• No, the scan shows the diseased section of bone. Further imaging is unlikely to be helpful
• Yes, more imaging please

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• Not applicable
• MRI whole femur
• CT spect or bone scan
• Labelled white cell scan
• Long leg alignment views
• US
• X-rays of the other leg

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• Advise he just lives with it. Take some deep samples for micro and then provide suppressive treatment with appropriate abx
• This leg is patently unsalvageable. Chop it off AK and then maybe look at an osseointegrated prosthetic leg, once residual infection is ruled out.
• I’d be looking to go in and do a localized resection of all the sequestrum (dead bone) seen on CT. Make a deep trough, scoop out all the diseased bone but leave the femur in continuity
• Go big - segmental resection of diseased section of femur - will result in a big transport afterwards.
• Go bigger - segmental resection of diseased bone and a cuff of apparently healthy bone above/below it - will result in a monster transport afterwards.
• Go massive - total femur replacement, either single or two-staged procedure with antibiotic spacer.

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• Go after the deformity first. Straighten the leg out and then replace the joints if they need it. Sometimes joints stop hurting once the leg is straight.
• Replace arthritic joints first and then see how the patient feels. If their pain has now gone, you might not have to correct the deformity.
• Go with the symptoms. If the pain localises clearly to the joints, then go after them. If it's due to mal-alignment, then go after that.
• The knee and ankle joints have to be straightened out before you consider replacing them; whereas for the hip, you can crack on with a hip replacement, treating the deformity secondarily

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• Replace the hip. Take away one problem and the rest become less complex
• Straighten out the femur. Once this is lined up, her knee and hip pain may improve.
• Straighten out the femur and the tibia. Where deformity is complex, such as here, a 2-level osteotomy may be needed to address the angulation and translation. Once straight, address the joints.
• Offer her an amputation, maybe with an osseointegrated prosthesis to give her a high-functioning leg
• Replace the knee with a long stem TKR, effectively doing deformity correction and replacement with one device and in one surgery - sweet!

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• IM nail and use the locking screws to secure articular fragments
• Plates and screws, once soft tissues settled. Best option for getting anatomic position of the fragments
• I wouldn't have bothered with the ex-fix. Primary plates and screws, ideally within first 48 hours of injury. This makes for easy fracture reduction and saves the poor patient an ex-fix
• Treat definitively in the monolateral ex-fix, maybe with some percutaneous screws to hold the joint fragments
• Convert to circular frame after a week or two, maybe with some supplementary screw fixation of the joint.

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• The alignment still looks ok so I'd let the fracture dynamise. Continue to wt bear as tolerated and the movement will stimulate callus for healing. No intervention right now.
• I'm worried about this falling into varus, so I'd re-plate the medial side
• As above, but I'd re-plate the medial side and bone graft the fracture at same time
• These idiots should have put a frame on in the first place. I'd remove the hardware and put a circular frame on to get it healed.

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• We gotta get this healed. No infection and good soft tissues = re-fix with plates/screws +/- bone graft.
• More plates in there are just going to get infected and even if they don't, it won't heal. So I'd go for a circular frame +/- bone graft. Might take a long time though.
• The middle segment is dead and will never heal. I'd excise the dead area and then transport the proximal shaft down onto either the distal tibia or the talus (if all the distal tibia is dead/mushy)
• Realign and hindfoot nail +/- bone grafting. I could prep/fuse the ankle joint too, if I felt it was unsalvageable.
• Chop out the entire distal tibia and replace it with a grafted scaffold down onto the talus, secured with a HF nail.

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