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Management of Femoral defects

2/6/2018

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femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate
Femoral defect are fortunately quite rare. Still we will see them often after high energy trauma, osteomyelitis or tumours. Until recently we managed them using one of the techniques:
  1. Bone graft (Autografts (iliac crest, RIA,...) or allografts)
  2. Weber's method using cable and fine wire frame for bone transport along the nail
  3. Bone transport using monorail external fixator
  4. Bone transport using cable and pulleys
​Just recently we started using PRECICE nails, which are telescopic nails controlled by external magnets.

 09 April 2018 
As you can see on the images below, the injury was pretty significant, high energy trauma with an open distal femoral fracture (Gustilo-Andresen 3B).
We can argue what is the best way of treating/managing injuries like this one. For us is as follows:
  1. ATLS protocol and resuscitation/stabilisation of the patient in A&E
  2. Adequate imaging
  3. Theatre as per BOA/BAPRAS guidelines
  4. Soft tissue debridement/management
  5. Bone debridement/management
  6. Dead space management with antibiotic carrier only (no cement spacers or cement beads)
  7. Temporary stabilisation with spanning external fixator
  8. Standard or negative pressure wound dressing if the wound can not be closed
  9. Definitve fixation when patient stable (using a nail or AxSOS3 plate). At this time will correct the rotation and the leg length (our aim is to keep the injured leg 1-2cm shorter comparing to the uninjured leg). At the same time microbiology samples are taken.
  10. After 6-8 weeks microbiology samples again, insertion of a PRECICE nail (retrograde if possible), low energy corticotomy and compression of the corticotomy using the nail at the same sitting (takes around 18min to compress for 2.5mm).
  11. 8 days after the distraction starts using external magnets, rate 0.25mm, 4 times per day until the whole defect is filled
  12. If the defect is longer than 5-8cm, intermittent unlocking of the nail, expanding and relocating of the nail is required.
  13. There is no docking procedure required as standard.
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate

 11 April 2018 
Definitive fixation was done as per our protocol above.

 11 May 2018 
Post operative X-rays are self explanatory.
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate

 31 May 2018 
We will wait for 6 weeks before we do anything with the bone defect. One of the reasons is infection and the second one is spontaneous bony activity in the defect which is not as rare as someone would expect.
Plan:
  1. Physio
  2. Chase microbiology results
  3. Start bone transport 8 days after the procedure
  4. Follow up in two weeks to monitor the progress

 15 June 2018 
Apart from pain in the thigh at the time of distraction everything else is going well. Clinically no sign of infection.

​If you compare the plate shape prior the transport and now you will see a significant bent suggesting a significant force on the plate. Exactly what we usually see.
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate
Plan:
  1. Physio
  2. Bone transport
  3. Remain non weight bearing

 29 June 2018 
As planned. 
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate
Plan:
  1. Continue with bone transport
  2. Follow up in 2 weeks
  3. Booked for surgery to reposition of the nail in 18 days

14 July 2018 
Good progress but there is a significant strain on the plate visible on the X-ray. I can only suspect that the force required for callus distraction can vary from patient to patient. I can see in the other patients that those plates are not loaded so much. We will probably have to consider augmentation of the plate.
For now I cannot see any sign of failure of the construct, eminent or waiting to happen, apart from the bend in the plate.
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate
Plan:
  1. Repositon of the nail in 10 days as there is still a lot of "nail" left
  2. Maybe we should consider "speeding up" the transport as the regenerate looks very strong.

26 July 2018 
Precice nail reached its final position in compression. To continue with the bone transport we have to:
  • lock the fragment to prevent proximal migration due to the regenerate elasticity,
  • unlock the nail,
  • re-expand the nail,
  • lock the nail, 
  • unlock the fragment and
  • continue with bone transport.
The main problem is(was) how to re-expand the nail in the same day as it takes around 6 hours to expand it with standard magnet and probably only 30 min with the fast distractor. With standard magnet we need to have two anaesthetics when with fast distractor we need significant wound to access the nail but one anaesthetic only.

Because we know that higher the number of procedures (opening of the skin), higher the chance of deep infection, we decided to proceed with percutaneous locking-unlocking and two anaesthetic sessions. First one first thing in the morning and second late in the afternoon leaving enough time to expand the nail using standard magnet.
First procedure
Second procedure
Everything went extremely well. Exactly as planned. It did take some preparation to coordinate theatre time, distraction on the ward and reprogramming the magnet every 2.5mm due to the software limitations, but it was well worth it. Only three small wounds in combined length less than 2 cm.
Plan:
  1. Continue with bone transport 1mm/day as of today
  2. Non weight bearing
  3. Passive and active physio to minimise the knee flexion contracture
  4. Repeting of the same procedure in approx. 45 days

07 August 2018 
So far everything well. Flexion contracture is gradually improving.
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate
Plan:
  1. Bone transport
  2. Physio
  3. Non weight bearing

28 August 2018 
No major problems, but as you can see, the plate is more and more bent. Will need to augment it, just don't know exactly how. Various options in consideration.
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate
PLan:
  1. Remain non weight bearing
  2. Continue with bone transport
  3. Regular physio
  4. For repositioning of the nail on 10/09/2018

10 September 2018 
We have reached the end of the nail compression. Repositioning of the Precise nail was required.
Whilst the AxSos plate is still bent, it didn't look more bent than before, hence we decided not to augment it with another plate.
It looks that 6 hours of expanding the nail on the ward with standard magnet is a good alternative to relatively large approach and use of fast 
distractor whilst in theatre.

