Quite often femoral fractures (particularly open ones) do not want to heal despite "dynamisation", bone graft, compression, exchange nailing,... One of the explanations is probably in "not neutralising" shear forces. There are a few examples on this website as to how I tackle "shear" forces and fracture/non-union healing.
I present a 2 year and 4 months old femoral non-union after an open femoral fracture which was previously treated with multiple procedures as mentioned above. Despite all the effort the non-union persisted and caused significant pain with leg shortening of 3-4 cm.
Due to previous failed attempts we decided to resect the non-union and start bone transport together with limb lengthening. For this purpose we exchanged the existing nail for a thinner one and applied a Modular Rail System from S&N.
X rays and a scanogram below show the nonunion.
Current strategy for femoral/tibial non-unions is:
Open tibia fractures have a high risk of infection.
It is well accepted that soft tissue injuries in open fractures should be debrided agressively, while bone should be preserved as much as possible. Is bone not a tissue or does it responds better to infection?
I am presenting a case of an open tibia fracture (high energy injury looking from the X-rays and CT scan) and the way we are managing it.
At the time of starting this blog we have completed or almost completed 20 patients with similar injuries. Results are encouraging and pending definitive review and publications.
Distal femoral fractures are complex injuries which do not tend to heal quickly. For closed injuries I tend to tell my patients that it will take at least 12 - 18 months for the fracture to heal. Open fractures with bone defects take even longer to heal and require special limb reconstruction techniques. Preventing complications, predominantly infection is of a paramount importance.
Comminuted distal femoral fractures are not easy fractures to treat and heal. If they are open fractures the problem is even bigger. Those fractures are usually seen in the young, active male population, but can happen in the senior age group as well.
I am presenting a case of an open comminuted distal femoral fracture with a bone defect in the region between 8-10 cm (it depends on how it is measured and if you accept any leg shortening as a result of it). Injury happened as a result of an RTA.
Femoral shaft non-union post closed non-comminuted fracture fixed using a locked intra-medullary nail
Prior to the knee replacement procedure lower limb should be in a reasonable alignment. Mechanical axis of femur and tibia should fall inside the joint level. Otherwise joint replacement with soft tissue balancing to accommodate for bone deformity is technically demanding if not impossible.
I am presenting a patient with previous surgeries to his lower limb due to the trauma and subsequent correction of alignment at the level of the femur.
Infected tibia non-union is difficult to treat. I am presenting patient currently undergoing a treatment of infected tibial non-union and non-infected humeral non-union with symptoms going on for 14months. Patient is currently having impressive range of movement in the knee, ankle, shoulder and elbow suggesting excellent compliance with physiotherapy.
CT images below speak for themselves. Significant open fracture with gas around bone and soft tissue defect which required massive free flap.
Mr Matija Krkovic, MD, PhD
I am Consultant Orthopaedic Trauma Surgeon with special interest in Limb reconstructions and bone infections.