A 12 cm Traumatic Femoral Defect Treated with a Long Oblique Diaphyseal Femoral Osteotomy and Lengthening Over a Nail

This case report details the management of a 12 cm femoral defect. A 35 year old male sustained an open distal femoral fracture after a motorcycle collision. Treatment stages included emergent debridement and irrigation, temporary external fixation, and acute shortening and internal fixation 1 week after injury. The lengthening procedure was started 5 months later. The lengthening technique included a 6 cm oblique diaphyseal femoral osteotomy, a retrograde femoral rod, and a monorail external fixator. A complete release of the tensor fascia lata at the patellar level was performed in order to prevent posterior subluxation of the leg. The retrograde rod served several purposes including preventing varus angulation and early removal of the external fixator before full healing of the osteotomy site. Distraction was initiated 10 days after the femoral osteotomy. It was continued at a rate of 1 mm/day. The monorail was turned on average four or more full turns in the later stages to achieve 1 mm/day of femoral lengthening. Weekly radiographs helped chart the progress. The lengthening required 4 months to complete. As soon as the appropriate femoral length was restored, the retrograde rod was locked, and the monorail external fixator was removed. The osteotomy continued to consolidate over the next several months. Rehabilitation was ongoing, and unrestricted weight-bearing was possible by month 4 after monorail removal. This treatment protocol succeeded in filling in a 12 cm femoral defect.