Case Report

The Journal of TRAUMA Injury, Infection, and Critical Care

Reconstruction of a Post-Traumatic Infected Bone Defect of an Open Diaphyseal Femur Fracture by Double LISS Fixation: A Case Report
M. Panzica, MD, T. Gosling, MD, P. Schandelmaier, MD, S. Hankemeier, MD, and C. Krettek, MD

J Trauma. 2007;62:12721276.

he treatment of post-traumatic extensive bone-loss is surgically challenging. The reconstruction of long bones of the lower extremity requires stable and reliable fixation for limb salvage and early weight bearing. With massive defects callus distraction takes a very long time with an uncertain success.1 4 Open multi-fragmentary femoral fractures show impairment in vascularization of the bone and surrounding softtissues associated with a higher risk of developing infections and osteomyelitis as severe complications. The philosophy behind the biological osteosynthesis of fractures is to minimize impairment of bone and soft tissue vascularisation.5 8 The variety of options demonstrates the complexity and difficulty in the treatment of large bony defects. Today, external fixation is the treatment of choice if distraction osteogenesis is desired.3 However, problems such as pininfection, pin-loosening, pain, axial deviation psychologic impairment, and joint stiffness are not rare.9 Autogenous or allogenous bone grafting or vascularized bone transfers are well-known treatment methods.10 In large defects the stability of the osteosynthesis is highly demanding. Usually bridging plating is used as fixation technique. This case report describes the reconstruction of a secondary 15 cm diaphyseal femoral bone defect after a grade two open two level femoral shaft fracture with a composite of autogenous and allogenous bone graft. To achieve adequate stability a long angular stable implant was created out of two commercially available locked screw plates (Less Invasive Stabilization System, Synthes AO ASIF, Solothum, Switzerland).11

CASE REPORT
A 30-year-old man was involved in a motor vehicle crash with his car. On the scene, the patient was trapped in his car for 30 minutes because of impingement of his left leg. After prehospital emergency treatment he was transferred by helicopter to our level one trauma center. At admission the patient was polytraumatized. On the left leg he sustained a Gustilo type II open two level femoral shaft fracture (AO 32-C2.2) with an additional lateral femoral condylar fracture (AO 33-B1.1), a comminuted patella fracture and an open knee dislocation. In 1986, the patient had been injured with a third degree open ipsilateral tibial fracture. Completing diagnostic algorithms, the patient was transferred to the operating room. Careful primary debridement and jet-lavage of the open and tom soft tissue was undertaken. A lateral femoral condylar fracture with adjacent lateral ligament complex was diagnosed intraoperatively and refixated with three cancellous screws after anatomic open reduction. Meniscal structures and cartilagineal joint surfaces of the femur and tibia were intact. A complete intraligamental ACL rupture and partial PCL rupture were also diagnosed. Additionally, the comminuted patella fracture was reconstructed after partial patellectomy with transosseous sutures. Primary external fixation was undertaken in the femur as damage control. The soft tissue were closed temporarily with an artificial skin substitute (Fig. 1). After primary stabilization, the patient was admitted to our trauma intensive care unit. Intravenous antibiotics were already started immediately after admission in the emergency room. Definitive fracture stabilization was done on day 4 after the trauma. The left femur was exposed over a lateral approach. Under fluoroscopic control a 22-hole dynamic condylar screw-plate (DCS) was put on the lateral aspect of the femur using the external fixateur as a reduction aid. The plate was turned, so the condylar screw was placed proximally into the femoral head. Intraoperative fluoroscopy showed a good alignment. Because the knee was unstable, across-the-knee external fixation was continued (Fig. 2). The postoperative clinical course was complicated by a deep wound infection with Staphylococcus aureus and May 2007

Submitted for publication September 17, 2004. Accepted for publication April 18, 2005. Copyright 2007 by Lippincott Williams & Wilkins, Inc. From the Department of Orthopaedic and Trauma Surgery, Hannover Medical School, Germany (M.P., T.G., S.H., C.K.); Department of Orthopaedic and Trauma Surgery, Klinikum Deggendorf, Germany (P.S.). Address for reprints: Martin Panzica, Hannover Medical School, Department of Trauma Surgery, Hannover, 30625 Germany; email: panzica. martin@mh-hannover.de. DOI: 10.1097/01.ta.0000233912.27163.24

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Fig. 1. Primary stabilization of the two level femur shaft fracture with external fixation and refixation of the lateral femoral condyle with three cancellous screws.

