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).
11 April 2018
Definitive fixation was done as per our protocol above.
11 May 2018
Post operative X-rays are self explanatory.
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.
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.
29 June 2018
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.
26 July 2018
Precice nail reached its final position in compression. To continue with the bone transport we have to:
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.
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.
07 August 2018
So far everything well. Flexion contracture is gradually improving.
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.
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.
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.
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.
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.
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.
27 November 2018
Moving 1mm/day. Not sure if the plate is more bent or not. So far no major pain or discomfort.
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.
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.
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.
29 January 2019
Back on track. Sincerely hope so.
12 February 2019
The nail is working again. Plat bending but we closed another 14 mm since the last time.
25 February 2019
Repositioning of the nail done. Unfortunately had to do it in two sessions as the fast distractor does not come close enough to re-expand the nail.
15 March 2019
Back on track. No major pain.Pate is bending again. Fingers crossed.
05 April 2019
No problems but no movement of the fragment either. Not clear what is the problem. Nail or external magnet?
I think that we can safely dismiss the explanation that new bone formation in the docking site is preventing the docking. In my opinion the nail is far too strong not to crush the new bone in the docking site.
12 April 2019
Nail has re-expanded as expected. Either the external unit is a problem (I sincerely hope so), or...
Another problem just became obvious. Proximal locking screws in the plate became "unlocked". Don't know how is this even possible.
26 April 2019
Nail has moved but not as much as expected - a bit more than 1cm. Still acceptable. We are not sure we know/understand what the problem is. The nail should be able to cope with the load.
10 May 2019
It is not moving.
13 May 2019
We had to go back to "old days". Not the happiest feeling. Hopefully will be able to finish it with and external fixator.
31 May 2019
The construct did not work as expected. No transport. It looks that I did not put the transporting pins in the fragment. Very disappointed. Cannot image what the patient is going through. Will have to reposition the two pins on coming Monday.
Mr Matija Krkovic, MD, PhD
I am Consultant Orthopaedic Trauma Surgeon with special interest in Limb reconstructions and bone infections.