Unexpectedly the right hip is very stiff. Must admit I wasn't expecting that  and haven't seen it before.
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate
Plan:
  1. Hip and knee physio
  2. Standard bone transport regime
  3. Non weight bearing

02 October 2018 
It looks that the plate is bending. Not completely sure that there is massive difference since the last X-ray but the plate is definitively bend.
In my opinion if we slow the transport will very likely create even more strain on the plate causing more bent comparing to proceed with the same speed and not let the regenerate mature prematurely. It is certainly a difficult call.
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate
Plan:
  1. Maintain the transport speed
  2. Non weight bearing
  3. Physio for hip and knee

19 October 2018 
Unfortunately the magnet stopped working. How and why we don't know yet. As you can see on the images below there is no improvement since the previous X-rays. Apart from stronger regenerate.
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate
Plan:
  1. To restart the movement of the magnets otherwise will exchange the nail (which will need to do anyway)

01 November 2018 
Not working nail exchanged for a shorter one. When existing nail removed and tested it worked. Not clear why it did not work whilst in.
Fragment was still not fixed so very unlikely premature consolidation was the reason. My though is that we put nail through many full cycles and this is very likely something the nail is not designed for. Something to bear in mind.
Plan:
  1. Continue with transport
  2. Physio for knee and hip
  3. FU on Tuesday coming to confirm everything is working

13 November 2018 
Moving. Causing some pain in the hip area. Will slow down back to 1mm/day as for the last week we were doing 1.6mm per day.
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate
Plan:
  1. 1mm/day in 4 increments
  2. Followup in 2 weeks.

27 November 2018 
Moving 1mm/day. Not sure if the plate is more bent or not. So far no major pain or discomfort.
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate
Plan:
  1. Bone transport
  2. Booked in 3 weeks to reposition the nail

17 December 2018 
Fragment locked to the plate, although the locking screw did not lock completely. Decided not to drill another hole as there were already too many in the fragment. Unfortunately it did not work as expected. Nail unlocked.

On lengthening the nail there was initially not response as I marked the magnet position to proximally. On corrected position the nail moved but moved the fragment as well .

20 December 2018 
Nail expanded to around 4 cm and but we were not able to move the fragment at all. Not even with femoral distractor. Decided to lock the nail back and re-lengthen it back to the position where we were on Monday, 17 December 2018.

Plan:
  1. Restart bone transport until the nail reaches the final position.
  2. Remove the nail, ream the canal, expand the nail with fast distractor and reinsert the nail for final compression.
Not ideal, but if this will be our main complication, it will be great.

04 January 2019 
It looks that the fragment has "sprung" back due to the nail malfunction. Not sure. But the plate is certainly straighter suggesting less tension.
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate
Plan:
  1. Exchange the nail

14 January 2019 
As expected the nail was faulty. It looks that 8.5mm nail is strong enough for pushing but not for pulling. Certainly when the nail removed, the telescoping part was mobile.
The fragment itself was not mobile anymore. Axial and rotational stable. New corticotomy was required to mobilise the fragment.

New tibial nail 10.7X155mm Precice nail was inserted.
Plan:
  1. Restart bone transport today 1mm/day
  2. Remain non weight bearing
  3. Follow up in 2 weeks

29 January 2019 
Back on track. Sincerely hope so.
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate
Plan:
  1. 1mm/day in 4 steps
  2. Walking with crutches non weight bearing
  3. FU in 2 weeks

12 February 2019 
The nail is working again. Plat bending but we closed another 14 mm since the last time.
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate
femoral defect, bone defect, bone transport, precise nail, bone lengthening, bone transport, corticotomy, limb alignment, AxSOS plate
Plan:
  1. 1mm/day
  2. Repositioning of the nail on 25 February
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    Mr Matija Krkovic, MD, PhD

    I am Consultant Orthopaedic Trauma Surgeon with special interest in Limb reconstructions and bone infections.

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  • Home
    • Knee Surgery >
      • Symptomatic Osteoarthritis of the Knee >
        • Primary Care >
          • Initial Management
          • Intermediate Care
          • Referral Treshold
        • Secondary Care >
          • Total Knee Replacement
          • High Tibial Osteotomy
          • Knee Arthroscopy
          • Complex Primary Total Knee Replacement
          • Postoperative Management
        • Procedures recommended by NICE
        • Procedures with limitations by NICE
        • Procedures not recommended by NICE
        • Viscosupplementation
      • Trauma to the Knee >
        • Meniscal Injuries
        • ACL Injury
      • Partial v Total Knee replacement
    • Limb Lengthening >
      • Femoral lengthening over the nail
  • Orthopaedic Trauma
    • Complex Trauma Impact
    • Principles of fine wire frame fixation >
      • Indications for fine wire frame
      • Complications >
        • Predictable complications
        • Unpredictable complications
      • Pin sites management
      • Activities >
        • Videos
        • Photos
    • Poller or Blocking screw >
      • Mechanic of Poller screw
      • Without and With a Poller Screw
      • Third Generation Poller Screws >
        • Epicentric poller screws in osteoporotic bone
        • Epicentric poller screws in comminuted spiral fracture
      • Use of Poller Screw(s) in Complex Cases >
        • Segmental Femoral Fracture
        • Low Supracondylar Femoral Fracture
        • Low Supracondylar Femoral Fracture 2nd case
        • Femoral Non-union - Antegrade Nail
        • Femoral Non-union - Retrograde nail
        • Distal Tibia Spiral Fracture
    • VAC irrigation
    • Complex Cases >
      • Femoral diaphysis defect
      • Capitellum Fractures
      • Distal Femoral Fractures
      • Proximal Humerus Fractures
      • Subtrochanteric Femoral Fractures
  • Osseointegration
    • Osseointegration-Physiotherapy
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