9: Limb Salvage After Massive Traumatic Femoral Bone Loss

Fig. 1

Clinical picture of the bone defect

Fig. 2

Three-dimensional CT reconstruction of the leg. Contrast agent was utilized for detecting a vascular injury

3 Preoperative Problem List

Polytraumatized patient

Left hip dislocation

Type 3 open femoral fracture (subtotal amputation)

Massive bone defect with absent patellar tendon

Vascular injury (femoral vein laceration)

Contaminated soft tissue

4 Treatment Strategy

(a)

Closed reduction of the hip dislocation.

(b)

Mounting of a joint-bridging external fixator.

(c)

Vascular repair of the femoral vein.

(d)

Fasciotomy of the upper and lower leg and temporary coverage with synthetic skin.

(e)

Custom-made spacer with bone cement and K-wires was placed into the bone gap (07/2010).

During the following weeks,

(f)

Several revision surgeries and changing of the Vacuum assisted closure (VAC) was performed until

(g)

Split-skin graft covered the soft tissue defect (08/2010).

The leg length discrepancy was treated by:

(h)

Mounting a monotube on the femur

(i)

A multiplanar ring fixator on the tibia. Osteotomies were performed just below the lesser trochanter and below the tibial plateau.

(j)

A Hoffman fixator was added to connect the two frames in the knee region (09/2010).

In the last step,

(k)

An arthrodesis nail was inserted after frame removal to reduce the consolidation time in the frame and to realign all fragments (05/2011).

5 Basic Principles

Anatomic joint reconstruction in cases of severe or destroyed articular fractures is usually not possible in the initial damage control surgery. In these cases a joint-bridging external fixator is useful to protect the soft tissue, to stabilize the joint when severe ligament injury is present, or when a vascular repair has been performed.

Vessel injuries commonly occur in multiple-injured patients especially in the lower extremity. Direct injuries are caused by sharp and stump violence, indirect mechanisms by tension, distraction, or torsion. The diagnosis or suspicion of a vascular injury begins with the clinical investigation. Hard signs include active hemorrhage, large expanding or pulsatile hematoma, absent palpable pulses distally, and distal ischemia.

Early surgical soft tissue debridement

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