Preoperative Plan

Planning remarks:  Preoperative Plan and Discussion: The preoperative plan involved an antegrade intramedullary nailing approach to minimize implant surface area in the knee joint and to protect the femoral neck. This strategy was selected to reduce the risk of medullary sepsis while achieving adequate fracture stabilization. During the preoperative discussion, multiple fixation strategies were considered: Retrograde nailing was ruled out due to the presence of a chronically infected knee joint with a draining sinus. Using this approach would have created a direct conduit between the infected joint and the sterile femoral canal, posing a high risk for medullary contamination and sepsis. Antibiotic-coated nails were contemplated, but the femoral canal was extremely narrow (8 mm), requiring aggressive reaming up to 11.5 mm. Even then, introducing a cement-coated nail would be technically challenging, with limited long-term protection once local antibiotic elution subsides. Lateral locking plate fixation was considered suboptimal due to high infection risk and the potential for septic nonunion. Although the plate could be coated in antibiotic cement, similar concerns about waning antibiotic coverage applied. Ilizarov external fixation offered a biologically safer option but was deemed impractical due to the patient's body habitus and anticipated poor tolerance of the frame. Above-knee amputation was discussed as a definitive solution to both infection and fracture; however, the patient was ambulating and functional before this injury and strongly wished to preserve the limb. Given these considerations, antegrade nailing was selected as the best compromise—offering fracture stability while avoiding direct contamination from the knee.