Gun shot fractures/non-unions are very difficult to manage.
Whenever approaching similar non-unions I have already a few conclusions already formed in my head:
X-rays below are self explanatory. Three years down the line and the fracture line is still visible. Impact on patient and family is in my opinion totally underestimated if not ignored.
For me, the only solution is remove the plate and screws, resect the non-union and start bone transport. In my practice, fine wire frame has proven its safety and efficiency. No doubt about it.
I don't offer any reconstructive option which does not not include fine wire frame when approaching a case like this one. It can be quite disheartening for the patient as they are going from bad to worse. This is the only way it works in my hands. And really, forget Masquelet.
What to do first, bone resection or frame? Where I know exactly how much to resect I would put the frame on first and than resect the bone. Otherwise I would resect as much as needed and than put on the frame. Easier than readjusting the frame.
At every revision surgery, microbiology samples get taken (5 deep tissue samples) and sent in bottles with Ballotini beads. I am still surprised how often the results are positive for an infection.
In this case we did distal corticotomy of the tibia for bone transport. Fibula got corticotomised as well as we initially planned acute shortening. Due to the scarring at the level of the non-union it was impossible to shorten the leg acutely for any significant amount, hence the decision was made to do simultaneous shortening and bone transport.
Of course, the defect was packed with Stimulan (5ml) with antibiotics.
28 January 2019
Patient got prescription for TSF and instructions how to turn the dice to get the regenerate growing. Walking and weight bearing as tolerated.
12 February 2019
X-rays post initial distraction look promising.
01 March 2019
All going well. Pain is building up as expected. Still weight bearing.
Good response on the corticotomy site.
15 March 2019
Going well. So far no mayor problems.
29 March 2019
Pain is building up. This was expected. Will increase the painkillers as much as needed.
There was a minor pin site infection treated by oral antibiotics and responded well. Otherwise the wires are cutting through the skin creating big wounds. Unfortunately this is necessary at this stage.
Patient is still extremely active, certainly much more than expected. Very likely one of the reasons the regenerate looks so nice on the most recent X-ray. And there is minimal if any equinuus deformity in the ankle.
27 April 2019
Wounds are getting bigger and sloughier. Pain more or let as it was.
I don't understand why we never have problems with bone transport wounds in acute fractures but quite often in patients with chronic infection.
10 May 2019
Wounds are improving so is the pain. Slower transport rate is certainly helping.
TSF prescription completed. Good alignment of the docking site. Good regenerate as well.
31 May 2019
Foot is getting stiffer but in varus as well. This can be a massive problem.
We cannot allow for the foot to deform hence we have to slow down the transport.
05 July 2019
Ankle movement has improvement with excellent physiotherapy and slower distraction speed. Leg is still about 1 inch shorter. Otherwise no major issues with the frame or pin sites. Docking completed.
02 August 2019
The foot is still not out of "varus" completely. Will slow down again to 0.5mm/day. Physio and walking as possible. It looks like docking site is already healing.
13 September 2019
CT confirmed union in the docking site (spot welding more than a full union) but it is getting in the right direction.
Foot still in varus but is it slowly improving.
Mr Matija Krkovic, MD, PhD
I am Consultant Orthopaedic Trauma Surgeon with special interest in Limb reconstructions and bone infections.