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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 6  |  Issue : 2  |  Page : 159-162

Saphenous nerve entrapment during bone transport in an ilizarov frame


1 Department of Orthopaedics, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
2 Department of Orthopaedics, All India Institute of Medical Sciences, Nagpur, Maharashtra, India
3 Department of Orthopaedics, VMMC and Safdarjung Hospital, New Delhi, India

Date of Submission03-May-2020
Date of Decision31-May-2020
Date of Acceptance19-Jul-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. Vishal Champawat
Department of Orthopaedics, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jllr.jllr_13_20

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  Abstract 


Ilizarov fixator system plays an important role in modern orthopedics due to its multiple uses. Complications related to its use are well documented and have been classified by many authors in the past. In this case report, we describe a rare complication of saphenous nerve dysfunction secondary to it getting entrapped in its course by a transfixation wire during the process of bone transport. The diagnosis and management of this complication has been discussed with an intention to make the surgeons aware of similar situation in their own practice.

Keywords: Ilizarov, Ilizarov complications, peripheral nerve damage, saphenous nerve dysfunction


How to cite this article:
Behera P, Champawat V, Tiwari V, Gupta V. Saphenous nerve entrapment during bone transport in an ilizarov frame. J Limb Lengthen Reconstr 2020;6:159-62

How to cite this URL:
Behera P, Champawat V, Tiwari V, Gupta V. Saphenous nerve entrapment during bone transport in an ilizarov frame. J Limb Lengthen Reconstr [serial online] 2020 [cited 2021 Apr 13];6:159-62. Available from: https://www.jlimblengthrecon.org/text.asp?2020/6/2/159/306106




  Introduction Top


Ilizarov ring fixator is a time-tested versatile system which finds use in the management of nonunion, limb lengthening, deformity correction, and fractures among other indications. The common complications of its use are pin-tract infection, joint stiffness, malunion, nerve palsy, and rarely, nonunion.[1]

Paley stated that the treatment with Ilizarov frame starts when the patient is taken for surgery and is completed only after the frame is removed. As the duration of frame use varies with the indication, the chance of getting a complication is high and attempts have been made to classify the complications.[2],[3],[4] Most of the reported complications of nerve injury are due to insertion of a wire or half pin, due to twisting movement done to complete a tibial corticotomy, and during distraction for limb lengthening procedures.[5],[6] However, there are limited reports of nerve complications during bone transport. In this report, the case of saphenous nerve dysfunction resulting after it got entrapped in its course by a transfixation wire during the process of bone transport has been presented.


  Case Report Top


A 16-year-old patient presented with a 6-month history of gradually increasing pain and swelling of his right leg. Clinical examination suggested a fusiform expansive bony hard lesion. Radiographs and magnetic resonance imaging [Figure 1] were suggestive of a radiolucent fusiform lesion with areas of intervening dense sclerotic bone in the diaphyseal area. Chest radiographs and computed tomography scans were unremarkable. No other bony lesion was seen on a bone scan. A core biopsy was done which was suggestive of adamantinoma.
Figure 1: Preoperative magnetic resonance imaging of the patient showing the well-defined fusiform lesion in the diaphyseal area of the tibia

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A plan of wide resection and limb salvage by performing a transport over nail with an Ilizarov apparatus was made. Resection of the entire tumor with 2-cm tumor-free bone on either end was performed. The entry point for a tibial intramedullary nail (IMN) was then made. Multiple drill holes were made at the planned osteotomy site just distal to the tibial tuberosity. An 8-mm stainless steel IMN was inserted and was locked on both ends. A preassembled Ilizarov frame was then applied. The middle segment which was to be transported was fixed with Ilizarov wires. Osteotomy was then completed through the predrilled holes using a thin osteotome. Distraction was started after 10 days at a rate of 0.25 mm four times a day [Figure 2]. After 8 weeks of distraction, the patient had a sudden onset of pain on the medial aspect of the leg which was radiating down to the medial border of the foot; as this pain was gradually increasing, he reported to the outpatient clinic. This was associated with paresthesia. The symptoms were aggravated when he extended his knee beyond 60° of flexion and were found to be arising medially around a transfixation wire placed in the fragment being transported [Figure 3] and [Figure 4]. Tapping along the course of the saphenous nerve led to an increase in paresthesia. The pin sites were healthy, and laboratory parameters were normal. An ultrasound examination of the lower limb showed no abnormalities. As the area of paresthesia was in the saphenous nerve distribution, a provisional diagnosis of saphenous nerve getting entrapped by the wire was made. Local infiltration of 10 ml of 2% lignocaine in the subcutaneous plane along the course of the saphenous nerve resulted in improvement of symptoms. However, nerve conduction studies were not performed. Under local anesthesia, the offending wire was removed, and a tapered half pin was inserted through a block attached to a hole in the same ring [Figure 5], respecting the cross-sectional anatomy of the tibia at that level as described by Catagni.[7] The patient was free from pain and paresthesia after the procedure, and distraction was continued at the previous rate. The fragment docked at the distal end at the end of transport process [Figure 6]. Transport over a nail allowed an early frame removal; a molded brace was prescribed. Activities were allowed as tolerated by the patient. The regenerate consolidated over time [Figure 7].
Figure 2: Radiographs (anteroposterior, oblique, and lateral) of the leg during the process of transport over nail

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Figure 3: Clinical picture showing surface marking of the saphenous nerve. The arrow is pointing at the offending wire

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Figure 4: Clinical picture with the knee in the position of comfort (60° flexion). Attempts to extend the knee from this position aggravated the pain

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Figure 5: Clinical picture obtained after removal of the offending wire. The arrow is pointing at the newly inserted half pin

