Complex Femoral Fracture Scenario

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A 31-years old male went through a complex scenario of a simple middle third fracture Femur through infection and multiple unwise unplanned decisions. https://www.instagram.com/p/Cq8OAwRI7lV/

Health & Medicine

Complex Femoral Fracture Scenario
AOTRAUMA Egypt Chapter Meeting
By:
Abdallah EL-Azanki
Trauma & Orthopedic Surgeon
Limb Lengthening & Deformity Correction
Thursday 19/10.2023

‫رمي‬ ‫سدد‬ ‫اللهم‬ ،‫شهائنا‬ ‫ارحم‬ ‫اللهم‬ ،‫غزة‬ ‫في‬ ‫اهلنا‬ ّ‫م‬‫ه‬ ‫ج‬ّ‫فر‬ ‫اللهم‬ ،‫الثبات‬ ‫و‬ ‫الصبر‬ ‫اللهم‬
‫المنتصر‬ ‫العزيز‬ ‫انت‬ ‫اللهم‬ ‫غزة‬ ‫في‬ ‫المجاهدين‬
.
‫تستبدلنا‬ ‫وال‬ ‫استخدمنا‬ ‫اللهم‬

 Male patient
 31 years old
 Medically free, Non smoker
 History started in April 2015 after RTA
 Open G2 Middle third Left Fracture Femur
 First Xray is missed

 3 weeks post-operative AP
view available.
 Puss discharge started a few
days prior to the x-ray.
 Debridement was done but the
puss returned 4-5 weeks after
debridement
#Dr_Azanki

• Plate removed
• Debridement
• LRS Ex-Fix applied
in August 2015.
• No infection signs
#Dr_Azanki

• LRS Removed in January
2016
• Active sinus tract just at
the Fracture site
• Debridement
• Patient was advised to
start Weight Bearing.
#Dr_Azanki

$The patient had a refracture to His Left Femur April 2016 Missing the X-ray$

• Patient underwent
Debridement and
acute shortening
by Ilizarov Ex-Fix
• May 2016

• Ilizarov Removed in December 2016
• No signs of infection
• No discharge after Frame removal
• Sound union Xray
• No pain with Weight Bearing
#Dr_Azanki

• August 2020 (3.5 years after union)
• LLD 4cm
• Gait abnormality
• Severe Low Back Pain.
#Dr_Azanki

• Patient had acute Lengthening by
nail and iliac autograft.
• Infection and puss drained 2
months postoperative.
• Nail was removed and debridement
in February 2021
#Dr_Azanki

• June 2021 Lt femur was clinically
calm ( No discharge, No warmness)
• Patient underwent a Novel femoral
Lengthening technique with fibular
anchoring and LRS

• Due to infection and active discharge
debridement and long Leg Back Slab were
done.
• Patient presented in January 2022
• Infected , Non united and LLD 6 cm.
#Dr_Azanki

 Patient underwent :
• Aggressive
debridement
• Acute shortening
• distal osteotomy for
Lengthening
#Dr_Azanki

While
lengthening and
simultaneous
compression
adjustment
#Dr_Azanki
#Dr_Azanki

Midway
After
lengthening
9 cm
#Dr_Azanki #Dr_Azanki

During the
consolidation
period for the
lengthened site
#Dr_Azanki

The patient is encouraged to
weight-bear while
dynamization

Immediately after
Frame removal
#Dr_Azanki
#Dr_Azanki

• United femur
• No LLD (9 cm lengthened)
• stiff knee (0-20) even after aggressive prolonged
physiotherapy (planned for Judet Quadricepse plasty)
Recent status

Take home Message
 Respect the soft tissue (less ST dissection is Less infection)
 Once infected don’t mask it with antibiotics
 Acute infection  Debride  deep ST cultures  implant exchange
S Steinmentz et al 2019

 Pain on Weightbearing is a sign of Non-union in lower limb
 LLD more than 2 cm is not favored due to consequences
 Never hesitate to refer or higher consult.
(AV Christiano et al 2016)
(Grill F et al 1999, Vitale MA et al 2006)
Ex-Fix is not a Joy card, stick to principles
 Fracture alignment
 Rotation
 LLD
 Stability (Schanze numbers and diameter, rods ..etc)
Sabharwel et al 2005

‫الناس‬ ‫يشكر‬ ‫ال‬ ‫من‬
‫هللا‬ ‫يشكر‬ ‫ال‬
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