A 24-year-old patient was admitted to our department due to a car accident with multiple injuries, including femur fractures of both sides which were treated with plate osteosynthesis in Belarus. No complication was apparent on the left side. However, a persistent wound secretion with subsequent osteomyelitis was present on the right side 3 years after initial surgery even after adequate surgical debridement and antibiotic regime. Biopsy revealed methicillin-resistant and borderline oxacillin-resistant S. aureus (BORSA). X-rays confirmed osteomyelitis with a sequestrum, a fistula, and significantly reduced bone stock. The patient presented with an Ilizarov ring fixator in situ in our department for the 1st time in 2012. The Ilizarov ring fixator was implanted in Belarus in 2011. The patient preferred an exceptional salvage procedure to preserve the limb since amputation was not an option (Fig. 1).
Therefore, we suggested a two-step-surgery approach to treat the osteomyelitis before performing the definitive osteosynthesis. The Ilizarov ring fixator was removed and a vigorous debridement was performed by refreshing the pseudarthrosis, removing the sequestrum, and dead bone. Finally, an AO fixator external was implanted after several efficient debridements (Fig. 2a and b).
An antibiotic therapy was established with vancomycin (20 mg/kg/d) for 4 weeks followed by clindamycin (1800 mg/d) and co-trimoxazole forte (sulfamethoxazole 2400 mg/d/trimethoprim 640 mg/d) for 6 weeks. Ciprofloxacin (1500 mg/d) was additional given for the first 2 weeks during the treatment with clindamycin.
The AO fixator external was removed after 10 weeks of antibiotic treatment and surgery was performed after an additional antibiotic-free window of 5 weeks. We decided to perform a definitive treatment without intraoperative local antibiotic carrier application since the laboratory blood test revealed no elevated infection parameters. Moreover, no signs of persistent infection were found during the operation. The bone defect was stabilized by a long gamma trochanteric nail (Stryker, UK). A wide resection of the non-union tissue was performed which was crushed and placed beside the nail to bridge the defect zone (Fig. 2c and d).
Surprisingly, biopsies of the proximal and distal non-union side revealed the same bacteria and resistogram when compared to the initial biopsies taken before the rigorous debridement procedures (Table 1). However, reimplantation of crushed bone tissue from the infected side did not result in a relapse of osteomyelitis. The most likely bacteria load was reduced and the local effect of antibiotics was improved by crushed bone even when used from non-union infected side. Antibiotic therapy was established with vancomycin (20 mg/kg/d) for 2 weeks followed by co-trimoxazole forte (sulfamethoxazole 2400 mg/d/trimethoprim 640 mg/d) for 10 weeks. Neoangiogenesis proceeds much faster in small autologous fragments as in large dimensioned bone stock. Therefore, the blood supply increased around the affected area along with the bioavailability of antibiotics.
Frequent radiographic and clinical controls showed remodeling of the femur during a period of 3 years with partial weight-bearing and no signs of infection (Fig. 3).
Due to the bone spanning with cancellous bone and the increase soft tissue tension by an infected, shortened, and for 3 years not loaded leg, we decided to restore the leg length of 4 cm in a further step.
The long gamma trochanteric nail (Stryker, UK) was removed after 2 years of no signs of in-fection and limb lengthening procedure was carried out by implanting a fully implantable mo-torized lengthening nail (Fitbone , Wittenstein, Germany). In addition, a varus supracondylar femur osteotomy was performed to correct for biomechanical alignment (Fig. 4a and b).
The fully implantable motorized lengthening nail (Fitbone ) was removed after successful limb lengthening and final bone biopsies revealed no infection (Fig. 4c and d).
Due to the long period of rest and partial loading, the knee and hip joint was severely re-stricted in the range of motion (ROM) and the bone showed osteopenia in the radiological control. After intensive physiotherapeutic treatment, the patient achieved an unrestricted ROM with his indolent hip and knee joints.