PMC8046487_01
Case 1 initial intraoperative images of 59-year-old man who sustained a right neck of femur fracture and right open femoral fracture treated with IM nail.
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F1
A 59-year-old man was referred for non-union right femur at transition between middle and distal third with a 3 cm shortening of the femur 22 months after a significant polytrauma resulting in a right neck of femur fracture and right open femoral fracture treated (at another center) with a dynamic hip screw and IM nail, respectively (Fig. 1).
Case 1 anterior posterior and lateral femoral films taken day 7 post-removal of old nail and insertion of PRECICE nail with proximal corticotomy. Compression started to obtain union.
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F2
The non-union and leg length discrepancy were treated with a one stage procedure; performing debridement of the non-union up to the bleeding bone; inserting a lengthening IM nail and compressing the fracture by five milometers using a hand-held external remote controller (Fig. 2).
Case 1 - anterior posterior and lateral femoral films taken 4 weeks post-operative when the distraction phase is complete.
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F3
After the compression was complete, the fracture was left for 4 weeks before beginning to distract the previous non-union gap by 1 mm/day in four increments with a re check X-ray within a week to confirm that the regenerate was moving (Fig. 3).
Case 1 - anterior posterior and lateral femoral films taken 24 weeks post-surgery (20 weeks post-distraction) showing 78 mm of regenerate.
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F4
The patient was kept touch toe weight bearing for 22 weeks, followed by partial weight bearing for an additional 8 weeks. 24 weeks post-surgery, the patient had gained 78 mm regenerate and was mobilizing pain free without aids (Fig. 4).
PMC8046487_02
(a) Case 2 - anterior posterior film of right tibia day 1 post-tibial corticotomy and fibular corticotomy and Taylor Spatial Frame placement for 12 cm bone defect. (b) Lateral film of right tibia 19 weeks post-Taylor Spatial Frame placement with lengthening protocol of 0.5 mm/day showing evidence of regenerate formation. (c) Lateral film of right tibia 21 months post-Taylor Spatial Frame placement showing 12 cm of strong regenerate with no evidence of refracture. Patient was mobilizing pain free.
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F5
With a 12 cm tibia bone defect, the patient was finally treated with proximal tibial corticotomy and fibular corticotomy and TSF placement (Fig. 5a). Fig. 5b shows patient 19 weeks into lengthening protocol. The frame was removed 14 months post-cessation of lengthening when the regenerate had remodeled completely (Fig. 5c).
PMC8046487_03
Case 3 - anterior posterior film of right femur of 28-year-old male day 1 post-operative following 1st stage of Masquelet (intramedullary nailing of femur with cement spacer).
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F6
Two days after the initial damage control surgery, the patient returned to theater for first stage of Masquelet and a meshed skin split graft (Fig. 6).
(a) Case 3 - anterior posterior film of proximal right femur taken day 1 proximal corticotomy, IM nail change and Orthofix monorail assembly with cable in proximal fragment of bone to be transported. (b) Case 3 - anterior posterior film of distal right femur taken day 1 post-IM nail insertion with cable and monorail assembly for bone transport. Note cable in proximal fragment of bone pulled submuscularly and extra-articularly to exist wound lateral to the knee; attached to pulley system on monorail.
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F7
Pulleys and clickers were assembled through the cable and threaded rod (Fig. 7).
Case 3 - anterior posterior film of distal femur showing transported fragment at docking site 53 weeks after bone transport commenced with ex-fix still in situ.
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F8
The distal fragment reached the docking site after 53 weeks; external fixation index of 31.3 days/cm (Fig. 8).
(a) Case 3 - anterior posterior film of femur post removal of ex-fix with seven hole small fragment locking plate applied between regenerate and docking site. (b) Case 3 - anterior posterior film of femur 34 months after bone transport was commenced showing strong regenerate formation.
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F9
The patient was made partially weight bearing (Fig. 9a). Twelve weeks post-removal of ex-fix, there was evidence of regenerate the entire 15 cm between corticotomy and docking site. 99 weeks after the ex-fix was applied this regenerate had remodeled completely with a mean lengthening rate of 46 days/cm (Fig. 9b).