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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
09 November 2018
To my surprise the docking site did not unite. X-ray below explains everything.
16 November 2018
All metalwork removed. Unfortunately magnetic nail was not available. Poller screws can be seen in action action. In this case it was quite difficult to find out where to put the screws but with a bit of luck it all came out much better than expected.
What is certainly something not to ignore is the fact that the patient was discharged next morning. Very impressive.
Mr Matija Krkovic, MD, PhD
I am Consultant Orthopaedic Trauma Surgeon with special interest in Limb reconstructions and bone infections.