The physician may be faced with some complex distal femur
fractures or nonunion where the bony stock is not adequate or the fixation may
have failed. It may also be a situation where a bone graft cannot be obtained
from the patient. In some of these cases, I use an intramedually fibular graft
in addition to plate fixation. The intramedullary fibular graft technique can
be used in: complicated cases, comminuted fractures with osteoporosis, failure
of traditional method of fixation, complex nonunion, and complex supracondylar
periprothetic fractures. How do you perform the technique?
The physician must find the starting point, which is the
center of the intercondylar notch just
superior to the Blumensaat’s Line. The
physician will insert a guide wire after reduction of the fracture. Then, the
physician will ream over the guide wire to the appropriate size of the fibular
graft, which you may need to fashion slightly. The physician needs to be sure
to change the beaded guide wire to a smooth one and put the fibular graft
through the guide wire into the medullary canal across the fracture of the
nonunion. If the medullary canal of the fibula is small and it will not go
through the guide wire, then place the fibular graft free hand. The physician
should be sure that the fibular graft is not prominent through the joint. Next,
fix the fracture or nonunion with a plate preferably a locking plate. You can
augment the fixation with bone graft, allograft, or bone graft substitute. This
procedure can also be helpful in periprosthetic fractures of the distal femur.
If the prosthesisi is stable, you will do fixation of the fracture of the
nonunion. It will be ideal to use a plate fixation after insertion of an
intramedullary fibular graft, especially if the bony stock is very poor and if
you can pass the fibular graft through the femoral component.
