Difficult Case of Distal Femur Nonunion in a 31 Y/O Patient- Blade Plate Still has a Roll

Y/S a 31-year-old male was referred to our institute 3.5 years following an open reduction with internal fixation, which was done abroad, for a distal femur fracture of his right thigh. He suffered an oligotrophic nonunion with a broken plate which was diagnosed half a year post operatively. Upon medical examination he is otherwise healthy and nonsmoker. With no systemic reason for a nonunion. Infection had been ruled out. He complained about pain around his right knee increasing during walking more than a few meters without night pain. Upon clinical examination he had significant valgus knee with pathological movement at the fracture site. Scars looks normally. He had an antalgic limp and had to walk with the aid of a crouch. Full ROM at the hip and a ROM of -10 to 60 degrees at his knee. He had axis malalignment of 20 degrees external rotation and 20 degrees of valgus originating from his femur. his neurovascular examination was normal.

Picture 1 depicting his stature and demonstrate his knee swelling. Note that he had a leg length discrepancy of approximately 4 cm on Colman`s block test.
x-ray shows the broken plate with scattered callus (Picture 2) and obvious sign of nonunion.

A team consultation of our trauma surgeons debated the case and decided to perform acute lengthening with incorporation of autologous stem cell bone graft which were harvested from the patient fat cells two weeks prior to the surgery. The treatment was performed as a part of a clinical study of Bonus Bio Group.

After receiving an informed consent, the patient went a liposuction according to the study protocol and two weeks after we performed the definitive surgery which was done through a lateral approach and included plate removal thorough debridement with cautious for the sciatic nerve and femoral vasculature. The length of 3.5 cm was achieved by the temporary usage of an Orthofix™ distractor following valgus + eternal rotation axis correction by placement of a 4.5mm 95 degrease blade plate. Finally, the stem cell bone graft was injected to the bone gap and meticulous closure was performed in order to prevent leakage of the bone graft. Ant the end of the procedure no vascular compromised was detected and the leg axis was measured with the bovie diathermia cord under fluoroscopy.

To date 3 months post op, the patient is feeling well. No sign of infection was detected and the scar heeled completely. He started full weight bearing with no aid and without any significant limp. His ROM is preserved and he reports no significant pain. His X-ray shows complete union with normal axis. And he is expected a full recovery.

Although today the common practice in a case like this is to perform an acute shortening following the usage of a tailored spatial frame or any other computer assisted external fixator versus the usage of a telescopic intramedullary nailing. We decided to perform this procedure especially due to the ability to incorporate the stem cell bone graft at the nonunion site.

We think that the usage of this technic is rare today and because of that it should be shared with our colleges with the aid of intraoperative pictures and fluoroscopic pictures from the operating theater, merely to increase the awareness of our surgical community to other surgical solutions for this type of pathologies.