- Email: [email protected]
Allograft for the treatment of massive bone loss in open and infected IIIA fracture of the distal femur: A case report
Accepted Manuscript Title: Allograft for the treatment of massive bone loss in open and infected IIIA fracture of the distal femur: A case report Authors: M. Cavanna, V. Peschiera, L. Staletti, M. Berlusconi PII: DOI: Reference:
S0020-1383(18)30714-9 https://doi.org/10.1016/j.injury.2018.11.046 JINJ 7959
To appear in:
Injury, Int. J. Care Injured
Received date: Revised date: Accepted date:
4 August 2018 27 November 2018 28 November 2018
Please cite this article as: Cavanna M, Peschiera V, Staletti L, Berlusconi M, Allograft for the treatment of massive bone loss in open and infected IIIA fracture of the distal femur: A case report, Injury (2018), https://doi.org/10.1016/j.injury.2018.11.046 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Allograft for the treatment of massive bone loss in open and infected IIIA fracture of the distal femur: a case report Corresponding author
IP T
matteo cavanna Humanitas Research Hospital Via manzoni 89,rozzano,Italy [email protected]
U
SC R
Infection; Open fracture; Bone loss; allograft.
CC
EP
TE D
M
A
N
Abstract Infection and bone loss after local debridement in high grade open fractures are two difficult issues. The treatment of bone infection needs a wide “oncological” debridement that leaves a segmental bone defect. Once the infection is deleted, the defect may be treated with different surgical techniques: bone graft, bone transport, Masquelet’s two stage reconstructions, allograft or vascularised fibular transplant. In literature these options are described only for bone loss less than 15 cm. We describe a case of a lady with an open IIIA fracture of the right distal femur with 25 cm of infected bone loss, treated with wide multistaged debridement, Masquelet technique and ORIF with massive allograft and autologous bone graft. This case gives the possibility to discuss the following principles: wide debridement, biological chamber, two stage reconstruction, internal stable fixation in infected bone.
A
KEY WORDS: infection; open fracture; bone loss; femur; allograft.
A
CC
EP
TE D
M
A
N
U
SC R
IP T
Introduction The severe contaminated open fractures present three main problems: the infection, the bone loss and the fixation of the fragments. Infection usually requires a combination of surgery and antibiotics [1-5]. The objective of surgery is a wide mechanical removal of the infected tissues (either bone fragments or soft tissues) and the fixation of the bone fragments with an external fixation [13]. The modern suggestions described in literature [1] are to leave the debrided wound open and to add the vacuum therapy in order to have a long lasting action of debridement on the infected soft tissues. The local examination of the microbiological environment gives the correct antibiotic for the general treatment. The repeated debridement usually leaves a bone loss. Once the infection is controlled, the main problem becomes how to treat and fix this bone loss in order to restore the length of the limb, give the healing of the fracture and the possibility at the patient to have a complete weight bearing. In literature there are different methods to solve these problem [9-12]. The Masquelet procedure [15] consist a wide debridement of the infected bone and soft tissues and the implant of cement spacer until the infection is solved. When the clinical and microbiological parameters will be at normal levels it will be possible to remove the spacer, put inside the bone graft to fill the defect and make the open reduction and internal fixation. This technique is indicated for tibia and for less than 6 cm of bone loss in the femoral shaft. The bone transport [9,10], once removed the infected bone, uses the bone regenerate, that fills the loss, to “kill” the remaining infection. It needs a very long period of distraction estimated in 35.7 day for each centimetre of bone loss. The microvascular double barrel vascularised fibula transplant has the problem both of the length, the size of the transported bone and of the residual vascularity of the injured site where there should be the anastomosis. It is indicated only for defect less than 15 cm. The autologous bone graft, when the defect exceeds 5-7 cm has a great number of non union (17-50%), refracture (17-30%) and infection (10-15%). The allograft is another option, but the history of infection and the quality and vascularization of the surrounding altered soft tissues may interfere with new bone apposition.
The bone transport with the circular frame has an intrinsic stability, the fixation in the other techniques should be discussed in every single case [7, 8]. We present this case of open infected fracture of the distal femur in order to show and discuss a possible solution in these cases applying different principles: wide debridement, biological chamber, two staged reconstruction, internal stable fixation in infected bone [14-20].