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Figure 6: Radiographs (anteroposterior, lateral, and oblique) of the leg obtained when the transported fragment docked at the distal fragment

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Figure 7: Radiographs obtained 6 weeks after removal of the Ilizarov frame showing good consolidation of the regenerate

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  Discussion Top


After its advent, there have been many modifications in the components and techniques of the Ilizarov ring fixator system, but it has its own share of complications which might be minor or major. The symptoms of nerve dysfunction due to compression or stretch commonly are burning and tingling sensation, radiculopathy, and numbness along the course of the involved nerve. Compression or stretch of nerves with a predominant motor supply can produce motor deficits. Most of the reports on neurological complications in Ilizarov are related to bone lengthening, and there is limited literature on neurological complications during transport. The reported neural complication rate in Ilizarov surgery varies from 5% to 30%,[1],[6] with an overall rate of 9.3%.[8] Nerve injuries during limb lengthening have been classified by Nogueira et al.[8] and are summarized in [Table 1].
Table 1: The classification of nerve injuries encountered during limb lengthening

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The saphenous nerve is the largest and longest cutaneous branch of the femoral nerve and the longest nerve in the body.[9] It branches off from femoral nerve in femoral triangle and enters the adductor canal, as it leaves the adductor canal it gives off an infrapatellar branch following which it descends along the medial border of the tibia with great saphenous vein till in front of the medial malleolus, where it usually terminates by dividing into two branches that lie on either side of the vein and bind closely to it.[9] The saphenous nerve gives sensory supply to the skin of the medial aspect of the lower leg, ankle, medial malleolus, and sometimes a small portion of the arch of the foot.[Figure 8].
Figure 8: Line diagram depicting the course of the saphenous nerve and its relation to involved wire

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Neurological complications in Ilizarov surgery are less commonly described. Wrong pin placement near any nerve can result in it getting pithed to result in an acute nerve injury. During distraction, a nerve might get wrapped around a transfixation wire or half pin. With continuation of distraction, the nerve can get displaced away from this area of constriction, thereby getting stretched to produce symptoms. This probably was the mechanism in the above-reported case. The saphenous nerve is primarily a sensory nerve, and to our knowledge, there are no documented reports on its complications during bone transport or limb lengthening. Other surgeons might have encountered similar complication too but probably have not reported it. Rozbruch et al.[10] have reported an entrapment of the radial nerve during distraction by a half pin, but no report of saphenous nerve entrapment was available in English language scientific literature.

The remedial measures which can be considered would be to decrease the rate of distraction, removing the involved wire and replacing with a different half pin/wire, stopping distraction, and finally removing the entire frame should the symptoms persist. Currently, surgeons are avoiding wires in the diaphyseal location as they have twice the risk of entrapping soft tissues and tapered half pins are being increasingly used, leading to a shift from all-wire frames to hybrid frames.

In conclusion, a surgeon must be vigilant about the development of neurological complications during the process of distraction. Furthermore, it is pertinent that he should educate the patient about the possibility of paresthesia and other neurological symptoms and to report them at the earliest. Early and efficient remedial measures will result in improved function and patient satisfaction.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Yin P, Ji Q, Li T, Li J, Li Z, Liu J, et al. A systematic review and meta-analysis of ilizarov methods in the treatment of infected nonunion of tibia and femur. PLoS One 2015;10:e0141973.  Back to cited text no. 1
    
2.
Paley D. Problems, obstacles, and complications of limb lengthening by the Ilizarov technique. Clin Orthop Relat Res. 1990:81-104.  Back to cited text no. 2
    
3.
Errors and complications of operative lengthening of the lower extremities in adults by the Ilizarov method. VestnKhirIm I Grek 1991;146:113-6.  Back to cited text no. 3
    
4.
Donnan LT, Saleh M, Rigby AS. Acute correction of lower limb deformity and simultaneous lengthening with a monolateral fixator. J Bone Joint Surg Br 2003;85:254-60.  Back to cited text no. 4
    
5.
Goldstein RY, Jordan CJ, McLaurin TM, Grant A. The evolution of the Ilizarov technique: Part 2: The principles of distraction osteosynthesis. Bull Hosp Jt Dis (2013) 2013;71:96-103.  Back to cited text no. 5
    
6.
Galardi G, Comi G, Lozza L, Marchettini P, Novarina M, Facchini R, et al. Peripheral nerve damage during limb lengthening. Neurophysiology in five cases of bilateral tibial lengthening. J Bone Joint Surg Br 1990;72:121-4.  Back to cited text no. 6
    
7.
Catagni MA. Levels of the anatomical cuts of the lower extremity. In: Maiocchi AB, editor. Atlas for the Insertion of Transosseous Wires and Half-Pins, Ilizarov Method. 2nd ed. Milan: Medi Surgical Video; 2003. p. 31-2.  Back to cited text no. 7
    
8.
Nogueira MP, Paley D, Bhave A, Herbert A, Nocente C, Herzenberg JE. Nerve lesions associated with limb-lengthening. J Bone Joint Surg Am 2003;85:1502-10.  Back to cited text no. 8
    
9.
Brion B, Shane Tubbs R. Pelvic girdle and lower limb-knee. In: Standring S, editor. Gray's Anatomy: The Anatomical Basis of Clinical Practice. 41st ed. Edinburgh: Churchill Livingstone; 2016.  Back to cited text no. 9
    
10.
Rozbruch SR, Fryman C, Bigman D, Adler R. Use of ultrasound in detection and treatment of nerve compromise in a case of humeral lengthening. HSS J 2011;7:80-4.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1]



 

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