation of Clinical evaluation of strabismus
power point presentation of Clinical evaluation  of strabismuspower point presentation of Clinical evaluation  of strabismus
power point presentation of Clinical evaluation of strabismusChandrasekar Reddy
 
How to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyHow to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyZurück zum Ursprung
 
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxDNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxMAsifAhmad
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondSujoy Dasgupta
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.kishan singh tomar
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentsaileshpanda05
 
Red Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfRed Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfMedicoseAcademics
 

Último (20)

Biologic therapy ice breaking in rheumatology, Case based approach with appli...
Biologic therapy ice breaking in rheumatology, Case based approach with appli...Biologic therapy ice breaking in rheumatology, Case based approach with appli...
Biologic therapy ice breaking in rheumatology, Case based approach with appli...
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functions
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologyppt
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024
 
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptxORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
 
AORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectionAORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissection
 
Unit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptUnit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.ppt
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
 
blood bank management system project report
blood bank management system project reportblood bank management system project report
blood bank management system project report
 
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationPhysiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
 
Adenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisAdenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosis
 
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptxANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
 
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdfSGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
 
power point presentation of Clinical evaluation of strabismus
power point presentation of Clinical evaluation  of strabismuspower point presentation of Clinical evaluation  of strabismus
power point presentation of Clinical evaluation of strabismus
 
How to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyHow to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturally
 
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxDNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and Beyond
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing student
 
Red Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfRed Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdf
 