C-REACTIVE PROTEIN
EP
WBC
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M
A
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Case Description In October 2010, a 74 -year-old lady, after a fall in a farm, reported an open III A fracture of the distal right femur. She was originally stabilized with an external fixator in an other hospital, treated with prophylactic antibiotic therapy (amoxicillinclavulanic acid three times a day) and, after 5 days, was admitted in our institution with a severe infection (Fig. 1a-1b). There was a wide skin reaction with reddening of the whole thigh, extending to the lumbar and dorsal side up to the breast. The knee was painful and swollen. There was also a pus secretion from the proximal screws of the fixator. The skin at the level of the exposure of the fracture was sutured. The internal temperature was 39° C. In according to AO classification the fracture pattern (Fig.2) was 33-C2 and based on Gustilo open fracture was type IIIA. There was diaphyseal comminution with articular extension. At admission, laboratory assessment such as C-reactive protein, and white blood cell studies demonstrated evidence of infection: 29.83
Mg/Dl (0.1 -1)
14.93
10^3 /mm^3 (4-10)
A CT-scan (Fig.3a-3b) demonstrated the presence of free air in intra-muscolar spaces.
A
CC
We performed an immediate surgical debridement of the fractured wound and thigh fasciotomies. We put a gentamicin impregnated polymethymethacrylate bead at the open fracture level and vacuum therapy at the fasciotomies sites. We debrided also the screws’ sites of the previous fixator that was changed, maintaining the spanning configuration. We put also a double way lavage system with betadine (1:5) that lasted two days. Colliquated material was collected for a bacteriological examination. We started a new antibiotic therapy with Vancocin 1 gr/die. She was daily debrided and hyperbaric oxygen therapy started at the same time. The microbiological results were positive for Escherichia coli, Enterobacter and Clostridium Perfringens, and the antibiotic therapy was adjusted.
A
CC
EP
TE D
M
A
N
U
SC R
IP T
After 5 days she had pain and severe anemia, we performed an angiography showing a bleeding from the superficial femoral arthery that was embolised. After 3 weeks, the laboratory indicators of infection, in particular the C-reactive protein, were still elevated, even if a CT scan revealed no more air in the muscular compartments so we closed the fasciotomies. After few days she still had fever (39°C) and pus secretion from the proximal screws of the fixator. She underwent a new surgical debridement (December 2010). We found a deep infection involving the bone that appeared avascular and severely contaminated, with some pus coming out from the pre-existing screws of the external fixator. The infected necrotic bone was removed. The quantity of the removed bone was 24 cm of the femoral shaft and we put a gentamicin cement spacer of the same length. A new external fixator with screws also in the distal femur, was put in order to give more stability. At this time the articular fracture line should have been consolidated (Fig.4). A systemic antibiotic therapy was continued and the c-reactive protein decreased progressively therefore. She was discharge to rehabilitation center. Four months after the injury (February 2011), when the laboratory assessment of infection such as erythrocyte sedimentation rate, C-reactive protein, and white blood cell studies demonstrated no evidence of infection, we decided to treat the bone loss. Massive bone allograft was preferred because it would have allowed rapid weight bearing in an old woman who was getting depressed for the whole disease. The program was to revise the fragments (eventually cutting the possible still contaminated edges) and to reinforce the allograft with a nail and a plate if the distal locking was weak. Then bone graft from the iliac wing and platelet factors were supposed to be useful at the “docking” sites (fig 5). By using a traction table to maintain the length, we removed the external fixator and we performed a lateral approach to the femur. No visible signs of infection were found during the surgery. After removing the cement spacer, we found a complete pseudomenbrane that enclosed either the spacer or the proximal and distal femur (the biological chamber of Masquelet). We cut 5mm of the edges of the fragments and prepared the site for a recon nail (LFN 400x12 mm Synthes Co. as planned); the allograft was reaming till 13.5mm, and assembled it inside the thigh. The nail , was blocked distally , trying to have a good contact between the allograft and the fragment the nail was pull back and locked it with femoral neck screws. The proximal locking was stable, the distal locking was quite weak either for the
Discussion The treatment of infected fractures is always a challenging.
IP T
bone porosis or for the previous screws of the external fixator, so we added a lateral plate (LCPDF Synthes Co.). The “docking sites” were added with bone graft from the iliac wing and also with platelet factors. The post care protocol was a partial weightbearing, with crutches (20kg toe-touch) in the first 4 weeks . At 3 months she was able to raise the stairs. (Fig. 6). One year after surgery (October 2011) she was considerated healed (Fig.7).
