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Author Topic: Malrotation following Intramedullary nailing of oblique fracture of left tibia  (Read 487 times)

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Offline Invicta

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Fillowing IM nailing of my tibia 6 weeks ago I noticed about two weeks ago after the swelling went down that my foot is pointing excessively to the inside and after some examination by a few different consultants it has been confirmed it is malrotation. They estimate it at 20-30 however calculation of my CT has yet to be done. At this point I was told since the bone has started healing they are not too sure what they can do apart from external fixation. I have seen some stories of malrotation fixed by second operation (nailing/plating). Does anyone here know of a surgeon who has had any success of fixing malrotation to an acceptable degree without external fixation?
I had seen reply to a similar topic by @missmyknee with his story however unfortunately he does not mention who fixed it for him
I have also got some problems with my knee however it is difficult to tell at this point if it'll heal and is part of the consequences of IM nailing or will need to be fixed at a later date after my fracture is dealt with
« Last Edit: December 13, 2017, 02:44:27 PM by Invicta »

Offline missmyknee

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Hi Invicta

I just saw this posting. You were wondering where I had surgery to correct the malrotation of the nailing of my tib-fib fracture. I live in the U.S. in Kansas. An orthopeadic surgeon there, who specializes in the lower leg, ankle and foot, did my surgery. I also developed arthrofibrosis in my knee from the incision and entry thru my patella tendon to insert the nail down the tibia. Where as you are inwardly malrotated , I was 40 degrees externally rotated.

I have a series of blogs about my experience in the community section of the website under blogs. Mine is the first one under arthrofibrosis

4Fx Clsd red
IMrod fib plate
derotate osteotmy tibfib
IPCS patbaja
DeLeeOsteotmy,LOA,LR Zplasty,bongrf,chondrplty
chondrplty,LOA,fatpad remvd
openLOA,neurectmy,ITB Zplasty,fabela
PLC recon,revison,LOA,synovec
MCL,revison LOA
openLOA,prox Zplasty
openLOA, 6 neuromas excised,synov
3 Fusions

Offline Invicta

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Hi Pam,

Thank you for your reply I just saw it. I have read all your blog and you have literally helped me save my leg. THANK YOU.  :)

I have been through so much I can't even believe it.

__\\TL;DR- Start//__

I have now had my leg fixed.

The reason for the malrotation in the first place? The surgeon did not have an assistant to hold the leg in place when inserting the nail and was himself a trainee. Appalling. 

__\\TL;DR- END//__

Cue the update in case someone finds themselves in a similar situation in the future. Mine is a long story so hold onto your hats.

I am based in the UK.

I found a surgeon in Leeds, UK who was able to fix the malalignment with the IM nail in situ (this guy is amazing :)). He removed the distal screws and did an osteotomy of the original fracture site around the nail to allow him to move the foot into the correct position. It is a very complicated procedure and there is not many surgeons who can do it or would want to take on the risks. (Did I say this guy is amazing? ;D) He also had to take bone grafts from my hip as after returning my foot to proper alignment there was a sizeable gap in my tibia. He was able to do the osteotomy around the nail also because at 6 months my tibia still has not healed despite the initial surgeons saying otherwise.

There is, however, a twist in the story. I still had some problems with my knee even after the corrective surgery. The amazing consultant has looked at all the xrays again and has concluded I must have had an injury to my knee from the original accident/or thereafter(1) that was missed by the doctors who treated me in the first place. I do not even want to think of what could happen if I didn't find this amazing surgeon as nobody in the city I had the first surgery believed (what he did) would even be possible.

(1) (I understood it to be a tear of some of the cartilage of the medial femoral condyle or something similar but basically a small tear in the articular cartilage/soft tissue in the knee on the medial side- which now explains pretty much everything I'd experienced. Additionally he said that during the initial accident my patella must have moved some laterally and still has not returned to the original position-does not have the proper tracking(?) with the muscle atrophy and all(?) I have no medical training so may have mixed something up)

I had to spoonfeed them treatment options and I honestly wondered what these people even do working in a hospital. In the end all they said was- the only options are illizarov frame, or exchange nailing, which by that time I'd already known as possible options. While maybe nothing wrong with these from medical perspective in my case it could have become a disaster.

I still insisted that the nail not be removed and had to jump through a series of hoops and do it privately (it was not as easy as it sounds because I still needed a referral from the NHS doctor I was under, and he was not happy to let me go) also no one but my family and the amazing surgeon in Leeds even wanted to believe me I was experiencing any problem with my knee(they never diagnosed any injury to my knee). As I had read @missmyknee (Pam's) posts I knew what I may be facing and was very lucky to have the surgeon in Leeds on my side. (He is amazing).

Additionally in the first hospital I was in following my accident, they said they couldn't do exchange nailing because apparently it was too risky and they would get shaky hands during the surgery due to the pressure associated with this being a second surgery. Only ilizarov they were willing to do.(This has its own problems on top of already many other surgical complications from the IM nail I was having) They gave me very little hope and told me I will never be able to walk normally, run or do anything I did before (I am quite into sports and martial arts)-> I am in my early 20s.

