HSS Journal
HSSJ (2016) 12:182–185 DOI 10.1007/s11420-015-9482-4
®
The Musculoskeletal Journal of Hospital for Special Surgery
CASE REPORT
Successful Immediate Re-implantation of an Extruded Femoral Segment: a Case Report Ashraf M. Fansa, MD & Daniel Paull, MD & Nabil Ebraheim, MD
Received: 1 July 2015/Accepted: 20 November 2015/Published online: 7 December 2015 * Hospital for Special Surgery 2015
Keywords
trauma . femur . extruded bone . re-implantation
Introduction The treatment of high-energy open fractures is challenging, due to the high rates of infection and delayed or non-unions. The severity of this situation is compounded when bone fragments are traumatically extruded creating a large bony defect. If a large bone segment is lost, reconstruction may be achieved by gradual distraction osteogenesis procedures [1] or by implantation of large cadaveric allografts or vascularized autografts [2]. When the extruded bone segment is brought in with the patient however, the surgeon needs to decide whether to re-implant the extruded segment or not. Furthermore, if the decision for re-implantation is made, how should it be sterilized and when should it be reimplanted. Due to the relative rarity of this scenario, clear protocols regarding sterilization, fixation, and reimplantation steps and techniques of extruded bone segments do not exist [3, 4]. Therefore, sharing our individual experiences with dealing with such devastating scenarios in the surgical community may help in the formation of protocols and guidelines pertaining to this condition. In this case report, we seek to present our experience with immediate re-implantation of an extruded femoral bone segment combined with delayed internal fixation. According to our literature review, this is the first report describing such a method for re-implanting an extruded femoral bone fragment. Work was done at The University of Toledo Medical Center, Toledo, OH, USA. Electronic supplementary material The online version of this article (doi:10.1007/s11420-015-9482-4) contains supplementary material, which is available to authorized users. A. M. Fansa, MD (*) : D. Paull, MD : N. Ebraheim, MD Department of Orthopaedic Surgery, University of Toledo Medical Center, 3000 Arlington Ave., Toledo, OH 43614, USA e-mail: [email protected]
Case Report We present the case of a 46-year-old male who was brought to our institution by helicopter after being involved in a motorcycle accident in which he was ejected from his motorcycle onto the windshield of the involved car. The patient initially complained of pain in his left thigh, left wrist, left ankle, and right arm. Upon examination, he was noticed to have an 8-cm horizontal laceration of his left thigh directly superior to his patella with noticeable thigh shortening. His leg was found to be without neurovascular compromise as he had intact dorsalis pedis and posterior tibial pulses, as well as intact sensation to light touch in all aspects of the lower leg. He was found to have a type 3A open comminuted left distal femur fracture with a large segmental defect (Fig. 1), a closed left distal radius fracture, a comminuted right midshaft humerus fracture, a left lateral malleolar fracture, a right fibular head fracture, and multiple transverse process fractures. For the purpose of this paper, only the left femoral fracture will be discussed in detail. A 12-cm long segment of extruded femoral bone was found on the scene, was placed in a saline-soaked gauze dressing, and brought in with the patient. After the initial evaluation and receiving intravenous Ancef (GlaxoSmithKline, Research Triangle, NC, USA), gentamycin, tetanus toxoid, and tetanus immunoglobulin in the emergency room, the patient was brought to the operating theater. Copious irrigation and debridement of the patient’s left thigh was done through his open wound, followed by placement of a kneespanning external fixator. The extruded bone was washed and scrubbed in copious amounts of saline and debrided to remove any dirt. This step was followed by soaking the bone in three separate basins of 10% povidone-iodine solution for a total duration of 60 min. Next, the extruded bone was placed and aligned with the rest of the femur. The reinserted femoral bone was then augmented with antibiotic-laden cement encircling the fracture site, both to provide stability and to keep the graft from becoming infected (Fig. 2). The wound was initially left open and packed with wet dressings which were changed twice a day. The patient then underwent multiple surgeries in the following
HSSJ (2016) 12:182–185
183
Fig. 1. Plain AP and lateral radiographic views that were obtained show the injury at presentation.
days. These included five irrigation and debridements; of which, the first three were done at two-day intervals. Two days after initial surgery, the femoral condyles were reduced and fixed with two long medial 7.0 cannulated screws (Fig. 3). Finally, the external fixator and antibiotic cement augmentation were removed on the fourth day. In the same sitting, open reduction and internal fixation of the comminuted distal femoral fracture was achieved with a Peri-Loc 13-hole distal femoral locking plate (Smith & Nephew, Andover, MA, USA). The plate spanned the defect gap, and the extruded bone fragment was fixed in place with a single screw and wire cerclage proximally (Fig. 4). Partial wound closure was achieved at this time with wires. All the while, the patient was kept on intravenous antibiotics and had his open wounds packed with wetted
Fig. 2. These AP and lateral radiographs were obtained after the initial surgery. The extruded fragment has been reimplanted and augmented with antibiotic cement. Fixation was achieved by application of an external fixator.