SC R
Repeated aggressive debridements are often required to remove dead and contaminated tissues creating various degrees of bone loss.
The bone reconstruction is the problem when the infection is eradicated.
N
the best results in gaps of less than 15 cm.
U
Many techniques have been proposed to fill these bone gaps, but all of them give
but a high failure rates are reported for bone losses of greater
M
centimeters
A
Autologous bone grafting is a reliable choice to obtain fusion in gaps up to 5-7
amounts.
TE D
In case of greater bone defects the most accepted techniques are the bone transport with the ilizarov circular frame and the Masquelet technique. Both of them have shown to be precious in post infective cases, but they also have their
EP
disadvantages.
CC
Bone transport is a long standing treatment that may not be tolerated by patients that have been already under treatment for months. Moreover pin track infection
A
and docking site nonunion are frequently reported. The Masquelet technique is more suitable in the tibia and not recommended for gaps of more than 10 cm in the femur. Vascularised fibular grafting is a complex and time consuming microsurgical technique that requires a good vascularisation of the receiving site and whose results have low predictivity.
Finally the use of a eterologous graft is not
recommended for treating the
sequaelae of an infection, due to the high probability of reinfection . In this case the amount of bone loss was greater than any other case available in the literature, therefore we thought that an “off label” treatment solution was required. Firstly we decided to use a strut allograft from our bone bank: we asked for an
IP T
entire cadaver femur of the same size and length, basing our measure on the radiograms taken on the opposite limb and resected the amount of diaphyisis
SC R
corresponding to the bone defect.
This was mainly intended to restore the integrity of the femoral shaft in order to allow immediate weight bearing. Moreover with such a graft an IMN could be used
U
to obtain fixation, with the biomechanical advantages of a centromedullary device.
N
We took care to obtain a compression between the allograft and the proximal and
A
distal femoral stumps in order to allow a proper healing of the contact areas. Unfortunately the nail alone was not able to guarantee enough stability to the distal
M
fragment that was too short, excavated and osteoporotic to give a good purchase to
TE D
the locking bolt. For this reason a DF LCP was used to increase stability and allow early movement without jeopardizing the outcome. Some additional fresh bone autograft from the iliac wing augmented by PRP around
EP
the contact areas between viable bone and allograft to increase the healing. The pseudomembrane created by the cement spacer was preserved and it was able
CC
to wrap completely the allograft. It is well known that the massive bone allografts do not integrate and tends to become osteoporotic.
A
The biologic chamber is able to to remodeling the allograft into viable bone as it has seen in a lesser defect, and we hope was possible also in this high defect. The patient recovered the limb function in terms of full weight bearing and stair climbing within 3 months after surgery. At one year the radiograms showed a complete fusion of both the graft ends to the viable bone and a diffuse formation of bone all around the diaphyseal allograft.
We explained this last phenomenon as a sign of the activity of the biological chamber in the process of remodeling of the graft into newly formed viable bone. Treatment of bone defects of more than 15 centimeters after eradication of an infection is a demanding procedure very rarely performed. Unfortunately no data or guidelines are available in the literature, therefore our decisions have to be well
IP T
planned and discussed with the patients, along with the risks and benefits related. The knowledge of the techniques described for lesser defects and the mixed use of
SC R
some of them, have permitted in our case to successfully treat this difficult case of massive bone loss.
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TE D
M
A
N
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Conflict of interest None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work.
