A 52-year-old man was assaulted and sustained a displaced open proximal tibia fracture. His condition was treated by antibiotics, debridement and bone fixation with an external fixator (Figure 1(a) & Figure 1(b)). An infected malunion in

valgus occurred. The deep bone infection with Staphylococcus aureus and fistula formation was treated intermittently with oral antibiotics for three months; ciprofloxacine 500 mg twice a day together with 160 mg trimethoprim/800mg sulfamethoxazol/once a day. After a minor trauma, a new fracture occurred seven years after the initial incident (Figure 2(a) & Figure 2(b)). Spontaneous healing in a plaster cast was not possible because of the renewed deep bone infection with fistula formation and soiling of the plaster cast. Masquelet’s technique was used to heal the infected non-union, no bone healing could be obtained. The infected nonunion was accepted by the patient and treated with oral antibiotic administration; ciprofloxacine 500 mg twice a day together with 160 mg trimethoprim/800mg sulfamethoxazol/once a day. Eventually, with long-lasting antibiotic therapy, the deep bone infection came under control, as there were no external infection signs. Because of the increasing varus of the tibia nonunion,

another attempt was made to achieve bone healing, this time with a biological nail (autologous strut graft) (Figure 2(c) & Figure 2(d)). The external tissue scarring was so extensive that a classical surgical approach to the fracture site proved impossible.

Surgical Technique:

First, a fibula osteotomy was performed to obtain a better alignment of the lower leg. Then, an autologous cortical tibia graft, taken from the other tibia, was inserted intramedullary via a suprapatellar approach (Figure 3(a) & Figure 3(b)). By this method, a one inch transverse incision is made 4 cm proximal from the patella. The quadriceps aponeurosis is split and with a long curved scissor the soft spot of the proximal tibia (area intercondylaris) is located. With a pointed hand riemer of 6 mm width, the cortical bone is perforated and the autologous tibia strut graft is carefully hamered in the intramedullary canal. Because of pliability of the tibia graft the Herzog curve of the proximal tibia is easely passed.

The tibia was then stabilised with an external fixator. Patient was not compliant and started immediate full weight bearing. One week after surgery, the cortical bone graft broke at the level of Herzog’s angle. After one year, there was sufficient endosteal bone formation around the intramedullary graft, and the fixator external could be taken off (Figures 3(a)-(c) and Figure 4(a) & Figure 4(b) and Figure 5(a) & Figure 5(b)). The patient is now walking with a cane for equilibrium reasons. Knee bending is 115˚ for an extension lag of 5˚.

A 55-year-old man, who smokes heavily, received a total knee prosthesis for severe gonarthrosis (Figure 6). Unfortunately, a deep infection occurred. The patient was given antibiotics as the only treatment because he refused further surgery. He sought surgical advice five years after the initial placement of the knee prosthesis. A bone scan with marked white blood cells showed profound osteomyelitis of the distal femur and proximal tibia. A cemented spacer was

used and then changed after three months by a hinged knee prosthesis (Figures 7(a)-(c)). Within a year, the deep infection reoccurred, necessitating the removal of the knee prosthesis. An attempt to perform an arthrodesis of his knee with a bridging external fixator failed (Figure 7(c)). After one year with an external fixator, the bone union did not occur, and a cortical autologous strut graft was placed anteriorly, spanning the arthrodesis site. The graft was fixed with two 4.5 mm cortical screws, one above and one below the arthrodesis site. A new spanning external fixator was placed to secure the knee arthrodesis (Figures 8(a)-(c)).

Three months after the last surgery, the patient fell on the street, breaking his strut graft with a skin laceration in front of his knee. The skin abrasion became infected. Antibiotics were given, and the anteriorly located wound was debrided. After six weeks, the wound became clean, and a posteriorly placed large fragment femoral plate was placed covering the former knee joint (Figures 9(a)-(c)). This patient had poorly vascularised, scarred-down and immobile tissue in the front of his knee. No attempt was made to remove the anteriorly located broken cortical strut graft. At the same time, a cortical strip of bone from the posterior side of the proximal tibia was taken and shifted proximally to bridge the fracture site. Removal of dead bone tissue was done with the same procedure. After the last surgery, the anteriorly located infected wound healed. The anteriorly (broken) and posteriorly cortical bone grafts were integrated after one year. Full weight-bearing activities were possible at that time.

