Plate augmentation for femoral nonunion: more than just a salvage tool?

Optimizing Fixation and Biologic Augmentation in Aseptic Femoral Nonunion Management: A Retrospective Case Series

Nonunion poses significant difficulties for both patients and orthopedic surgeons, often requiring intricate reconstructive surgeries to achieve bone healing and eliminate infections. Surgeons must navigate numerous contributing factors to nonunion, and they also face challenging hardware issues during revision procedures. These issues can include infections, loose or failing hardware, misaligned components, or inappropriate hardware configurations. This case series includes five cases of nonunion femur fractures and the goal is to carefully analyze the best treatment option for treating nonunion. All the cases underwent the removal of whole or part of the hardware followed by bone grafting and attainment of the stable construct with load-sharing devices and augmentation with neutralizing plates. All the cases had a radiological bone union at an average of four to seven months with improvement of Harris Hip Score.

Primary arthrodesis for diabetic ankle fractures using a modified retrograde femoral intramedullary locking nail combined with lateral plating, surgical technique, and early results of a pilot study

PURPOSE

We aimed to report the early results of performing acute ankle arthrodesis using a modified retrograde femoral intramedullary locking IMN concomitant with plating at the same setting for managing diabetic patients' acute ankle fractures.

METHODS

We prospectively included patients who presented acutely with ankle fractures, where hemoglobin A1C (HbA1C) on admission was > 7%, and the Adelaide Fracture in the Diabetic Ankle (AFDA) algorithm score was 5 or above. All patients were treated by acute ankle arthrodesis using a modified retrograde femoral IMN combined with lateral plating. Functional assessment was reported according to a modified American Orthopaedic Foot and Ankle Society ankle hindfoot scale (AOFAS), and complications were documented.

RESULTS

Six patients had an average age of 55.7 years (37-65). The average HbA1C on admission was 7.9 (7.3-9), and the average AFDA score was 7.3 (6-8). The average operative time was 79.2 min (70-90). All patients, except for one, achieved union at the arthrodesis site after an average of 10.3 weeks (8-14). After an average last follow-up of 9 months (6-12), the average modified AOFAS was 73.2 (82 to 62); four patients had an excellent score and one good. Complications developed in two, one deep infection after 2 weeks treated by metal removal and Ilizarov, and the other patient developed a stress fracture at the tibial end of the nail, which was treated by open reduction and internal fixation using a plate and screws.

CONCLUSION

Using a modified femoral IMN combined with lateral plating is a promising technique to achieve ankle arthrodesis in diabetic patients with acute ankle fractures with acceptable outcomes; however, further studies with larger numbers are needed.

LEVEL OF EVIDENCE

IV.

Resistant distal femoral nonunion treated with combined nail/plate construct and reamer-irrigator-aspirator technique

OBJECTIVE

This study was performed to evaluate the effectiveness of intramedullary nailing and a lateral locking plate combined with the reamer-irrigator-aspirator (RIA) bone grafting technique for resistant distal femoral nonunion.

METHODS

This retrospective observational study was performed from January 2018 to December 2021 and involved five patients who presented with resistant distal femoral nonunion despite undergoing several surgeries. They were treated with intramedullary nailing and a lateral locking plate combined with the RIA bone grafting technique. Postoperative follow-up was performed to observe the healing time, and functional outcomes were evaluated using the Lower Extremity Functional Scale (LEFS).

RESULTS

After the patients had been monitored for a mean of 17.9 months, complete bone healing was observed in every patient (mean healing time of 4.8 months). Postoperative wound failure in an older patient was successfully treated with resuturing and nutritional assistance. At the last follow-up, the mean LEFS score was 71.2/80 and the mean knee flexion was 109 degrees.

CONCLUSIONS

Our study demonstrates that combining intramedullary nailing and a lateral locking plate with the RIA bone grafting technique enhances biological properties, provides good structural support, and achieves good union and functional results in the management of resistant nonunion of the distal femur.