References Gopal S, Majumder S, Batchelor AG, Knight SL, De Boer P: “Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia”, J Bone Joint Surg Br, 2000 Sep;82(7):959-66. Crowley DJ, Kanakaris NK, Giannoudis PV: ”Irrigation of the wounds in open fractures”, J Bone Joint Surg Br, 2007 May;89(5):580-5. 3. Kural C, Kaya I, Yilmaz M, Demirbaş E, Yücel B, Korkmaz M, Cetinus ME :” A comparison between three irrigation methods in the debridement of contaminated bovine cancellous bone and the effect of duration of irrigation on the efficiency of debridement”, Acta Orthop Traumatol Turc. 2009 Aug-Oct;43(4):359-65. 4. Kalteis T, Lehn N, Schröder HJ, Schubert T, Zysk S, Handel M, Grifka J.: “Contaminant seeding in bone by different irrigation methods: an experimental study“, J Orthop Trauma. 2005 Oct;19(9):591-6. 5. Fernandez R, Griffiths R.:“ Water for wound cleansing” Cochrane Database Syst Rev. 2008 Jan 23;(1):CD003861. 6. Rajasekaran S, Dheenadhayalan J, Babu JN et al.:”Immediate primary skin closure in type-IIIA and B open fractures: results after a minimum of five years”, J Bone Joint Surg Br, 2009: 217-224. 7. Parekh AA, Smith WR, Silva S, Agudelo JF, Williams AE, Hak D, Morgan SJ: “Treatment of distal femur and proximal tibia fractures with external fixation followed by planned conversion to internal fixation”, J Trauma, 2008 Mar;64(3):736-9Bernat M, Lecoq C, Lempidakis M, Martin G, Aswad R, Poitout DG : “Secondary internal osteosynthesis after external fixation for recent or old open fracture of the lower limb ", Rev Chir Orthop Reparatrice Appar Mot. 1996;82(2):137-44.Lai D, Chen CM, Chiu FY, Chang MC, Chen TH:” Reconstruction of iuxtaarticular huge defects of distal femur with vscularized fibular bone graft and Ilizarov’s distraction osteogenesis”, J Trauma, 2007, (62), 166-173 10. Green SA: “Skeletal defects. A comparison of bone grafting and bone transport for segmental skeletal defects”, Clin Orthop Relat Res, 1994 Apr;(301):111-7Jean JL, Wang SJ, Au MK. Treatment of a large segmental bone defect with allograft and autogenous bone marrow graft. J Formos Med Assoc. 1997 Jul;96(7):553-7.Kong Z, Tian D, Yu H, Feng W, Liu C. Treatment of traumatic bone defect with graft material of allogenic cancellous combined with autologous red marrow Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2008 Oct;22(10):1251-4.
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1.
15.
16.
17.
A
CC
EP
TE D
20.
M
A
19.
N
U
18.
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14.
Ali F, Saleh M:”Treatment of isolated complex distal femoral fractures by external fixation”, Injury, 2000, (31), 139-146. Romanò CL, Meani E et al:”Profilassi dell’infezione nell’osteosintesi e classificazione ICS come guida al trattamento”, Arch Ort Reum, 3, 2006, 811 Giannoudis PV, Faour O, Goff T, Kanakaris N, Dimitriou R “Masquelet technique for the treatment of bone defects: tips-tricks and future directions. Injury. 2011 Jun;42(6):591-8. Epub 2011 May 4. Pelissier P, Martin D, Baudet J, Lepreux S, Masquelet A C. Behaviour of cancellous bone graft placed in induced membranes. Br J Plast Surg 2002; 55: 596-8. Pelissier P, Boireau P, Martin D, Baudet J. Bone reconstruction of the lower extremity: complications and outcomes. Plast Reconstr Surg 2003; 111: 2223 Pelissier P, Masquelet A C, Bareille R, Pelissier S M, Amedee J. Induced membranes secrete growth factors including vascular and osteoinductive factors and could stimulate bone regeneration. J Orthop Res 2004; 22: 739. Charles E. Dumont1,2, Ulrich G. Exner2 Reconstruction of Large Diaphyseal Defects of the Femur and the Tibia with Autologous Bone. European Journal of Trauma and Emergency Surgery Focus on Soft Tissue and Bone Reconstruction J. Ristiniemi · T. Flinkkilä · H. Pakarinen · P. Jalovaara Articular bone loss treated with a staged method using bone cement or beads as a spacer and subsequent autografting: a report of two cases, Arch Orthop Trauma Surg (2009) 129:79–82.