Fig. 2. Secondary change of method from external fixation to internal fixation with a 22-hole DCS-plate.

Enterococcus faecalis, which required a soft tissue revision 7 days after the trauma. An extensive wound infection involving the subcutaneus and subfascial soft tissue was seen and required debridement of the tensor fasciae latae and vastus lateral muscles. Additional levofloxacin antibiotics were given intravenously. Ten days after the trauma the patient required increasing quantities of blood transfusions. The abdominal computed axial tomography (CAT) scan showed a secondary rupture of the spleen that was followed by laparotomy and by splenectomy. A revision and debridement of his left thigh was performed simultaneously. Later, two additional wound revisions were necessary until adequate soft tissue granulation was achieved for the mesh graft transfer that was done 1 month after the trauma. The mesh graft healed regularly. However, 2 weeks later, pyogenic secretion was recognized at the proximal part of the wound. Again, thorough wound revision with complete exposure of the lateral femur was performed. A second look operation 4 days later showed no clinical signs of infection and after jet lavage the wound could be closed without complications. Because of the complicated clinical course, mobilization of the patient was limited. Two months after the incident, the complex knee instability was splinted in a range of motion Volume 62 Number 5

(ROM)-brace and the patient was dismissed under partial weight bearing with 15 kg on crutches. The radiographs showed the presence of a bony defect in the proximal part. Bone grafting was planned at a second stage. Three months after the accident, the patient was seen for clinical follow-up in our outpatient department. Clinical examination showed intact soft tissue and a vital mesh graft without any signs of infection. Range of motion of the left knee joint was 0 to 85 degrees. No evidence of implant loosening or dislocation was seen on the radiograph. The proximal fracture side showed no signs of healing on the radiograph (Fig. 3). The patient was readmitted for secondary bone grafting. The left femur was exposed over a lateral approach from the greater trochanter down to the knee. Evacuation of pyogenic liquid was undertaken, whereby chronic osteomyelitis was suspected. The planned cancellous bone grafting was cancelled. The DCS was removed and an external fixator was applied. Radical bony debridement and wound irrigation was necessary. Six months after the trauma multiple wound revisions and repeated sequestrectomy led to a 15 cm two-thirds circumferential lateral bone loss of the intermediate bone segment. The defect was temporarily filled with gentamicin antibiotic chains to support eradication of the infection. After three consecutive operations with negative swabs reconstruction of the femur was planned 8 months after the injury (Fig. 4). 1273

The Journal of TRAUMA Injury, Infection, and Critical Care

Fig. 4. Follow-up radiograph 6 months after trauma shows twothirds circumferential lateral bone defect after sequestrectomy. Fig. 3. Three months after internal fixation with 22-hole DCSplate. The proximal and distal fracture region shows no sufficient callusformation.

It was decided to leave the remaining medial one-third of cortex inside. Bone grafting was planned supported by an internal bridging fixation. Because of the previous infection a two-stage procedure was favored. Bone grafting was postponed to minimize the risk of an infected graft. Because of the huge bony defect we were confronted with two small fragments proximally and distally. These fragments were of minor bone quality because of reduced amount of mobilization and weight bearing. Conventional plate osteosynthesis seemed to be risky. We decided to use an angular stable internal fixation device that should improve fixation strength in the remaining fragments. By the time of the operation no commercially available angular stable internal fixator was available that fitted the required size. We decided to use two overlapping 13 hole Less Invasive Stabilization Systems for the Distal Femur (LISS-DF, Synthes AO ASIF, Solothurn, Switzerland). The pre-existing lateral approach was used. First a 13 hole LISS was fixed with seven angular stable self-tapping screws on the proximal fragment using the former central DCS-hole as an orientation for placement (Fig. 5A). Consecutively a second 13-hole LISS was anchored in the distal fragment, whereby axial alignment was checked under fluoroscopy. Corresponding to the preoperative planning both 13 hole LISSs were placed with 11 holes overlap1274

Fig. 5. (A) Intraoperative lateral view fixating LISSs proximally and distally before reduction. (B) Final intraoperative view on double LISS fixation with five cerclages wires.

ping. Angular stable screws were locked in the threaded holes. Additionally, both LISS were connected with five titanium cerclage wires (Fig. 5B). May 2007

Reconstruction of a Post-Traumatic Infected Bone Defect

Fig. 6. Postoperative radiograph showing double LISS construction. Fig. 7. Final follow-up radiograph.