Two years later, the posteriorly located femur plate broke (Figure 10(a)). The broken implant was replaced by two cannulated crossing screws of 7.3 mm screws to secure the former knee joint together with a solid femur allograft which spans the non-union side. This graft was secured to the femur with six 4.5 mm cortical screws: three screws above and three screws below the non-union site (Figure 10(b)). It took another two years post-surgery to see the bony union and peripheral integration of the allograft. Four years after the allograft strut graft placement, the patient is pain free at his knee and walks with one cane. He developed a severe bilateral omarthrosis of both shoulders because of the long standing use of his elbow crutches.

A 28-year-old female was involved in a car crash. An isolated closed femur fracture was diagnosed and treated with open femoral nailing and cerclage wiring. One year later, there was a painful mobile pseudarthrosis with a leg shortening

of three centimetres on the same site (Figure 11(a) & Figure 11(b)).

She did not experience any infection after her initial treatment. The clover leaf nail was replaced by a locking femoral nail. At the same time, an allograft was placed at the lateral side of the femur, bridging the non-union fracture side (Figure 12).

Unfortunately, the deep tissue samples came back positive for Enterobacter cloacae, Streptococcus oralis and Escherichia coli. All the implants and allograft were removed, and her leg was put in a spanning external fixator, spanning her hip as well as her knee joint (Figures 13(a)-(c)).

The patient wore the external fixator for three months while receiving intravenous antibiotics.

After this period, the external fixator was removed and replaced by a 4.5 mm locking plate, which protected a 25 cm long autologous tibia on-lay graft (Figure 14(a) & Figure 14(b)). The contralateral tibia served as the donor side. Full weight-bearing activities were possible six months after the last surgery. During this period, she received oral antibiotics (ciprofloxacine 500 mg twice a day together with 160 mg trimethoprim/800mg sulfamethoxazol/once a day. Full integration of the cortical graft was visible one year after the last surgery. Five years

after her last surgery, she remains infection free but does walk with a slight limb. She has a shortening of 2.5 cm, which she compensates with inlay shoe soles. Her knee flexion is 110˚ for a full extension and her hip function is normal. Her donor tibia site is pain-free on full weigth bearing with complete peripheral integration of the allograft (Figure 14(c)).

A 54-year-old man was involved in a motorcycle accident abroad. He sustained an open bifocal femur fracture and a closed base-cervical femur fracture on the same side—the cloverleaf nail protracted from his knee when he returned to Europe (Figure 15). Pus was pouring out the level of the bone segment and his knee joint. The intertrochanteric fracture went unnoticed and was not stabilised. A mixed flora of Escherichia coli, Actinobacteria baumanii and a multiresistant Proteus mirabilis was found after deep tissue sampling.

The nail and bone sequester were removed, and his leg was placed in an external fixator, spanning his hip and knee (Figure 16).

After three months, an autologous tibial cortical graft was placed inside the bone gap, and the bone was stabilised with a femoral plate (Figure 17). Reinfection then

occurred, which was treated with antibiotics and removal of the hard ware. The femur was stabilized by an external fixator. Spontaneous breakage of the cortical graft was noted two months after the placement (Figure 18). An oncological resection of the infected bone and soft tissue was carried out, and a mega prosthesis was done, including his hip and knee joints, at another institution (Figure 19).

A 28-year-old man fell on slippery ice and broke the distal third of his femur. It was a closed fracture. A locked plate (LISS DePuy-Synthes) was used to stabilise the distal femur fracture. Unfortunately, the plate had to be removed two months later because of a deep infection (Staphylococcus aureus). The femoral fracture was stabilised by an external fixator, and antibiotics were given. After eight months, the external fixator was removed because of an ongoing pin tract infection (Figure 20). Thirteen months after the initial trauma, revision surgery was performed using a contralateral autologous cortical tibia graft.

The cortical strut graft (Figure 21) was brought into the medullary cavity by the retrograde way (from his knee on) and stabilised by a lateral placed locked plate. Six months after the last surgery, graft integration was also seen with fracture healing (Figure 22). However, some function of his knee was lost: 20˚ of flexion. At his follow up at three years, no infection was seen. The patient refused further surgery. He now walks with a cane.