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Fig. 1a-1b Clinical presentation. a wide skin reaction with reddening of the whole thigh, extending to the lumbar and dorsal side till the breast. The knee was painful and swollen. There was also a pus secretion from the proximal screws of the fixator Fig.2 X-ray: The fracture pattern was 33-C2 based on AO classification and type III A based on Gustilo open fracture classification. There was diaphyseal comminution with articular extension. Fig 3a-3b CT-scan demonstrated the presence of free air in intra-muscolar spaces. Fig 4 X ray after surgical debridement We removed all the infected necrotic bone (24 cm of the femoral shaft) and put a gentamicine cement spacer of the same length and a new external fixator. Fig 5a-5b Planning pre operative and x ray intra operative Fig 6 Patient aftre 3 month after surgery. Fig 7 X ray one year after surgery. she was judged healed
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S0020-1383(18)30714-9 https://doi.org/10.1016/j.injury.2018.11.046 JINJ 7959
To appear in:
Injury, Int. J. Care Injured
Received date: Revised date: Accepted date:
4 August 2018 27 November 2018 28 November 2018
Please cite this article as: Cavanna M, Peschiera V, Staletti L, Berlusconi M, Allograft for the treatment of massive bone loss in open and infected IIIA fracture of the distal femur: A case report, Injury (2018), https://doi.org/10.1016/j.injury.2018.11.046 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Allograft for the treatment of massive bone loss in open and infected IIIA fracture of the distal femur: a case report Corresponding author
IP T
matteo cavanna Humanitas Research Hospital Via manzoni 89,rozzano,Italy [email protected]
U
SC R
Infection; Open fracture; Bone loss; allograft.
CC
EP
TE D
M
A
N
Abstract Infection and bone loss after local debridement in high grade open fractures are two difficult issues. The treatment of bone infection needs a wide “oncological” debridement that leaves a segmental bone defect. Once the infection is deleted, the defect may be treated with different surgical techniques: bone graft, bone transport, Masquelet’s two stage reconstructions, allograft or vascularised fibular transplant. In literature these options are described only for bone loss less than 15 cm. We describe a case of a lady with an open IIIA fracture of the right distal femur with 25 cm of infected bone loss, treated with wide multistaged debridement, Masquelet technique and ORIF with massive allograft and autologous bone graft. This case gives the possibility to discuss the following principles: wide debridement, biological chamber, two stage reconstruction, internal stable fixation in infected bone.
A
KEY WORDS: infection; open fracture; bone loss; femur; allograft.
A
CC
EP
TE D
M
A
N
U
SC R
IP T
Introduction The severe contaminated open fractures present three main problems: the infection, the bone loss and the fixation of the fragments. Infection usually requires a combination of surgery and antibiotics [1-5]. The objective of surgery is a wide mechanical removal of the infected tissues (either bone fragments or soft tissues) and the fixation of the bone fragments with an external fixation [13]. The modern suggestions described in literature [1] are to leave the debrided wound open and to add the vacuum therapy in order to have a long lasting action of debridement on the infected soft tissues. The local examination of the microbiological environment gives the correct antibiotic for the general treatment. The repeated debridement usually leaves a bone loss. Once the infection is controlled, the main problem becomes how to treat and fix this bone loss in order to restore the length of the limb, give the healing of the fracture and the possibility at the patient to have a complete weight bearing. In literature there are different methods to solve these problem [9-12]. The Masquelet procedure [15] consist a wide debridement of the infected bone and soft tissues and the implant of cement spacer until the infection is solved. When the clinical and microbiological parameters will be at normal levels it will be possible to remove the spacer, put inside the bone graft to fill the defect and make the open reduction and internal fixation. This technique is indicated for tibia and for less than 6 cm of bone loss in the femoral shaft. The bone transport [9,10], once removed the infected bone, uses the bone regenerate, that fills the loss, to “kill” the remaining infection. It needs a very long period of distraction estimated in 35.7 day for each centimetre of bone loss. The microvascular double barrel vascularised fibula transplant has the problem both of the length, the size of the transported bone and of the residual vascularity of the injured site where there should be the anastomosis. It is indicated only for defect less than 15 cm. The autologous bone graft, when the defect exceeds 5-7 cm has a great number of non union (17-50%), refracture (17-30%) and infection (10-15%). The allograft is another option, but the history of infection and the quality and vascularization of the surrounding altered soft tissues may interfere with new bone apposition.
The bone transport with the circular frame has an intrinsic stability, the fixation in the other techniques should be discussed in every single case [7, 8]. We present this case of open infected fracture of the distal femur in order to show and discuss a possible solution in these cases applying different principles: wide debridement, biological chamber, two staged reconstruction, internal stable fixation in infected bone [14-20].