The role of an augmentative plating in the management of femoral subtrochanteric nonunion

INTRODUCTION

Owing to its distinct biomechanical properties, nonunion is common (7-20%) after intramedullary (IM) nailing of subtrochanteric femoral fractures. Unlike diaphyseal nonunion, it is difficult to provide sufficient stability by exchanging nailing alone in subtrochanteric nonunion. This study investigated the clinical outcomes of femoral subtrochanteric nonunion initially treated with an IM nail and subsequently managed with minimally invasive augmentative plate fixation.

MATERIALS AND METHODS

Nineteen patients were enrolled retrospectively. The mechanisms of initial injury were traffic accidents in 8, falls from a height in seven, and slipping in two patients. Two patients with atypical subtrochanteric femoral fractures without a specific trauma history were further included. All patients underwent IM nailing as the index operation. Nonunion surgery was performed an average of 45.2 weeks after the initial surgery. In cases of hardware damage and/or atrophic nonunion, exchange nailing and bone grafting were performed in addition to augmentative plating, as necessary. Conversely, augmentative plating alone was performed in cases of hypertrophic nonunion without any failure of the preexisting IM nail or malalignment. A narrow locking compression plate was fixed after contouring according to the shape of the proximal femur. The mean follow-up period was 36.1 months.

RESULTS

Bony union was achieved in 18/19 patients (94.7%), at an average of 19.8 weeks after nonunion surgery. In the case that did not heal even after exchange nailing, additional plating and bone grafting, further autogenous bone grafting was required after 11 months, which healed uneventfully. There were 2 cases of soft tissue irritation over the plate, but no major complications were observed.

CONCLUSIONS

Additional plate augmentation over a retained IM nail yields satisfactory outcomes in terms of the bony union in subtrochanteric nonunion. Given its expected biomechanical superiority and relatively easy surgical technique, it may be a reasonable option for the management of femoral subtrochanteric nonunion.

Augmented Stability in Leaving Original Internal Fixation with Multidimensional Cross Locking Plate through Mini-Open Femoral Anterior Approach for Aseptic Femoral Shaft Nonunion: A Retrospective Cohort Study

OBJECTIVE

Aseptic femoral shaft nonunion constitutes approximately 1%-10% of all femoral shaft fractures treated with intramedullary nail (IMN) fixation, possibly attributable to the lack of anti-rotational stability. Although a lateral locking plate (LP) with retainment of original IMN has shown the most success, lateral LP inflicts significant surgical trauma on patients. Therefore, the Multidimensional Cross Locking Plate (MDC-LP) was designed based on a mini-open femoral anterior approach. We aim to report and compare the technical aspects and clinical outcomes of using anterior MDC-LP or lateral LP with retention of original IMN for the treatment of aseptic femoral shaft nonunion.

METHODS

In this single center retrospective cohort study, records of 49 patients who had undergone revision of femoral shaft aseptic nonunion with anterior MDC-LP or lateral LP while retaining the original IMN from January 2015 to October 2019 were retrospectively reviewed. Information on patients' demographics, clinical data, and surgical outcomes were gathered and analyzed. X-ray and CT scans were used for bone union evaluation and the lower extremity functional scale (LEFS) was used for follow-up functional evaluation. For quantitative data, the Student's t-test was used if the data were normally distributed. The Mann-Whitney U-test was used for non-normally distributed data. For qualitative data, the Chi-square test was used for comparisons.

RESULTS

Twenty-seven patients were treated with anterior MDC-LP, and 22 patients were treated with lateral LP. There are no significant differences in age, sex, BMI, time since initial femoral shaft fracture, initial fracture type (close/open), nonunion type, or nonunion location between patients' group. Among patients treated with anterior MDC-LP, an average of 2-months advantage in time to union was observed (4.09 months vs. 6.8 months in the lateral LP group: P = 0.000), smaller incision was required for MDC-LP installment (7.7 cm vs 17.1 cm in lateral LP group: P = 0.000).

