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 are going to wait 6 weeks before we do anything with the bone defect. One of the reasons for waiting 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 there is no sign of infection.
If you compare the plate shape prior to the transport and now, you can see a significant bend which suggests that there is a significant force on the plate. This is exactly what we usually see.
29 June 2018
14 July 2018
Good progress but there is 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 as 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 has reached its final position in the compression. To continue with the bone transport we have to:
Because we know that the higher the number of procedures (opening of the skin), the higher the chance of deep infection, we decided to proceed with percutaneous locking-unlocking and two anaesthetic sessions. The first one first thing in the morning and the second one late in the afternoon leaving enough time to expand the nail using standard magnet.
Everything went extremely well and 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 definitely worth it. Only three small wounds with combined length of less than 2 cm.
07 August 2018
So far everything has gone well. Flexion contracture is gradually improving.
28 August 2018
No major problems, but as you can see, the plate is bending more and more. We will need to augment it, although not entirely sure how just yet. We are considering various options.
10 September 2018
We have reached the end of the nail compression. Repositioning of the PRECICE nail was required.
Whilst the AxSos plate is still bent, it does not look more bent than before, and hence we decided not to augment it with another plate.
It looks that 6 hours of expanding the nail on the ward with a standard magnet is a good alternative to a relatively large approach and use of fast distractor whilst in theatre.
Unexpectedly the right hip is very stiff. I must admit I wasn't expecting that and have never 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 bent.
In my opinion, slowing the transport will very likely create an even bigger strain on the plate causing it to bend further comparing to proceeding with the same speed and not letting the regenerate mature prematurely. It is certainly a difficult call.
19 October 2018
Unfortunately, the magnet has stopped working. We don't yet know why and how. As you can see on the images below there has been no improvement since the previous X-rays. Apart from stronger regenerate.
01 November 2018
This approach was not working and therefore we exchanged the nail for a shorter one. When we removed the existing nail and tested it, it worked. There is no obvious reason as to why it did not work whilst it was in.
Fragment was still not fixed so very unlikely premature consolidation was the reason. My thought is that we put the nail through too many full cycles and this is very likely something the nail is not designed for. Definitely something to bear in mind.
13 November 2018
Moving. Causing some pain in the hip area. We will slow it down back to 1mm/day as for the last week we have been 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. We decided not to drill another hole as there were already too many in the fragment. Unfortunately, it did not work as expected. The nail was unlocked.
On lengthening the nail there was initially no response as I marked the magnet position to proximally. After the position was corrected the nail moved which also moved the fragment.
20 December 2018
Nail expanded to around 4 cm but we were not able to move the fragment at all. Not even with the femoral distractor. Therefore, we decided to lock the nail back and re-lengthen it back to the position where it was on Monday, 17 December 2018.
This is definitely not ideal, but if this is going to be be our main complication, that's 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 which suggests 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. When the nail was removed, the telescoping part was certainly 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
Looks like we are back on track. I sincerely hope so.
12 February 2019
The nail is working again. Plate is bending but we have closed another 14 mm since the last time.
25 February 2019
Repositioning of the nail was done. Unfortunately, we 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. Plate is bending again. Fingers crossed.
05 April 2019
No problems but there is no movement of the fragment either. Not clear what the problem is: the nail or the 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 would 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...
Moreover, another problem just became obvious. Proximal locking screws in the plate have "unlocked". I don't know how that is even possible.
26 April 2019
Nail has moved but not as much as we expected - a little bit more than 1cm, which is 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 the "old days". Not the happiest feeling. Hopefully will be able to finish it with an external fixator.
31 May 2019
The construct did not work as expected and there was no transport. It looks that I did not put the transporting pins in the fragment. Very disappointed. I cannot image what the patient is going through. We will have to reposition the two pins on the coming Monday.
21 June 2019
The two middle pins were replace and "put into the bone". As you can see below, the fragment is moving again. There are some issues with the pin sites but no more than we expected. Infection of the previous two pin site holes required antibiotics with good response.
05 July 2019
Docking complete. The leg is clinically 1-2cm shorter.
We will lengthen it in the next two weeks and then lock the docking site with a plate, lock the nail and remove the frame.
Mr Matija Krkovic, MD, PhD
I am Consultant Orthopaedic Trauma Surgeon with special interest in Limb reconstructions and bone infections.