C-REACTIVE PROTEIN
EP
WBC
TE D
M
A
N
U
SC R
IP T
Case Description In October 2010, a 74 -year-old lady, after a fall in a farm, reported an open III A fracture of the distal right femur. She was originally stabilized with an external fixator in an other hospital, treated with prophylactic antibiotic therapy (amoxicillinclavulanic acid three times a day) and, after 5 days, was admitted in our institution with a severe infection (Fig. 1a-1b). There was a wide skin reaction with reddening of the whole thigh, extending to the lumbar and dorsal side up to the breast. The knee was painful and swollen. There was also a pus secretion from the proximal screws of the fixator. The skin at the level of the exposure of the fracture was sutured. The internal temperature was 39° C. In according to AO classification the fracture pattern (Fig.2) was 33-C2 and based on Gustilo open fracture was type IIIA. There was diaphyseal comminution with articular extension. At admission, laboratory assessment such as C-reactive protein, and white blood cell studies demonstrated evidence of infection: 29.83
Mg/Dl (0.1 -1)
14.93
10^3 /mm^3 (4-10)
A CT-scan (Fig.3a-3b) demonstrated the presence of free air in intra-muscolar spaces.
A
CC
We performed an immediate surgical debridement of the fractured wound and thigh fasciotomies. We put a gentamicin impregnated polymethymethacrylate bead at the open fracture level and vacuum therapy at the fasciotomies sites. We debrided also the screws’ sites of the previous fixator that was changed, maintaining the spanning configuration. We put also a double way lavage system with betadine (1:5) that lasted two days. Colliquated material was collected for a bacteriological examination. We started a new antibiotic therapy with Vancocin 1 gr/die. She was daily debrided and hyperbaric oxygen therapy started at the same time. The microbiological results were positive for Escherichia coli, Enterobacter and Clostridium Perfringens, and the antibiotic therapy was adjusted.
A
CC
EP
TE D
M
A
N
U
SC R
IP T
After 5 days she had pain and severe anemia, we performed an angiography showing a bleeding from the superficial femoral arthery that was embolised. After 3 weeks, the laboratory indicators of infection, in particular the C-reactive protein, were still elevated, even if a CT scan revealed no more air in the muscular compartments so we closed the fasciotomies. After few days she still had fever (39°C) and pus secretion from the proximal screws of the fixator. She underwent a new surgical debridement (December 2010). We found a deep infection involving the bone that appeared avascular and severely contaminated, with some pus coming out from the pre-existing screws of the external fixator. The infected necrotic bone was removed. The quantity of the removed bone was 24 cm of the femoral shaft and we put a gentamicin cement spacer of the same length. A new external fixator with screws also in the distal femur, was put in order to give more stability. At this time the articular fracture line should have been consolidated (Fig.4). A systemic antibiotic therapy was continued and the c-reactive protein decreased progressively therefore. She was discharge to rehabilitation center. Four months after the injury (February 2011), when the laboratory assessment of infection such as erythrocyte sedimentation rate, C-reactive protein, and white blood cell studies demonstrated no evidence of infection, we decided to treat the bone loss. Massive bone allograft was preferred because it would have allowed rapid weight bearing in an old woman who was getting depressed for the whole disease. The program was to revise the fragments (eventually cutting the possible still contaminated edges) and to reinforce the allograft with a nail and a plate if the distal locking was weak. Then bone graft from the iliac wing and platelet factors were supposed to be useful at the “docking” sites (fig 5). By using a traction table to maintain the length, we removed the external fixator and we performed a lateral approach to the femur. No visible signs of infection were found during the surgery. After removing the cement spacer, we found a complete pseudomenbrane that enclosed either the spacer or the proximal and distal femur (the biological chamber of Masquelet). We cut 5mm of the edges of the fragments and prepared the site for a recon nail (LFN 400x12 mm Synthes Co. as planned); the allograft was reaming till 13.5mm, and assembled it inside the thigh. The nail , was blocked distally , trying to have a good contact between the allograft and the fragment the nail was pull back and locked it with femoral neck screws. The proximal locking was stable, the distal locking was quite weak either for the
Discussion The treatment of infected fractures is always a challenging.
IP T
bone porosis or for the previous screws of the external fixator, so we added a lateral plate (LCPDF Synthes Co.). The “docking sites” were added with bone graft from the iliac wing and also with platelet factors. The post care protocol was a partial weightbearing, with crutches (20kg toe-touch) in the first 4 weeks . At 3 months she was able to raise the stairs. (Fig. 6). One year after surgery (October 2011) she was considerated healed (Fig.7).
