14 May 2017
Severe lower leg injury which required immediate below knee amputation due to the vascular compromise at the level of lower leg. Despite severe comminution and soft tissue defect, parts of the femur and thigh have been saved. There were other concomitant injuries but not life threatening.
Our aim is always to preserve the limb. If an amputation is required, we want to amputate as low as possible due to the increased level of energy consumption with higher level amputations.
After the below knee amputation and debridement was completed, spanning external fixator was applied together with cement spacer at the level of the femoral defect.
The discussion whether shouldn't we just proceed with an above knee amputation took place and the patient was presented with all known pros and cons. The patient decided to proceed with the limb reconstruction, in this case re-growing of his femur. At the moment we are estimating the defect in the range of 15cm, but will know more about it when the whole femur X-ray is taken. Estimated time to complete the treatment is 1 year.
22 May 2017
After stabilisation, repairing of the injuries we proceeded with internal fixation of the femur using AxSOS3 plate from Stryker on the basis of our previous positive experience with plate's endurance and stability.
AxSOS3 plate was used for the fixation after additional debridement of the bone - proximal and distal fragment up to the bleeding edges, or close to it. Cement spacer (Palacos Bone Cement) was used to fill the gap together with Stimulan beads with Vacomycin and Gentamycin. Wound was closed and the residual skin defect was grafted (mesh skin graft).
16 June 2017
So far going well. All wounds healed. No sign of infection. The defect length is around 20cm.
The knee joint is stiff and will be working on it.
08 July 2017
All set for bone transport. Because in young patients bone growth can be quite unexpected we X-rayed the femur before the surgery. As you can see on the X-rays below, there is a significant bone growth at the back of the femur.
I don't think this is as a result of the Masquelet technique. At least this is not what we see in majority of our patients. Bone cement and "pseudomembrane technique" are in my opinion not a substitute for a bone transport.
During the surgery we were able to confirm significant bone plate at the back of the thigh securely connected to the proximal and distal fragment.
01 August 2017
To my great surprise the new bone just continues to grow. Very unusual response but we were aware of the possibility. I personally don't have any significant experience with this type of bone growth and don't know what to expect in the future. Current strategy is "wait and see".
Wounds all healed and it looks that infection is very likely under control.
29 September 2017
Bone continues to grow. The knee range of movement is improving as well - close to 90 deg of flexion. Wounds all healed.
01 December 2017
All wounds healed. Right knee range of movement is from 0-90 deg. Very impressive.
Current X-rays do show good bony consolidation but the improvement since the last appointment is minimal, if any. Reassuring part is that there is no signs of loosening of the metalwork.
What are the chances to get a strong bone in the defect before the plate fail? I honestly don't know. Whilst for smaller defects it is certainly worth waiting, for the defect of this size I don't know.
At the moment we will start with the prosthetic part of the treatment and allow partial weight bearing with a prosthesis.
02 February 2018
Patient started walking with a prosthesis but the pain on the medial side of the knee is restricting him. Clinically it feels like a too long screw on the medial side of the distal femur. X-ray confirms it. Otherwise no sings of instability and no significant increase of the bone volume.
27 March 2018
After exchanging of the too long screw, the pain on the medial side of the knee is gone. Much more comfortable using prosthesis.
Unfortunately there is no progress visible on the X-ray in the regenerate of bone. Metalwork still look stable. What next?
Mr Matija Krkovic, MD, PhD
I am Consultant Orthopaedic Trauma Surgeon with special interest in Limb reconstructions and bone infections.