Managing A Distal Femoral Physeal Nonunion secondary to Knee joint sepsis in an Eight year old Child

Authors : Sanjeev Musuvathy Ravi, SachindraNayak Kapadi, AkshathAdapa

Introduction: Neonatal bone and joint infections can cause physeal damage

resulting in either physeal growth disturbance or complete growth arrest. (1)Leg lengthening is a technically difficult procedure, used in leg-length discrepancies of 5-15 cm. The Ilizarov fixator method involving knee spanning fixation is commonly used (2). Removal of the Ilizarov frame can result in a loss of flexion secondary to a ‘rebound phenomenon’(3) .Extension contracture of the knee is a common complication of femoral lengthening (4).Quadricepsplasty is a technique devised to release extra-articular adhesions or contractures which prevent useful flexion of the knee(5).

Objectives : - To achieve union at distal femur - To correct limb length discrepancy - To tackle knee stiffness and achieve acceptable knee

range of motion

History: 8 YO child presented to us with

distal femoral physeal nonunion and shortening secondary to neonatal sepsis.

• On examination: right lower limb had shortening of 14 cm. Knee range of motion could not be assessed as movements were occuring at the physeal nonunion. Ankle in equinus. No distal neuro-vascular deficits

Treatment plan:

Stage 1: acute docking of fracture site and femoral lengthening using ilizarov ring fixator(short proximal segment - 9cm)

Stage 2: at 9 years of age: 2nd limb lenghthening, As had knee stiffness, JudetsQuadricepsplasty was planned to achieve knee ROM and to further help in lengthening process

Stage 3: further lengthening ,later during adolescent age to correct residual total future limb length discrepancy

Stage 1 :Acute docking and limb lengthening with Ilizarov ring fixator

➢Due to severe shortening, tibia was also lengthened

➢Due to severe shortening, tibia was also lengthened

Stage 2 : Operative procedure: Judet’s quadricepsplasty:

3 years post initial lengthening, knee was stiff, due to soft tissuecontractures. To achieve knee ROM, Judet’s Quadricepsplasty was done

Initially limb was kept in maximum flexion immobilized in a flexion slab.Post op day 5, flexion slab was removed, and intensive physiotherapy wasinitiated, a CPM machine was used and after 4 weeks of hospital stay thechild achieved 85 degrees of active knee flexion.

DiscussionLong standing infected nonunion at distal femur can lead to knee stiffness ; Femoral lengthening can also add to knee stiffness and an extension contracture. Short femur segment limits our choices of fixator use, ilizarov ring fiaxator being the most feasible.As LLD was very severe, one Stage limb lengthening is not possible, hence staged treatment was planned. Kettelkamp et al have shown that 70 degrees of flexion during swing portion of gait is required for normal ambulation (6) The Judet quadricepsplasty is performed in phases with increments of flexion achieved by passive manipulation after each phase of the release. This technique of disinsertion and muscle sliding is associated with rapid recuperation, little extension lag and almost complete maintenance of the range of passive movement found at operation.

References1. Beaty, James H.; Kasser, James R ,Rockwood and Wilkins Fractures in Children, 7th Edition, pg 922. H. S Hosalkar, S.Jones , M. Chowdhary, J. Hartley, R.A Hill : Quadricepsplasty for knee stiffness after femoral lengthening in congenital short femur; The journal of bone and joint surgery; Vol – 85-B, no. 2 , march 20033. Dae-Hee Lee, MD, Tae-Ho Kim, MD, PhD, Se-Joon Jung, MD, Eun-Jong Cha, PhD and Seong-Il Bin, MD: Modified Judet Quadricepsplasty and Ilizarov Frame Application for Stiff Knee After Femur Fractures, Journal oforthopedic trauma; Vol – 24, number 11, November 20104. Saurabh Khakharia MD, Austin T.Fragomen MD, S. Robert Rozbruch MD: Limited quadricepsplasty for contracture during femoral lengthening; Clinical orthopedics and related research; Vol -467,number 11, nov 20095. H. Daoud, T O’Farrel and R.L. Cruess :Quadricepsplasty , The Judet’s technique and results of six cases , The Journal of bone and jont surgery; Vol-64 B, No.2 , 19826. Kettelkamp DB, Johnson RJ, Smidt GL, Chao EYS, Walker M. An electrogoniometric study of knee motion in normal gait. J Bone Joint Surg [Am] 1970;50-A:775-90

ConclusionTreating distal femoral nonunion due to destruction of physis by infection is difficult as it leads to a lot of limb length discrepancy. The short femoral segment limits the choice of implants to Ilizarov fixator .Hence, Ilizarov ring fixator was a good choice to lengthen very short limb segments and also achieve union.Judets quadricepsplasty improves knee ROM in complicated cases like long standing infection associated with knee stiffness even after aggressive physiotherapy.