SC R
Repeated aggressive debridements are often required to remove dead and contaminated tissues creating various degrees of bone loss.
The bone reconstruction is the problem when the infection is eradicated.
N
the best results in gaps of less than 15 cm.
U
Many techniques have been proposed to fill these bone gaps, but all of them give
but a high failure rates are reported for bone losses of greater
M
centimeters
A
Autologous bone grafting is a reliable choice to obtain fusion in gaps up to 5-7
amounts.
TE D
In case of greater bone defects the most accepted techniques are the bone transport with the ilizarov circular frame and the Masquelet technique. Both of them have shown to be precious in post infective cases, but they also have their
EP
disadvantages.
CC
Bone transport is a long standing treatment that may not be tolerated by patients that have been already under treatment for months. Moreover pin track infection
A
and docking site nonunion are frequently reported. The Masquelet technique is more suitable in the tibia and not recommended for gaps of more than 10 cm in the femur. Vascularised fibular grafting is a complex and time consuming microsurgical technique that requires a good vascularisation of the receiving site and whose results have low predictivity.
Finally the use of a eterologous graft is not
recommended for treating the
sequaelae of an infection, due to the high probability of reinfection . In this case the amount of bone loss was greater than any other case available in the literature, therefore we thought that an “off label” treatment solution was required. Firstly we decided to use a strut allograft from our bone bank: we asked for an
IP T
entire cadaver femur of the same size and length, basing our measure on the radiograms taken on the opposite limb and resected the amount of diaphyisis
SC R
corresponding to the bone defect.
This was mainly intended to restore the integrity of the femoral shaft in order to allow immediate weight bearing. Moreover with such a graft an IMN could be used
U
to obtain fixation, with the biomechanical advantages of a centromedullary device.
N
We took care to obtain a compression between the allograft and the proximal and
A
distal femoral stumps in order to allow a proper healing of the contact areas. Unfortunately the nail alone was not able to guarantee enough stability to the distal
M
fragment that was too short, excavated and osteoporotic to give a good purchase to
TE D
the locking bolt. For this reason a DF LCP was used to increase stability and allow early movement without jeopardizing the outcome. Some additional fresh bone autograft from the iliac wing augmented by PRP around
EP
the contact areas between viable bone and allograft to increase the healing. The pseudomembrane created by the cement spacer was preserved and it was able
CC
to wrap completely the allograft. It is well known that the massive bone allografts do not integrate and tends to become osteoporotic.
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The biologic chamber is able to to remodeling the allograft into viable bone as it has seen in a lesser defect, and we hope was possible also in this high defect. The patient recovered the limb function in terms of full weight bearing and stair climbing within 3 months after surgery. At one year the radiograms showed a complete fusion of both the graft ends to the viable bone and a diffuse formation of bone all around the diaphyseal allograft.
We explained this last phenomenon as a sign of the activity of the biological chamber in the process of remodeling of the graft into newly formed viable bone. Treatment of bone defects of more than 15 centimeters after eradication of an infection is a demanding procedure very rarely performed. Unfortunately no data or guidelines are available in the literature, therefore our decisions have to be well
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planned and discussed with the patients, along with the risks and benefits related. The knowledge of the techniques described for lesser defects and the mixed use of
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some of them, have permitted in our case to successfully treat this difficult case of massive bone loss.
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Conflict of interest None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work.
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Fig. 1a-1b Clinical presentation. a wide skin reaction with reddening of the whole thigh, extending to the lumbar and dorsal side till the breast. The knee was painful and swollen. There was also a pus secretion from the proximal screws of the fixator Fig.2 X-ray: The fracture pattern was 33-C2 based on AO classification and type III A based on Gustilo open fracture classification. There was diaphyseal comminution with articular extension. Fig 3a-3b CT-scan demonstrated the presence of free air in intra-muscolar spaces. Fig 4 X ray after surgical debridement We removed all the infected necrotic bone (24 cm of the femoral shaft) and put a gentamicine cement spacer of the same length and a new external fixator. Fig 5a-5b Planning pre operative and x ray intra operative Fig 6 Patient aftre 3 month after surgery. Fig 7 X ray one year after surgery. she was judged healed
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