PMC5358950_01
AP and Lateral Femur X-rays before presenting to our hospital; A: Initial presentation; B: Post Operative-1 showing missing plate and screw in fixing the proximal fracture above the plating; C: Two weeks Post Operative-2 showing another proximal plating; D: Post Operative-3 showing proximal plating failure; E: Intramedullary nailing conversion showing improper nail insertion and locking fixation; F: Femur nailing has been revised and patellar fracture was fixed with screw and wire; G: Three months post-operative; H: Five months post-operative showing infected and sequestered middle segment of femoral shaft.
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One year ago, patient was involved in a motor vehicle accident, and diagnosed with closed fracture of the right femoral shaft (Fig. 1A) and patella. Three days after the first operation, patient was informed that the ORIF was insufficient (Fig. 1B) and went for a second revision surgery for another proximal plating. An X-ray was done one-month post-op to evaluate the healing process which showed a new fracture line and proximal plating failure (Fig. 1C). No history of trauma was reported and patient was sent for a third operation for revision of the internal fixation with intramedullary interlocking nail (Fig. 1D). X-ray showed improper nail insertion and fracture of the patella (Fig. 1E). Revision of intramedullary nailing and tension band wiring was performed for the patellar fracture (Fig. 1F). Unfortunately, three months after the revision surgery, the middle segment of the femoral shaft fracture developed infection and sequestrated (Fig. 1G and H).
Clinical presentation of the patient. Note the presence of a purulent discharge producing sinus at initial presentation.
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On physical examination, a sinus producing purulent discharge from the previous operation scar was noted (Fig. 2).
Modified Masquelet Technique; A: Insertion of bone cement spacer after debridement and middle segment sequester was removed (Masquelet Stage I), B: Bone cement spacer was removed and femoral fracture was fixed by reverse distal femur LCP and middle segment bone defect was filled with HA granules, BMP-2 and allogeneic UC-MSCs (modified Masquelet Stage II).
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Technique for treatment of segmental bone defects with the addition of UC-MSCs was done (Fig. 3A and B).
Exposure of bone defect before and after removal of spacer.
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A 12 cm bone defect was noted after spacer removal (Fig. 4A and B).
Post-Operative follow up AP and Lateral Femur X-Rays; A: 1 month; B: 3 months; C: 6 months; D: 9 months; E: 12 months.
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Patient was followed up for up to 12 months and clinical evaluation and radiographic imaging were taken (Fig. 5).
A: 6-month post-operative. Patient walked with partial weight bearing using crutches. B: 11-month post-operative. Patient walked with full weight bearing.
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At 6 months post-op, patient exhibited clinical union and started to walk using crutch on the right side (Fig. 6A). By the 11-month follow up period, clinical examination showed that patient was able to perform full weight bearing walk (Fig. 6B) with no pain (VAS: 0), LEFS of 65%, with no change in leg length discrepancy.