Fig. 3. These AP and lateral radiographs were taken 2 days after the initial surgery. The femoral condyles are reduced and fixed with two long medial 7.0 cannulated screws.
saline dressings which were changed twice a day. After approximately two weeks, the patient was felt to be stable enough to leave the hospital, was made non-weightbearing, prescribed a physical therapy regimen with passive exercises, and was discharged to a facility on four weeks of oral antibiotics with continued wet dressing changes, with the goal of eventual split thickness skin graft application.
Fig. 4. These AP and lateral views were taken 4 days after initial surgery. The external fixator and antibiotic cement augmentation are removed. Open reduction and internal fixation is achieved with a distal femoral locking plate. The extruded bone fragment is fixed in place with a single screw and wire cerclage proximally.
184
We proceeded with routine follow-up in the outpatient setting and noted that his femoral fracture showed signs of healing and that he did not have any signs of infection related to his left open thigh wound. Split thickness skin grafting was then undertaken at approximately seven weeks after the injury, which went on to heal without complication. Because of the patient’s continued knee pain and limited knee flexion, left knee arthroscopy with manipulation under anesthesia was undertaken about a month later. The arthroscopy showed extensive synovitis, scar formation, and various osteochondral defects, which were debrided. The left knee manipulation improved the patient’s range of motion from 0–60 to about 0–90 degrees. Post-operatively, the patient’s pain improved, and he was made weight bearing at 16-week post-injury. At the 12 months’ time point, his active range of motion was 0–85, with 5/5 quadriceps strength and no appreciable limb shortening; radiography showed evidence of healing with abundant fracture callus (Fig. 5).
Discussion The benefits of re-implanting an extruded bone fragment include that it serves as a perfectly fitting spacer for fracture bridging and maintaining bone and soft tissue length, avoids the need to harvest an autologous graft causing donor-site morbidity to an already severely injured patient, averts immunogenic rejection associated with allografts, and may spare the patient lengthy and tedious distraction osteogenesis procedures. All that being said, even after meticulous debridement and sterilization, reimplanting an extruded bone that has been exposed to severe contamination may lead to devastating infections. Regarding sterilization techniques, Kirkup was the first to report on re-implantation of an extruded femoral bone. They described boiling the fragment and then sterilizing it in an autoclave immediately before re-implantation [5]. Since then, several authors described their successful experiences with different sterilization techniques including boiling, autoclaving,
HSSJ (2016) 12:182–185
gamma irradiation, and soaking in chlorhexidine, povidone-iodine, and antibiotic solutions [3–13]. Autoclaving seems to be the most efficient method of decontamination but there are multiple concerns regarding loss of graft osteoinductive properties [4, 14]. Due to the fact that data regarding the efficacy of different sterilization techniques cannot provide a clear guide as to which technique is ultimately superior, we do not believe that the type of sterilization solution used will accurately predict the outcome. Rather, it seems to be a combination of the nature of the injury, the viability of the re-implanted bone, the quality of the soft tissue bed, and the stability of the fixation, along with immediate and continued antibiotic coverage. We believe that immediate re-implantation of the extruded bone fragment together with antibiotic cement augmentation helped in addressing some of those factors. Reported timing of re-implantation and definitive fixation has ranged from immediate re-implantation to postponed reimplantation to up to 20 days after injury [3–5, 11, 12]. In all the previous reports, the extruded bone fragment was always fixed internally whenever the bone was re-implanted, regardless of timing being immediate or delayed. In our case, we debrided and sterilized the extruded fragment and re-implanted it immediately without internal fixation. Rather, the fracture was reduced with a knee-spanning external fixator, and the fragment was reimplanted and augmented with an antibiotic-laden cement. Four days after injury, the external fixator and cement were removed, and the bone fragment was fixed internally with plate and screws. Due to the fact that this was a polytrauma patient and the local severity of the femoral injury, we decided to delay internal fixation. Re-implantation of the extruded fragment on the other hand was not delayed in an effort to fill the gap early in order to provide stability and allow exposure of the bone fragment to patient’s innate defense mechanism. This method could also be safely followed when sterile freezing is not available to maintain the patient’s extruded bone until definitive fixation is performed. Compliance with Ethical Standards Conflict of Interest: Ashraf M. Fansa, MD, Daniel Paull, MD and Nabil Ebraheim, MD have declared that they have no conflict of interest. Human/Animal Rights: All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5). Informed Consent: N/A Required Author Forms: Disclosure forms provided by the authors are available with the online version of this article.
