Femoral Fracture
with a
Critical Bone Defect
In my understanding a critical bone defect of long bones is any bone defect longer than 2 diameters of the shaft. Currently, I am not aware of a treatment which would have any significant advantages over other treatments (evidence based?). Bone graft is still a golden standard however it comes with mixed results. In combination with Masquelet technique it should give us predictable results. Unfortunately this is not the case in my practice. It is possible that I do not harvest enough bone graft for the defect, but this cannot explain the increased rate of infection, particularly in tibia bone defects.
As a result I went back to callus distraction method in all critical bone defects. For femoral bone defects in particular, I prefer lengthening over a nail comparing to a mono lateral Ex-fix or a frame.
I am presenting a patient with a critical bone defect after an open femoral shaft fracture, complicated with a below knee amputation as a result of high energy trauma.
As this is a retrospectively written presentation some chronological facts may not be correct.
As a result I went back to callus distraction method in all critical bone defects. For femoral bone defects in particular, I prefer lengthening over a nail comparing to a mono lateral Ex-fix or a frame.
I am presenting a patient with a critical bone defect after an open femoral shaft fracture, complicated with a below knee amputation as a result of high energy trauma.
As this is a retrospectively written presentation some chronological facts may not be correct.
28 October 2014
On the same day a below knee amputation has been done and the open femoral fracture has been debrided and stabilised with a monolateral Ex-fix.
31 October 2014
After additional debridement of the femur, definitive fixation was done using retrograde femoral nail and the bone defect was filled with bone cement and reabsorbable bone substitute beads with antibiotics. As you can see on the middle image intensifier picture below, I used a poller screw to add stability to the fixation.
After additional debridement of the femur, definitive fixation was done using retrograde femoral nail and the bone defect was filled with bone cement and reabsorbable bone substitute beads with antibiotics. As you can see on the middle image intensifier picture below, I used a poller screw to add stability to the fixation.
16 December 2014
All wounds healed, cement spacer in place.
All wounds healed, cement spacer in place.
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12 January 2015
As everything went well we continued with second stage Masquelet using RIA bone graft.
As everything went well we continued with second stage Masquelet using RIA bone graft.
27 February 2015
There are no problems with the wounds, no obvious signs of infection are present. And an up-to-date X-ray showed some uptake of bone graft although not what expected.
There are no problems with the wounds, no obvious signs of infection are present. And an up-to-date X-ray showed some uptake of bone graft although not what expected.
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01 May 2015
No further improvement/growth of the bone graft. Otherwise wounds healed.
No further improvement/growth of the bone graft. Otherwise wounds healed.
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17 June 2015
As there was no improvement in the callus formation a decision was made to proceed with bone transport over the nail using external fixator in combination with cable - Weber's technique. Corticotomy was done using drill and osteotom. Completeness of the corticotomy was confirmed under image intensifiers as visable on the images below. A cable was attached to the transported fragment using a crimp, brought through the skin distally, around the plastic pulley and attached to a clicker for controlled transport.
As there was no improvement in the callus formation a decision was made to proceed with bone transport over the nail using external fixator in combination with cable - Weber's technique. Corticotomy was done using drill and osteotom. Completeness of the corticotomy was confirmed under image intensifiers as visable on the images below. A cable was attached to the transported fragment using a crimp, brought through the skin distally, around the plastic pulley and attached to a clicker for controlled transport.
25 June 2015
Whole femur X-rays are presenting the construct in more details. So far everything is under control.
Whole femur X-rays are presenting the construct in more details. So far everything is under control.
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09 July 2015
Everything as planned. Some problems with the pulley and its position but nothing major.
Everything as planned. Some problems with the pulley and its position but nothing major.
17 July 2015
Fragment started to move. Regenerate visible but progress was slower than it should be. A CT scan was organised.
Fragment started to move. Regenerate visible but progress was slower than it should be. A CT scan was organised.
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23 July 2015
The CT scan confirmed abundant callus formation at the level of corticotomy. Significantly more than anticipated.
The CT scan confirmed abundant callus formation at the level of corticotomy. Significantly more than anticipated.
06 August 2015
Clear premature consolidation.
Clear premature consolidation.
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12 August 2015
Redo of corticotomy and application of two half pins to the transported fragment to begin with transport of the fragment over a rail external fixator. The main problem with this technique is how to miss a nail but still get two cortices involved. There are certain ways. Complications anticipated.
Redo of corticotomy and application of two half pins to the transported fragment to begin with transport of the fragment over a rail external fixator. The main problem with this technique is how to miss a nail but still get two cortices involved. There are certain ways. Complications anticipated.
