Surgical Discussion

Patient positioning:  Supine position on a radiolucent table, with full sterile prep and draping of the affected limb. C-arm imaging used intraoperatively.

Operative remarks: 

Extensive debridement, with anticipation of serial staged debridement due to suspected devitalized tissue

Retrieval of any retained wadding or ballistic fragments

Intramedullary nail fixation chosen for load-sharing stability through the metaphyseal region

Residual quadriceps tendon was lengthened, advanced, and repaired primarily

If primary repair fails, reconstruction with an allograft tendon is planned

No immediate bone grafting (e.g., Masquelet technique), based on preserved bone vascularity and potential for native healing

Postoperative protocol:   Serial wound checks and monitoring for signs of infection or necrosis Delayed weight bearing until radiographic signs of union Periodic radiographs to monitor implant position and healing Early physiotherapy focused on ROM and progressive quadriceps activation Backup plan for delayed allograft reconstruction if quadriceps function is not restored Multidisciplinary support including physiotherapy and psychosocial assessment due to the nature of ballistic trauma