References Fig. 5. Plain AP and lateral radiographic views obtained at 12-month follow-up demonstrate healing of his fracture site with exuberant callus incorporating the re-implanted segment.
1. Rigal S, Merloz P, Le Nen D, Mathevon H, Masquelet AC. Bone transport techniques in posttraumatic bone defects. Orthop Traumatol Surg Res. 2012; 98(1): 103-8. PubMed PMID: 22257763.
HSSJ (2016) 12:182–185
2. Ridha H, Bernard J, Gateley D, Vesely MJ. Reconstruction of large traumatic segmental defects of the femur using segmental allograft with vascularized fibula inlay. J Reconstr Microsurg. 2011; 27(6): 383-90. PMID: 21717390. 3. Aizah N, Su Y, Shaifulnizam C, MRos M. Reimplantation of an Extruded Femoral Segment After Gamma Sterilization in A Type IIIA Supracondylar Femur Fracture: A Case Report. Malays Orthop J. 2014; 8(2): 66-8. doi:10.5704/MOJ.1407.015. PubMed PMID: 25279099, PubMed Central PMCID: PMC4181077. 4. Rouvillain JL, Navarre T, Noseda O, Garron E. Traumatic femoral bone defect reconstruction with an autoclaved autologous femoral segment. A 10-year follow-up. Acta Orthop Belg. 2006; 72(2): 229-233. 5. Kirkup JR. Traumatic femoral bone loss. J Bone Joint Surg Br. 1965; 47: 106-110. 6. Abell CF. Extrusion of femoral shaft fragment by trauma and successful replacement: a case report. J Bone Joint Surg Am. 1966; 48: 537-541. 7. Asada N, Tsuchiya H, Kitaoka K, Mori Y, Tomita K. Massive autoclaved allografts and autografts for limb salvage surgery. A 1–8 year follow-up of 23 patients. Acta Orthop Scand. 1997; 68: 392-395. 8. Farrelly E, Ferrari L, Roland D, Difelice GS. Reimplantation of an extruded osteoarticular segment of the distal tibia in a 14-year-old girl. Case report and review of the literature. J Orthop Trauma.
185
9. 10.
11.
12. 13. 14.
2012; 26(3): e24-8. doi:10.1097/BOT.0b013e31821a06b0. PubMed PMID: 22048178, Review. Kao JT, Comstock C. Reimplantation of a contaminated and devitalized bone fragment after autoclaving in an open fracture. J Orthop Trauma. 1995; 9: 336-340. Han K-J, Chung N-S, Lee HS, Lee YS. Reimplantation of an Extruded Humeral Segment into an Intact Periosteal Envelope in a Child. A Case Report. JBJS Case Connect. 2012; 2(3): e48. http://dx.doi.org/10.2106/JBJS.CC.K.00149. Mazurek MT, Pennington SE, Mills WJ. Successful reimplantation of a large segment of femoral shaft in a type IIIA open femur fracture: a case report. J Orthop Trauma. 2003; 17(4): 295-9. PubMed. Van Winkle BA, Neustein J. Management of open fractures with sterilization of large, contaminated, extruded cortical fragments. Clin Orthop. 1987; 223: 275-281. Wu CC, Shih CH. A femoral fracture with an extruded 14-cm fragment treated by secondary locked nailing: a case report. Acta Orthop Scand. 1996; 67: 295-296. Yaman F, Unlü G, Atilgan S, Celik Y, Ozekinci T, Yaldiz M. Microbiologic and histologic assessment of intentional bacterial contamination of bone grafts. J Oral Maxillofac Surg. 2007; 65(8): 1490-4. PubMed.