Charlotte: Complex Lower Limb Deformity

  • 1. Case Study: Charlotte Complex Lower Limb Deformity Age Range During Treatment: 14 years to 16 years David S. Feldman, MD Chief of Pediatric Orthopedic Surgery Professor of Orthopedic Surgery & Pediatrics NYU Langone Medical Center & NYU Hospital for Joint Diseases
  • 3. Charlotte has been my patient since she was three years old. Over the years, I’ve collaborated with other medical professionals to treat her for various issues with her right leg.
  • 4. Her issues began with a hemangioma that involved her entire right tibia. The hemangioma damaged her knee, ankle, and foot joints in addition to her growth plates which inhibited the growth of new bone. After several minimally invasive procedures, the hemangioma was finally stabilized when she was eight years old.
  • 5. At the age of 11, Charlotte underwent osteotomies and plates were put in place to treat rotational and angular deformities that had developed in her leg and foot.
  • 6. Charlotte later suffered fractures in her fibula and tibia and the rods from the osteotomies had to be removed because the hemangioma had caused her bones to shift out of position and the rods to protrude causing pain.
  • 7. Delayed bone growth caused by the hemangioma resulted in a large limb length discrepancy (over three inches). At the age of 13, we discussed the option of surgically correcting her limb length discrepancy and deformity with a Taylor Spatial Frame.
  • 10. Removal of Lock Plate from the Proximal Tibia An incision was made over the proximal tibia at which point the lock plate was found and the plate along with all screws were removed. Removal of Intramedullary (IM) Rod from Tibia The IM rod was located within the tibia but could not be easily removed. A surgical drill was used to cut the IM nail and to saw the rod into pieces that could be more easily removed in parts.
  • 11. Proximal & Distal Tibia Deformity Correction & Lengthening w/ Application of Taylor Spatial Frame A Taylor Spatial Frame was applied in a bifocal manner with three rings and six struts. The tibia was noted to be quite small and abnormal due to distal deformities that caused the bone to bend outwards (valgus) and inwards (varus) along with a severe proximal deformity where her knee bent backwards (recurvatum). In a rather complicated procedure, osteotomies were performed both proximally and distally as I tried to achieve approximately 5cm (2in) of increased length. Charlotte in the hospital after having her Taylor Spatial Frame applied.
  • 12. Post Op Charlotte was given schedules for adjusting the struts of the frame to create space and allow the bone to grow. Charlotte’s mom inspects her Taylor Spatial Frame.
  • 13. Observations Two weeks after surgery, her sutures were removed and all pin sites were found to be clean. A week later, there was good range of motion in her knee and foot. X-rays revealed the tibia was lengthening well and in proper alignment.
  • 14. Over the next few weeks, various struts in the upper and lower frames were changed to accommodate the new length of the limb.
  • 15. Four months after surgery, the regenerated bone at the distal tibia osteotomy site appeared to have healed. However, the union of the regenerated bone at the proximal tibia osteotomy site was delayed. Plans were made to remove the distal frame and inject the proximal tibia site with bone marrow to promote bone growth.
  • 17. Injection of Bone Marrow Aspirate, Demineralized Bone Matrix into Delayed Union of Lengthening A few struts were removed from the distal frame to allow for examination of the osteotomy site to determine if it had healed. A Jamshidi needle was used to draw 20cc of bone marrow from the right iliac crest. The bone marrow was then mixed with demineralized bone matrix and dye (Hypaque). 16cc of the bone marrow mixture was injected into the proximal delayed nonunion site and 2cc were injected into the distal site. Removal of Wire From Proximal Tibia The entire frame was left in place but some of the transfixion wires were removed from the proximal tibia.
  • 18. Observations Two months after surgery, x-rays revealed insufficient bone formation. It was decided that a bone graft would be performed.
  • 20. Iliac Crest Graft & Infusion of Bone Morphogenetic Protein (BMP7) The distal tibia osteotomy site was tested and noted to be moving, indicating there was still a nonunion. An incision was made over the posterior iliac spine and a graft was taken from the iliac crest. Another incision was made over the nonunion distal site, the nonunion tissue and bone was debrided, and the iliac crest graft and BMP 7 were applied to the area. This procedure was repeated at the proximal nonunion site.
  • 21. Observations Charlotte made one emergency visit to the office due to swelling in her right knee. The combination of having her leg extending for a long period of time while being fitted for a new brace and then extensive walking around school placed a lot of stress on her knee which resulted in swelling. However, there was no need for intervention beyond elevating and icing the leg while at rest.
  • 23. Hardware Removal A check was performed to ensure that there was continuity of the bone within the tibia. The Taylor Spatial Frame was then removed, all pin sites were debrided, and Charlotte’s leg was placed in a short-leg cast. The bone was thin but appeared intact and x-rays showed good positioning.
  • 24. Observations One month after surgery, x-rays showed no major changes from previous x-rays but a small area of buckling at the proximal tibia was of some concern. Charlotte’s short leg casts were replaced with new waterproof casts and she was able to place full weight on the leg.
  • 26. Open Reduction Internal Fixation (ORIF) with William’s Nail & Synthes Locking Plate An incision was made over the nonunion and proximal tibia. The bone edges were aligned and a Williams rod and small plate were used to hold the previous area of nonunion in place. Infuse at the Tibial Nonunion Site BMP7 was used at the nonunion site to stimulate healing of the bone. Charlotte’s leg was then placed in a bivalved long-leg cast.
  • 28. Change of Plaster & Manipulation Right Foot with Long Leg Casting Charlotte was taken back into the operating room and her stitches and cast were removed. The wound was clean and completely healed with no signs of infection. The osteotomy, fracture, and nonunion sites appeared to be in good position and healing/strengthening. Dressings and a long leg cast were applied.
  • 29. Observations One week after surgery, Charlotte’s leg cast was shortened to below her knee to allow for bearing weight on her right leg. Four months after surgery, x-rays showed excellent bone formation in the tibia and that all hardware was in place. Plans were made for Charlotte to walk at home with her brace and no crutches and then without braces or crutches.
  • 30. Five months after surgery, x-rays revealed excellent bone formation and a normal ankle. However, there was severe arthritis and a deformity in the subtalar joint which caused severe pain when the joint was moved. It was decided that Charlotte would wear a Jobst stocking for support and continue physical therapy. Her foot would be reevaluated in six months at which point triple arthrodesis would be considered if there was no improvement.
  • 32. An x-ray of Charlotte’s ankle five weeks before her seventh surgery.
  • 33. Triple Arthrodesis of the Right Foot & Ankle Including the Subtalar, Calcaneocuboid, & Talonavicular Joints with Plates & Screws Utilized for Fixation An incision was made over the joint between the ankle and heel (sinus tarsi) and clear liquid flowed from the wound as a result of a hemangioma on the foot; a tourniquet was applied. At this point, cartilage was stripped (denuded) from the medial and posterior facets of the joint (arthroplasty).
  • 34. The talonavicular and calcaneocuboid joints were then opened with a closing wedge osteotomy on the talonavicular joint. An opening wedge osteotomy was performed at the calcaneocuboid joint. Arthroplasties were performed on all of the joints. Next, a plate was inserted into the talonavicular joint and screws were then applied to the calcaneocuboid joint. A bone transplant (allograft) was then applied to the calcaneocuboid joint and held in place with a plate and screws. Good fixation was achieved and Charlotte’s foot and all hardware were in proper position. The wound was closed and dressed, the tourniquet was removed, an ankle block was put in place, and a bivalved short- cast was applied.
  • 36. Change of Plaster & Removal of Sutures All wounds were found to be dry and clean and sutures were removed. Dry sterile dressings were applied and short-leg casts were reapplied.
  • 38. Charlotte is doing well overall and is actively involved with sports. I’ve recommended a 1cm shoe lift for better balance and symmetry in addition to ongoing physical therapy for strengthening which will allow her to eventually walk without her crutch. While it’s possible that Charlotte’s lower right limb may never be as strong as her left, treatment has allowed her to avoid the need for an above knee amputation and prosthesis. This case is an example of multiple complex factors requiring an extended course of treatment that is now concluding with a well functioning limb.
  • 39. David S. Feldman, MD Pediatric Orthopedic Surgeon www.davidsfeldmanmd.com