Atrophic femoral non-union with shortening of the leg

Quite often femoral fractures (particularly open ones) do not want to heal despite "dynamisation", bone graft, compression, exchange nailing,... One of the explanations is probably in "not neutralising" shear forces. There are a few examples on this website as to how I tackle "shear" forces and fracture/non-union healing.

I present a 2 year and 4 months old femoral non-union after an open femoral fracture which was previously treated with multiple procedures as mentioned above. Despite all the effort the non-union persisted and caused significant pain with leg shortening of 3-4 cm.

Due to previous failed attempts we decided to resect the non-union and start bone transport together with limb lengthening. For this purpose we exchanged the existing nail for a thinner one and applied a Modular Rail System from S&N.

X rays and a scanogram below show the nonunion.

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​CT scan of the femur shows atrophic non-union with oblique fracture configuration

​05 January 2017
Existing intramedullary nail was removed, canal reamed. Broken screws from the distal femur were removed as well. Significantly thinner intra-medullary nail was inserted and locked proximally. Before insertion of the nail the non-union was debrided to bleeding edges. Monoral external fixator was applied and corticotomy completed. Corticotomy compressed using the ex-fix. Intraoperative radiographs are below.

Whole femur X-rays are below.

Plan:

1. Simultaneous lengthening of the leg and bone transport until the leg length restored
2. Chase microbiology
3. Pain control
4. Physio using CPM (stiff knee due to the distal pins)
5. Follow up in 4 weeks

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​03 February 2017
Patient was discharged relatively comfortable with respect to the pain. Unfortunately pain started few days after and is still there.
I cannot find any other explanation than the increased level of activities just being at home. Pin sites are clean, the knee is swollen but does not look infected.

Plan:

1. Continue with femoral lengthening until the length is restored (4 1/4 turns per day, if pain increases either 3 1/4 turns or alternatively 2 1/4 turns opposite direction to the distal fragment)
2. Continue CPM
3. Regular Pin sites care
4. Weight bearing as tolerated 
5. Follow up in 3 weeks

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10 March 2017
Pain is still an issue. Patient can put some weight on his leg. Transporting pin sites are a problem with some discharge but nothing more than anticipated. So far as expected. Around 6 cm of bone still missing - approximately 9 cm altogether.

Plan:

1. Slow down the transport speed to 1/2 mm per day to improve the regenerate and minimise pin site problems
2. Continue with physio
3. Weight bearing as pain allows
4. Follow up in 4 weeks

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27 March 2017
Patient was admitted to hospital for septic complications. Unfortunately this is something what we see in majority of the cases. No surgical intervention required, but antibiotics and supportive treatment.
In this case proximal pins became infected, what is slightly unusual, but does happen. After few days of antibiotics sepsis has gone. On the long run and especially because of the multiple previous procedures will very likely decide to start a suppressive antibiotic treatment.
Otherwise radiologically everything looks better then expected. Certainly new bone formation is much stronger then what we usually see in "over the nail" method.
​After we dock it, will start lengthening the leg. 

Plan:

1. Antibiotics
2. Supportive treatment
3. Physio
4. Continue with bone transport 1/2mm per day in two increments

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15 April 2017
Infection under control. Swelling decreased significantly. Patient felling well.
X-rays show further progress with excellent regenerate. Docking will be completed in  next two weeks and then will continue with the lengthening of the femur utilising compression of the docking site for faster union. Will  also consider antibiotic suppression treatment until the frame is on.

Plan:

1. Continue with the same speed - 1/2mm per day
2. Antibiotic suppression therapy
3. Home when safe

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05 May 2017
Patient walking with crutches on shorter distances. Infection under control. Still transporting 1/2mm per day. No additional concerns. No antibiotics at the moment.

Plan:

1. Continue with distraction 1/2mm per day
2. Docking will happen in next 5-7 days
3. After the docking is complete with continue with the lengthening for approx. 25-30mm
4. Follow up in 3 weeks with long leg alignment X-ray to determine the exact leg leg discrepancy

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12 June 2017
Lengthening and docking completed. Good regenerate. 

Still significant pain issues and discharge mainly form the central two pin sites. Managed with dressing.
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​To ease the pain and minimise the infection burden we will remove external fixation as originally planned. Before removing it, we will lock the nail and put a short plate on the docking site to secure the position.

This was on the day of the removal of the ex-fix. Although the docking site does not convincingly healed, it was healing when the plate was put in.

​Antibiotics in Stimulan were added in the wound before closure.

After the nail was locked, in this case from medial to lateral due to the Ex-fix position, the docking site was plated and Ex-fix removed.

Plan:

1. Home when safe and comfortable
2. Antibiotics until the samples results are back and then adjust
3. Non weight bearing
4. CPM and physio

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14 July 2017
Significant improvement since the last appointment. Walking with crutches, non-weight bearing. All wounds healed, clinically no sign of infection. Knee range of movement has improved as well, full extension and flexion to 90 degrees.

Plan:

1. Continue with physio
2. Non weight bearing
3. Follow up in 6 weeks

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15 September 2017
Pain has improved. Patient walking with one crutch on longer distances and no walking aid for shorter distances. No clinical sign of infection.
​It is 8 months since we started. 

Plan:

1. Weight bearing as tolerated
2. Follow up in 3 months to discus further management and nail exchange, yes or no

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01 December 2017
Still walking with one crutch although the pain returned since stopped morphine based painkillers. The main issue currently is pain in the proximal thigh.
I don't have any good explanation for it, particularly as the X-rays looks really good. Significant improvement in the regenerate and also further healing of the docking site with no obvious sign of nail instability.
​We discussed nail exchange and decided to wait and see. 

Plan:

1. The same treatment regime
2. Add painkillers to the existing one
3. Follow up in 3 months

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