HSSJ (2016) 12:182–185 DOI 10.1007/s11420-015-9482-4
®
The Musculoskeletal Journal of Hospital for Special Surgery
CASE REPORT
Successful Immediate Re-implantation of an Extruded Femoral Segment: a Case Report Ashraf M. Fansa, MD & Daniel Paull, MD & Nabil Ebraheim, MD
Received: 1 July 2015/Accepted: 20 November 2015/Published online: 7 December 2015 * Hospital for Special Surgery 2015
Keywords
trauma . femur . extruded bone . re-implantation
Introduction The treatment of high-energy open fractures is challenging, due to the high rates of infection and delayed or non-unions. The severity of this situation is compounded when bone fragments are traumatically extruded creating a large bony defect. If a large bone segment is lost, reconstruction may be achieved by gradual distraction osteogenesis procedures [1] or by implantation of large cadaveric allografts or vascularized autografts [2]. When the extruded bone segment is brought in with the patient however, the surgeon needs to decide whether to re-implant the extruded segment or not. Furthermore, if the decision for re-implantation is made, how should it be sterilized and when should it be reimplanted. Due to the relative rarity of this scenario, clear protocols regarding sterilization, fixation, and reimplantation steps and techniques of extruded bone segments do not exist [3, 4]. Therefore, sharing our individual experiences with dealing with such devastating scenarios in the surgical community may help in the formation of protocols and guidelines pertaining to this condition. In this case report, we seek to present our experience with immediate re-implantation of an extruded femoral bone segment combined with delayed internal fixation. According to our literature review, this is the first report describing such a method for re-implanting an extruded femoral bone fragment. Work was done at The University of Toledo Medical Center, Toledo, OH, USA. Electronic supplementary material The online version of this article (doi:10.1007/s11420-015-9482-4) contains supplementary material, which is available to authorized users. A. M. Fansa, MD (*) : D. Paull, MD : N. Ebraheim, MD Department of Orthopaedic Surgery, University of Toledo Medical Center, 3000 Arlington Ave., Toledo, OH 43614, USA e-mail: [email protected]
Case Report We present the case of a 46-year-old male who was brought to our institution by helicopter after being involved in a motorcycle accident in which he was ejected from his motorcycle onto the windshield of the involved car. The patient initially complained of pain in his left thigh, left wrist, left ankle, and right arm. Upon examination, he was noticed to have an 8-cm horizontal laceration of his left thigh directly superior to his patella with noticeable thigh shortening. His leg was found to be without neurovascular compromise as he had intact dorsalis pedis and posterior tibial pulses, as well as intact sensation to light touch in all aspects of the lower leg. He was found to have a type 3A open comminuted left distal femur fracture with a large segmental defect (Fig. 1), a closed left distal radius fracture, a comminuted right midshaft humerus fracture, a left lateral malleolar fracture, a right fibular head fracture, and multiple transverse process fractures. For the purpose of this paper, only the left femoral fracture will be discussed in detail. A 12-cm long segment of extruded femoral bone was found on the scene, was placed in a saline-soaked gauze dressing, and brought in with the patient. After the initial evaluation and receiving intravenous Ancef (GlaxoSmithKline, Research Triangle, NC, USA), gentamycin, tetanus toxoid, and tetanus immunoglobulin in the emergency room, the patient was brought to the operating theater. Copious irrigation and debridement of the patient’s left thigh was done through his open wound, followed by placement of a kneespanning external fixator. The extruded bone was washed and scrubbed in copious amounts of saline and debrided to remove any dirt. This step was followed by soaking the bone in three separate basins of 10% povidone-iodine solution for a total duration of 60 min. Next, the extruded bone was placed and aligned with the rest of the femur. The reinserted femoral bone was then augmented with antibiotic-laden cement encircling the fracture site, both to provide stability and to keep the graft from becoming infected (Fig. 2). The wound was initially left open and packed with wet dressings which were changed twice a day. The patient then underwent multiple surgeries in the following
HSSJ (2016) 12:182–185
183
Fig. 1. Plain AP and lateral radiographic views that were obtained show the injury at presentation.
days. These included five irrigation and debridements; of which, the first three were done at two-day intervals. Two days after initial surgery, the femoral condyles were reduced and fixed with two long medial 7.0 cannulated screws (Fig. 3). Finally, the external fixator and antibiotic cement augmentation were removed on the fourth day. In the same sitting, open reduction and internal fixation of the comminuted distal femoral fracture was achieved with a Peri-Loc 13-hole distal femoral locking plate (Smith & Nephew, Andover, MA, USA). The plate spanned the defect gap, and the extruded bone fragment was fixed in place with a single screw and wire cerclage proximally (Fig. 4). Partial wound closure was achieved at this time with wires. All the while, the patient was kept on intravenous antibiotics and had his open wounds packed with wetted
Fig. 2. These AP and lateral radiographs were obtained after the initial surgery. The extruded fragment has been reimplanted and augmented with antibiotic cement. Fixation was achieved by application of an external fixator.
