This document discusses several orthopedic complication cases: 1) A young lady with grade IIIB fractures of both legs from a car accident who developed infection, nonunion, and failed corticotomy before finally achieving union with IM nailing. 2) A woman with recurrent sacrococcygeal chordoma after excision who underwent marginal excision with nerve root preservation and post-op radiation for recurrence. 3) A young lady with a neglected patellar tendon cut who underwent reconstruction with a semi-T tendon graft and hardware fixation to regain extension. 4) A young lady with a recurrent giant cell tumor of the distal radius with infection who underwent wide excision and reconstruction with a nonvascular

1. Complications in Orthopedics: Our
Experience with few Case illustration
Suresh Pandey
Associate Professor
AP Regmi, J Shrestha, J Sitaula, B Sharma
Dept. of Orthopaedics
Chitwan Medical College Teaching Hospital, Bharatpur

2. Background
 All surgery has risk of complication
 Though its minimal, it occurs despite our best care
 Some complications are specific to injury while others
are general to surgery

3. Background
 Complications can be minimised with due care,
technique and planning but cant be avoided
completely
 There is more to learn from complications and difficult
case
 This helps to avoid or minimize complication in
future

4. 24 yr young lady with Grade IIIB fracture
B/B bilateral legs due to RTA

5. Problems
 Bone exposed and gross contamination
 High chance of infection, nonunion
 Prepare for multiple intervention
 patience from both surgeon and patient side
 Cost and time factors

6. WD and ext fixator and repeated debridemet SSG
for soft tissue management

7. Debridement, Ilizarov fixation with
corticotomy and BG after 3 mth

8. Failed corticotomy

9. Segmental fracture status with uncontrolled infection at
8th mth

10. Exhausted with
• repeated debridement and fixation
• BG
• dressing
• uncontrolled infection,
• failed corticotomy
• C/S and antibiotics
• and nonunion after 9 mth

11. • Decided to remove all the implants
debridement and vancomycin impregnated cement
beads on nonsegmental fracture side

12.  Put on PTB cast

13. After 15 mth active infection controlled but nonunion
persistent and planned for next and hopefully final
intervention with IM nailing

14. 3mth of IL nail and BG with controlled infection
and hope for union

15.  Both sides united well with infection controlled at 5
mth of IM nailing
 Discharging sinus healed
 Walking with full wt bearing with shoe raise of 2 cm
on Rt.

16. 45 yr lady with recurrence of
sacrococcygeal Chordoma
after 8 mth of excision with
non healing wound

17. Problems
 Recurrence
 Discharging sinus
 Wound healing
 Preservation of Nerve roots

18. Options?
 RT: If margin positive or doubtful
 CT?
 Operative: mainstay of treatment
 Combined

19. Approach
Posterior
Anterior and posterior
Operative Procedure
 Surgical marginal excision
done with preservation of S1
and S2 nerve roots thru
posterior inverted U
approach with excision of
sinus tract

20.  Subjected to post op adj RT
 Healed well
 No neurological deficit
 No fresh problem till 18 mth follow up

21. 26 year lady with 5 mth old Neglected patellar
tendon cut with limping, pain, quadriceps
wasting and extensor lag

22. Aim of Treatment
 Repair the extensor apparatus
 ROM
 Build up quadriceps

23. What is so special in
reconstruction?
 Very rare entity with limited case reports in the
literature with variable results with different technique
 Bringing patella down
 Availability of tendon stump on each side

24. Surgical Procedure
 Anterior midline approach
 Stump clearance
 Patella down with quadriceps V-Y plasty
 Sutured the availabile remnant tendon stump
 SemiT Tendon hravesting keeping the distal insertion
intact
 Patellar drilling transverse for semiT tendon loop and
SS wire fixation thru patella to tibial tubercle through
transverse drill

25. Technique described

27. Post Op
 Slab removal at 6 weeks and
gradual wt bearing and ROM
exercise
 Pain due to stress of hardware
on tibial tuberosity
 Tackled with early SS wire
removal at 2.5 mth

28. 3 mth post op ROM and regain of active
extension and normal painless gait. Patient
satisfied with the outcome

29. 19 year young lady with twice operated GCT distal
radius with recurrence with nonresolving pus
discharing sinus for one year with path fracture

30. Problems
 Tumor contamination to soft tissue due to discharging
sinus and repeated previous operation
 Path fracture
 Risk of injury to radial A and N due to fibrosis around
because of previous surgery and infection
 Risk of local recurrence

31. WLE and reconstruction with nonvascularised
ipsilateral prox. Fibula with BG

32. 6 wks post op

33. United well with near full ROM without any
neurovascular deficit without evidence of local
recurrence or lung mets till 2 yr follow up

34.  Minor concern with dorsal
bony prominence due to
fibular head
 Plan to debulk

35. 35 year young man with complete degloving of
ankle, heel, foot and sole all around with multiple
MT fracture with doubtful viability with opposite
leg both bone fracture Gustillo grade II

36. Debridement, pinning and closure

37. Complete necrosis of the flap all around foot,
ankle, heel pad and sole within 1 week

38. Redebridement and healthy granulation tissue
appeared but calcaneum and TA exposed
ap

39. Problem
 Large area to be covered with flap
 No intraop doppler to see the perforators that forms
anastomoses
 Risk of flap necrosis due to largest possible size
 Distal perforators area of the flap is compromised due
to degloving above lat. malleolus
 Orthopedic surgeon in the role of plastic surgeon

40. Sural A reverse fasciocutaneous
flap
 Masquelet desccribed it
in 1992
 Fasciocutaneous reverse
artery flow flap due to
suprafascial anastomosis
between sural A and
perforators from
peroneal A 5 cm above
lat malleous

41. Intraop planning and raising flap

42. Post Op: good viability of flap and
graft take up

44. Gradual wt bearing walking with complete healing
of flap and graft.ROM normal
Opposite tibia uniting well on PTB cast after fixator
removal

45. What is so special?
 Largest such flap described in
literature is 17x14 cm
 This was 18x15 cm
 Distal to the pedicle was not
normal due to degloving upto
above ankle area.
 Patient able to walk with painless
gait after 4 mth of operation with
normal ROM
 Opposite side tibia showed good
union on PTB cast

46. 45 y young man with grossly
displaced and comminuted I/A
fracture distal end radius

47. ?CR and ligamentotaxis

48. At 3 mth gross deformity,
stiffness and nonunion with
almost nonfunctional hand

50. Operative procedure
ORIF with plating
with BG after
deformity correction

51. Result
Union and correction of deformity at 3 mth
of plating with normal, painless ROM