The postoperative clinical course was uneventful. Because of the long immobilization period and chronic osteomyelitis, severe loss of knee joint motion and reduced bone stock resulted. To prevent implant failure, the patient was discharged under partial weight bearing for physical rehabilitation (Fig. 6). Ten months after the trauma a composite of autograft and allograft was used to fill the bony defect. Tricortical grafts were harvested from both iliac crests together with spongiosa. Donor femur heads were used as allografts. The grafts were fitted in the defect between the double LISS and the medial callus formation thus bridging the defect. The postoperative clinical course was uncomplicated, whereby the patient could be mobilized under partial weight bearing with 15 kg for 6 weeks and then 40 kg for another 2 weeks. Follow-up radiographs showed sufficient integration of the grafts within the reconstructed defect site. One year after the polytrauma the patient started with full weight bearing. Clinical examination continued to demonstrate limited function of his left knee (ROM 0 35 degrees). There was no evidence of soft tissue irritation. Finally, follow-up radiograph showed complete consolidation of the former bone defect without any signs of implant loosening; however, a slight valgus deformation of the left femur was registered (Fig. 7). Computed tomography scanning revealed an external rotational difference of 6 degrees. During the following 6 months the patient developed a cutaneous inflammation of his left leg twice, which was successfully treated by systemic antibiotics. Skeletal scintigraphy showed no evidence of osVolume 62 Number 5

teomyelitis. The patient was dismissed again under full weight bearing without any further complaints. Three years after injury the patient was contacted by telephone. He had moved to another country and started working again. No signs of infection have occurred since the last stay in our hospital.

DISCUSSION
Treatment results of grade two and grade three open fractures of long tubular bones showed infection rates between 11% and 22%.12,13 The presence of infection was found to be the strongest determinant for nonunion. Infected nonunions require a radical excision of the complete infected bone-soft-tissue-scar resulting in large bone loss.14 After recovery of the soft tissues a variety of reconstruction options are known, but none of these have been seen as golden standard. The choice of treatment method often depends on each individual surgeons experience and preference. Callus distraction with different types of external fixators is one of the central treatment options for reconstruction of long bone defects.4 Successful callus distraction demands on stable fixation and physiologic limb movement. The Ilizarov ring fixator offers excellent stability, compression, and correction opportunities for tibial callus distraction. However, femur soft tissue problems frequently occur and knee range of motion can be severely restricted. For that reason, unilateral external fixators are adventageous for femoral callus distraction.3 In noninfected situations the monorail technique for callus distrac1275

The Journal of TRAUMA Injury, Infection, and Critical Care

tion is recommended. The intramedullary nail provides intramedullary stabilization, while the external fixation is only for the distraction of the bone segment.1517 Axial mal-alignment, fracture of the callus tissue, and delayed union at the docking site because of soft tissue interposition or ad latus displacement are frequently observed complications. After completed segment transport, conversion of external fixation to intramedullary nailing increase patients comfort and decrease infection rate after removing the external fixator. Usually plating and grafting of the docking site has to be done secondarily.2,18,19 The reconstruction of defect in the femoral shaft with vascularized transfers of the fibular bone is another valuable procedure. The fibular graft can be inserted as a single strut or as a double-barrel composite. Usually the fibular graft hypertrophy to the complete femoral circumference and donor site morbidity is negligible. Delayed union and stress fracture were seen in those cases reconstructed by single strut fibular graft.19 22 In this case we were confronted with two special conditions. First, we had a defect of 150 mm. With callus distraction the time for lengthening is 150 days with another 300 to 450 days for consolidation.9 Second, the medial one-third of the bone was still present. For callus distraction this vital part of bone had to be removed. Hemicallotasis is an alternative to remain vitable parts of the bone, but minor experience is reported.1 These conditions lead us to graft the bony defect. We decided to use a composite of allograft and autograft. The medial third of the femur was left intact to improve the integration of the graft. Nevertheless, a long consolidation time had to be expected. Therefore, reliable stability had to be achieved. Locked screw plating offers advantages in fixation strength over conventional plate osteosynthesis.2325 Another advantage of locked screw plating is the minor comprised blood supply of the proximal and distal fragments. The more elastic fixation technique may stimulate remodeling of the osseous grafts.24,26 At the time of the operation no commercially available locked screw plate that fit the size was available. Therefore, we used the described composite of the two LISS-DF devices. We feel that locked screw plates that rely on angular stability are ideal for the bridging of huge osseous defects in long bones. However, the successful reconstruction of long bone defects requires a treatment regimen that is individualized on a case-by-case basis.
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