Fig. 3. These AP and lateral radiographs were taken 2 days after the initial surgery. The femoral condyles are reduced and fixed with two long medial 7.0 cannulated screws.
saline dressings which were changed twice a day. After approximately two weeks, the patient was felt to be stable enough to leave the hospital, was made non-weightbearing, prescribed a physical therapy regimen with passive exercises, and was discharged to a facility on four weeks of oral antibiotics with continued wet dressing changes, with the goal of eventual split thickness skin graft application.
Fig. 4. These AP and lateral views were taken 4 days after initial surgery. The external fixator and antibiotic cement augmentation are removed. Open reduction and internal fixation is achieved with a distal femoral locking plate. The extruded bone fragment is fixed in place with a single screw and wire cerclage proximally.
184
We proceeded with routine follow-up in the outpatient setting and noted that his femoral fracture showed signs of healing and that he did not have any signs of infection related to his left open thigh wound. Split thickness skin grafting was then undertaken at approximately seven weeks after the injury, which went on to heal without complication. Because of the patient’s continued knee pain and limited knee flexion, left knee arthroscopy with manipulation under anesthesia was undertaken about a month later. The arthroscopy showed extensive synovitis, scar formation, and various osteochondral defects, which were debrided. The left knee manipulation improved the patient’s range of motion from 0–60 to about 0–90 degrees. Post-operatively, the patient’s pain improved, and he was made weight bearing at 16-week post-injury. At the 12 months’ time point, his active range of motion was 0–85, with 5/5 quadriceps strength and no appreciable limb shortening; radiography showed evidence of healing with abundant fracture callus (Fig. 5).
Discussion The benefits of re-implanting an extruded bone fragment include that it serves as a perfectly fitting spacer for fracture bridging and maintaining bone and soft tissue length, avoids the need to harvest an autologous graft causing donor-site morbidity to an already severely injured patient, averts immunogenic rejection associated with allografts, and may spare the patient lengthy and tedious distraction osteogenesis procedures. All that being said, even after meticulous debridement and sterilization, reimplanting an extruded bone that has been exposed to severe contamination may lead to devastating infections. Regarding sterilization techniques, Kirkup was the first to report on re-implantation of an extruded femoral bone. They described boiling the fragment and then sterilizing it in an autoclave immediately before re-implantation [5]. Since then, several authors described their successful experiences with different sterilization techniques including boiling, autoclaving,
HSSJ (2016) 12:182–185
gamma irradiation, and soaking in chlorhexidine, povidone-iodine, and antibiotic solutions [3–13]. Autoclaving seems to be the most efficient method of decontamination but there are multiple concerns regarding loss of graft osteoinductive properties [4, 14]. Due to the fact that data regarding the efficacy of different sterilization techniques cannot provide a clear guide as to which technique is ultimately superior, we do not believe that the type of sterilization solution used will accurately predict the outcome. Rather, it seems to be a combination of the nature of the injury, the viability of the re-implanted bone, the quality of the soft tissue bed, and the stability of the fixation, along with immediate and continued antibiotic coverage. We believe that immediate re-implantation of the extruded bone fragment together with antibiotic cement augmentation helped in addressing some of those factors. Reported timing of re-implantation and definitive fixation has ranged from immediate re-implantation to postponed reimplantation to up to 20 days after injury [3–5, 11, 12]. In all the previous reports, the extruded bone fragment was always fixed internally whenever the bone was re-implanted, regardless of timing being immediate or delayed. In our case, we debrided and sterilized the extruded fragment and re-implanted it immediately without internal fixation. Rather, the fracture was reduced with a knee-spanning external fixator, and the fragment was reimplanted and augmented with an antibiotic-laden cement. Four days after injury, the external fixator and cement were removed, and the bone fragment was fixed internally with plate and screws. Due to the fact that this was a polytrauma patient and the local severity of the femoral injury, we decided to delay internal fixation. Re-implantation of the extruded fragment on the other hand was not delayed in an effort to fill the gap early in order to provide stability and allow exposure of the bone fragment to patient’s innate defense mechanism. This method could also be safely followed when sterile freezing is not available to maintain the patient’s extruded bone until definitive fixation is performed. Compliance with Ethical Standards Conflict of Interest: Ashraf M. Fansa, MD, Daniel Paull, MD and Nabil Ebraheim, MD have declared that they have no conflict of interest. Human/Animal Rights: All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5). Informed Consent: N/A Required Author Forms: Disclosure forms provided by the authors are available with the online version of this article.