CONCLUSIONS

For the treatment of aseptic femoral shaft nonunion with retainment of original IMN, anterior MDC-LP via mini-open femoral anterior approach described in this study is a better option than lateral LP for achieving faster bone union and satisfactory functional outcome with less surgical trauma.

Plate Augmentation in Aseptic Femoral Shaft Nonunion after Intramedullary Nailing: A Literature Review

BACKGROUND

Femoral shaft fractures (FSFs) are a frequent injury in traumatology for which intramedullary nailing (IMN) is considered the gold standard treatment. Nonunion (NU) is one of the most frequent complications in FSF treated with IMN, with a percentage from 1.1% to 14%. Plate augmentation (PA), the addition of a compression plate and screws, with or without bone graft has been described as an effective option for the treatment of NU, improving the biomechanical conditions at the fracture site. The aim of this review was to analyze the literature relating to the use of PA in NU after IMN in FSFs to assess the efficacy of the technique.

METHODS

An electronic search on PubMed, Google Scholar, and Web of Science was conducted to search for all studies concerning PA of femoral shaft NUs after IMN.

RESULTS

Twenty-four studies were included in the review comprising a total of 502 patients with a mean age of 39.5 years. Of these, 200 hundred patients had atrophic pseudoarthrosis and 123 had hypertrophic pseudoarthrosis, while in 179, the type of pseudoarthrosis was not reported. The most frequently used plate for PA was the dynamic compression plate (DCP); in 87.1% of the cases, the authors added a bone graft to the plate fixation. In 98.0% of the patients, a complete bone union was achieved in a mean time of 5.8 ± 2.12 months.

CONCLUSION

The patients treated with PA included in this review showed a good rate of consolidation in the femoral shaft NUs, with good functional recovery and a low incidence of complications.

Nonunion of the femoral shaft associated with limb shortening treated with a combined technique of external fixation over an intramedullary nail versus the Ilizarov method

INTRODUCTION

Post-traumatic nonunion of the femur remains a challenging problem even for experienced orthopedic surgeons. The main question is the choice of the optimal surgical tool.

MATERIALS AND METHODS

Management of 20 patients with nonunion of the femoral diaphysis associated with anatomical shortening was retrospectively analyzed. Group A (n = 14) was treated with a hybrid technique that combined the Ilizarov external fixation and intramedullary nailing. The Ilizarov bone transport was used in group B (n = 6). Patients of both groups had aseptic post-traumatic nonunion. Mean shortening was 4.5 ± 0.4 cm in group A and 4.8 ± 1.0 cm in group B (p = 0.459959).

RESULTS

Union was achieved in 85.7% of group A and 100% of group B patients. External fixation was repeated in two cases of group A and achieved consolidation. Deep infection developed in one case of group A after 15 months post-frame with the nail in. It was resolved by nail removal, surgical debridement and external fixation. Limb shortening was fully eliminated in eleven cases of group A and four patients of group B. The average duration of distraction was 35.3 ± 1.7 days in group A and 47.8 ± 9.3 days in group B. The total duration of external fixation was 49.1 ± 3.5 and 177.2 ± 21.9 days with an external fixation index of 13.1 ± 1.2 and 52.4 ± 6.4 days/cm, respectively. Distraction regenerate consolidated in all the cases.

CONCLUSION

Hybrid technique provides bone union with compensation of limb shortening and reduces the treatment period as compared with the Ilizarov method used alone. However, deep infection may happen.

Plate augmentation and bone grafting in treatment of femoral shaft nonunion initially fixed by intramedullary nail

INTRODUCTION

This study aims to evaluate the results of plate augmentation and bone grafting without removing the nail in the treatment of nonunited, nailed femoral shaft fractures.

METHODS

Twenty patients with atrophic nonunion femoral shaft fractures initially fixed by intramedullary nail were treated by augmentation plating and iliac bone graft with retention of the nail. Patients were evaluated at regular intervals using an X-ray and Wu scoring system, which assesses clinical and radiological signs of healing.

RESULTS

All 20 patients achieved bony union at a mean time of 4.9 months (3-8 months). According to Wu's score, 12 cases showed excellent results, and 8 cases obtained good results with no complications recorded.