 In any case the two options I was given would have meant taking the nail out at a time where my knee was in a bad place potentially resulting in more problems down the road, but not one of the smarty pants in my city cared about my knee. Also they planned to break a healthy part of my tibia above the initial fracture after they removed the nail. A plan I was not on board with.

 Fortunately I have read all of Pam's posts and blog and did some research into arthrofibrosis as well as other patellofemoral disorders which without a doubt saved me.

The doctors also said it is all in my head as there is nothing wrong with my knee and I am being too sensitive about the situation(still not trying to investigate my claims). They tried insisting I stay with them as it is free on the NHS and questioned me on my financial ability as they were surprised I'd want to spend money and go privately if I can have another doctor do it "for free". In the end I think I got some help from the amazing people in Leeds and managed to squeeze the referral out of the NHS doctor to go and do it privately(privately but still in an NHS hospital LOL). Before the private referral I'd had seen 8 different surgeons. As far as I am concerned all of them so out of their depth it is mind boggling. Some couldn't even see the 30 malrotation.

I stopped trusting the circus I was seeing so I created a third option with the help from the amazing people in Leeds. I am sooo sooo lucky they believed me and wanted to help me even though I was hundreds of miles away.

Additionally as the derotation osteotomy was not done until about 6 months after the initial accident, I was unable to walk for the first 4-5 months (first due to swelling later due to pain) which resulted in a shortening of my Achilles tendon and muscle atrophy. The reason for such a delay between malrotation(internal tibial torsion) diagnosis and second surgery was due to transfer of my case to a different hospital and some nay sayers who wanted to do exchange nailing and who dismissed my knee problems completely, saying nothing was wrong with it. (and yet I was unable to bend it without great discomfort and quite a "stiff"/swollen feeling).

I had my derotation done at the end of March.

I have now been able to get back almost all ROM in my ankle although I can not point it out as far as I could before the accident- it may still improve as the area around the inside of my ankle still feels quite "stiff". There is about 5-10 missing to get full dorsiflexion as compared to my uninjured leg; got all plantarflexion back. This should still improve as I am yet to do any proper physiotherapy/ training. From what I am able to feel my knee is about 70% there, it still gets quite "stiff" and like it's "swollen" on the inside particularly felt when walking. While still it is not what I want it to be I have options that I wouldn't have had were I to get exchange nailing. I stopped using crutches around the house about ~5 weeks after the osteotomy surgery and was now cleared to ditch them when going outside as the fracture has almost healed and should heal completely within the next 3-4 weeks.

I was so fortunate to be treated by this expert in Leeds it all still seems very surreal. (He is amazing 8))

When someone says something is impossible, it may as well be impossible- for them. I suppose a 200k degree isn't worth nothing if once someone gets it they start thinking they know it all and have seen everything, and they are the be all and end all. While I get it everyone will have a different opinion when faced with the same problem there are always options and it is important to be able to choose and know what consequences there may be as at the end of the day it is the patient not the smartypants who will have to live with it.

Finding a surgeon one can trust is vital. The surgeon I found not only listens to what you say but he takes it and analyses it to see if maybe there is something that is missing from the picture. I trust him completely and if I ever need any help again I hope I get him or one of his colleagues in the first place, so that I do not have to go around trying to fix mistakes.

Also worth mentioning I had three physiotherapy sessions privately before I went for my surgery in March and one on the NHS. The NHS physio appt was in the middle of January- my accident at the end of October. She didn't say much and dismissed me at the second appointment as she found out from my files I will have another surgery to fix the mistake made by the first surgeon (at this point it was still unknown who or when will fix me and I was trying to get the private referral). I then decided to go privately as my knee and the whole leg just seemed to deteriorate at an alarming rate. I found this guy who- while he's never seen anything like my leg- was able to put me back on my feet(heh) and got me walking again. I was able to walk without crutches starting about two weeks before the 2nd surgery (End of March) although I was tripping over my own foot(due to the unnatural rotation). Quite a limp at this point. As all the soft tissue was sort of twisted/stretched I had quite a lot of pain in my ankle and going into my foot(add the shortened achilles tendon+knee injury "stiffness"/swelling, liquid in the knee and pain and you may just about get the picture). TFW you trip over your own foot and there is nothing you can do - absolutely terrifying.

While I am still not out of the woods as I need to rebuild all my leg muscles with my knee still being quite tender and weak, I have had an unbelievable improvement under the care of the surgeon I am with now. He believes there will still be improvement as it has not all settled yet. (He is amazing beyond belief- really)

When doing physio and trying to walk I also got a static bike and did some 10-20min every day or two- depending how my knee felt. Nothing crazy just to get it going. I find it helped me a ton. I also used ice packs a lot- so as not to freeze my knee to death I kept reusable coolpacks in the fridge (door compartments) and took 2-3 and changed them more frequently than taking one from the freezer.

I do not know if anyone will ever find this useful but I am still posting it just in case anyone will.

I am thinking of starting a blog, and just documenting everything that happened there.


Edit: Some clarification as I felt it may be easier to understand now.
« Last Edit: June 13, 2018, 05:45:58 PM by Invicta, Reason: Some clarification as I felt it may be easier to understand now. »