References Fig. 5. Plain AP and lateral radiographic views obtained at 12-month follow-up demonstrate healing of his fracture site with exuberant callus incorporating the re-implanted segment.
1. Rigal S, Merloz P, Le Nen D, Mathevon H, Masquelet AC. Bone transport techniques in posttraumatic bone defects. Orthop Traumatol Surg Res. 2012; 98(1): 103-8. PubMed PMID: 22257763.
HSSJ (2016) 12:182–185
2. Ridha H, Bernard J, Gateley D, Vesely MJ. Reconstruction of large traumatic segmental defects of the femur using segmental allograft with vascularized fibula inlay. J Reconstr Microsurg. 2011; 27(6): 383-90. PMID: 21717390. 3. Aizah N, Su Y, Shaifulnizam C, MRos M. Reimplantation of an Extruded Femoral Segment After Gamma Sterilization in A Type IIIA Supracondylar Femur Fracture: A Case Report. Malays Orthop J. 2014; 8(2): 66-8. doi:10.5704/MOJ.1407.015. PubMed PMID: 25279099, PubMed Central PMCID: PMC4181077. 4. Rouvillain JL, Navarre T, Noseda O, Garron E. Traumatic femoral bone defect reconstruction with an autoclaved autologous femoral segment. A 10-year follow-up. Acta Orthop Belg. 2006; 72(2): 229-233. 5. Kirkup JR. Traumatic femoral bone loss. J Bone Joint Surg Br. 1965; 47: 106-110. 6. Abell CF. Extrusion of femoral shaft fragment by trauma and successful replacement: a case report. J Bone Joint Surg Am. 1966; 48: 537-541. 7. Asada N, Tsuchiya H, Kitaoka K, Mori Y, Tomita K. Massive autoclaved allografts and autografts for limb salvage surgery. A 1–8 year follow-up of 23 patients. Acta Orthop Scand. 1997; 68: 392-395. 8. Farrelly E, Ferrari L, Roland D, Difelice GS. Reimplantation of an extruded osteoarticular segment of the distal tibia in a 14-year-old girl. Case report and review of the literature. J Orthop Trauma.
185
9. 10.
11.
12. 13. 14.
2012; 26(3): e24-8. doi:10.1097/BOT.0b013e31821a06b0. PubMed PMID: 22048178, Review. Kao JT, Comstock C. Reimplantation of a contaminated and devitalized bone fragment after autoclaving in an open fracture. J Orthop Trauma. 1995; 9: 336-340. Han K-J, Chung N-S, Lee HS, Lee YS. Reimplantation of an Extruded Humeral Segment into an Intact Periosteal Envelope in a Child. A Case Report. JBJS Case Connect. 2012; 2(3): e48. http://dx.doi.org/10.2106/JBJS.CC.K.00149. Mazurek MT, Pennington SE, Mills WJ. Successful reimplantation of a large segment of femoral shaft in a type IIIA open femur fracture: a case report. J Orthop Trauma. 2003; 17(4): 295-9. PubMed. Van Winkle BA, Neustein J. Management of open fractures with sterilization of large, contaminated, extruded cortical fragments. Clin Orthop. 1987; 223: 275-281. Wu CC, Shih CH. A femoral fracture with an extruded 14-cm fragment treated by secondary locked nailing: a case report. Acta Orthop Scand. 1996; 67: 295-296. Yaman F, Unlü G, Atilgan S, Celik Y, Ozekinci T, Yaldiz M. Microbiologic and histologic assessment of intentional bacterial contamination of bone grafts. J Oral Maxillofac Surg. 2007; 65(8): 1490-4. PubMed.
