Management of Femoral defects

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.

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 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.

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

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 11 May 2018 
Post operative X-rays are self explanatory.

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 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

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 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.

Plan:

1. Physio
2. Bone transport
3. Remain non weight bearing

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