20 August 2015
Transport started. Instead of 8 days delay I believe we started the transport on day 5.
Transport started. Instead of 8 days delay I believe we started the transport on day 5.
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08 September 2015
The fragment is moving. At that time no major pin site problems, but they were not anticipated at that point.
The fragment is moving. At that time no major pin site problems, but they were not anticipated at that point.
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22 September 2015
Good progress so far with no significant problems. Quality of the regenerate was acceptable. Transporting half pins have started to bend.
Good progress so far with no significant problems. Quality of the regenerate was acceptable. Transporting half pins have started to bend.
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06 October 2015
Quality of the regenerate is still low, but it is visible. I believe that the speed of the transport was 0.5mm/day instead of standard 1mm/day. It follows my experiences with "over the nail transport". I believe that blood supply can be lower due to the nail.
Quality of the regenerate is still low, but it is visible. I believe that the speed of the transport was 0.5mm/day instead of standard 1mm/day. It follows my experiences with "over the nail transport". I believe that blood supply can be lower due to the nail.
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20 October 2015
More and more pin site problems. Patient became septic at a certain stage and required hospitalisation with aggressive antibiotic and supportive treatment. Reason for sepsis was not collection but pin sites. We are prepared for this type of event in any patient who is on bone transport using external fixators.
More and more pin site problems. Patient became septic at a certain stage and required hospitalisation with aggressive antibiotic and supportive treatment. Reason for sepsis was not collection but pin sites. We are prepared for this type of event in any patient who is on bone transport using external fixators.
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10 November 2015
Regenerate is growing but the patient is experiencing more and more pin sites issues, mainly on the transporting two half pins, while the proximal and distal pins are doing reasonably well. Knee movement is not improving.
Regenerate is growing but the patient is experiencing more and more pin sites issues, mainly on the transporting two half pins, while the proximal and distal pins are doing reasonably well. Knee movement is not improving.
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01 December 2015
Continuous progress. Constant battle with pin sites and potential sepsis.
Continuous progress. Constant battle with pin sites and potential sepsis.
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02 February 2016
Still progressing with 0.5mm/day. Regenerate of an acceptable quality. Pin sites infections are more controlled. Docking site is getting narrower.
Still progressing with 0.5mm/day. Regenerate of an acceptable quality. Pin sites infections are more controlled. Docking site is getting narrower.
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15 March 2016
Further compression of the docking site using external fixator. Half pins bent even more. Over the next week the docking site will be compressed as much as possible and then secured with a small fragment locking plate, to be followed by the removal of the external fixator.
Further compression of the docking site using external fixator. Half pins bent even more. Over the next week the docking site will be compressed as much as possible and then secured with a small fragment locking plate, to be followed by the removal of the external fixator.
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22 March 2016
Docking site compressed, samples for microbiology taken. External fixator removed.
Docking site compressed, samples for microbiology taken. External fixator removed.
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19 April 2016
Wound healed as well as pin sites. Regenerate visible.
Wound healed as well as pin sites. Regenerate visible.
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21 June 2016
Further progress. So far no obvious sign of infection. Regenerate shows signs of significant improvement since last X-ray. In my opinion the docking site is also healing.
Further progress. So far no obvious sign of infection. Regenerate shows signs of significant improvement since last X-ray. In my opinion the docking site is also healing.
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23 August 2016
As you can see from the X-rays bellow callus is maturing further. Also docking site is healing despite no bone graft used. Today for the first time patient walked in the clinic with his prosthesis. Really impressed.
Currently no sign of infection. At the moment I am of opinion that we do not have to change the nail as it is very likely that the bone will mature before the nail fails.
As you can see from the X-rays bellow callus is maturing further. Also docking site is healing despite no bone graft used. Today for the first time patient walked in the clinic with his prosthesis. Really impressed.
Currently no sign of infection. At the moment I am of opinion that we do not have to change the nail as it is very likely that the bone will mature before the nail fails.
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22 November 2016
Patient walking with the prosthesis using crutches. No signs of infection. Docking site healed. Regenerate improved further.
Patient walking with the prosthesis using crutches. No signs of infection. Docking site healed. Regenerate improved further.
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09 May 2017
Continuous improvement in the leg function and in regenerate. Further healing of the docking site. Knee stiffness beyond 80 deg of flexion remain an issue. At the moment will wait with any surgical intervention until the bone is fully consolidated.
Continuous improvement in the leg function and in regenerate. Further healing of the docking site. Knee stiffness beyond 80 deg of flexion remain an issue. At the moment will wait with any surgical intervention until the bone is fully consolidated.
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