CONCLUSION

augmentation plating and iliac bone graft provide a good and safe method of treatment of previously nailed and non-united femoral shaft fractures.

LEVEL OF EVIDENCE

Level 4; Case Series.

Revision with Locking Compression Plate by Compression Technique for Diaphyseal Nonunions of the Femur and the Tibia: A Retrospective Study of 54 Cases

Nonunion after diaphyseal fracture of the femur or the tibia is a common but difficult complication for treatment. Currently, the main treatment modalities include nail dynamization, exchange nailing, and bone transport, but revision with compression plating in these nonunions was rarely reported. To evaluate the outcomes of compression plating in the treatment of femur and tibia shaft nonunions, we retrospectively reviewed 54 patients with diaphyseal nonunion of the tibia or the femur treated with locking compression plate (LCP) by compression technique. There were 46 aseptic and 8 septic nonunions in the case series. Patient's history, fracture characteristics, previous interventions, and types of nonunion were recorded. The possible reason which might lead to nonunion was also analyzed for each case. Patients with aseptic nonunions were revised by hardware removal and compression plating with or without bone grafting. For septic nonunions, a two-stage surgery strategy was used. Compression plating with iliac crest bone grafting (ICBG) or free vascularized fibular grafting (FVFG) was used as the final treatment for septic nonunions. The compression technique and bone grafting method were individualized in each case according to the patient's history and architecture of the nonunion. Each patient finished at least a two-year follow-up, and all cases achieved healing uneventfully. Our study showed that compression plating with LCP was an effective method to treat diaphyseal nonunions of the tibia and the femur. It is compatible with different bone grafting methods for both infected and noninfected nonunions and is a good alternative to the current treatment methods for these nonunions.

Poller blocking screw augmentation to treat delayed union of proximal tibial shaft fracture after locked IM nailing

CASES

We present the cases of two adult male patients with painfully delayed union of proximal tibia diaphyseal fracture after intramedullary nailing. Patients underwent to nail dynamization and Poller blocking screw augmentation at 3 and 5 month, respectively, after the index surgery. Both patients were pain-free after the surgery and bone-union were radiographically evident after 3 months. At 12-month follow-up, patients returned to their previous activities.

CONCLUSIONS

Although nail dynamization is the choice treatment to obtain fracture compression for delayed union of tibial shaft fractures, augmentation with Poller blocking screw could provide additional mechanical stiffness in unstable supra-isthmic shaft fractures of the tibia and favour bone union.

The biology and treatment of acute long-bones diaphyseal fractures: Overview of the current options for bone healing enhancement

Diaphyseal fractures represent a complex biological entity that could often end into impaired bone-healing, with delayed union and non-union occurring up to 10% of cases. The role of the modern orthopaedic surgeon is to optimize the fracture healing environment, recognize and eliminate possible interfering factors, and choose the best suited surgical fixation technique. The impaired reparative process after surgical intervention can be modulated with different surgical techniques, such as dynamization or exchange nailing after failed intramedullary nailing. Moreover, the mechanical stability of a nail can be improved through augmentation plating, bone grafting or external fixation techniques with satisfactory results. According to the "diamond concept", local therapies, such as osteoconductive scaffolds, bone growth factors, and osteogenic cells can be successfully applied in "polytherapy" for the enhancement of delayed union and non-union of long bones diaphyseal fractures. Moreover, systemic anti-osteoporosis anabolic drugs, such as teriparatide, have been proposed as off-label treatment for bone healing enhancement both in fresh complex shaft fractures and impaired unions, especially for fragility fractures. The article aims to review the biological and mechanical principles of failed reparative osteogenesis of diaphyseal fractures after surgical treatment. Moreover, the evidence about the modern non-surgical and pharmacological options for bone healing enhancement will discussed.

Comparison of a multidimensional cross locking plate versus a locking compression plate for the treatment of femoral shaft nonunion: Finite element analysis

The purpose of this study was to explore the advantages and disadvantages of a multi-dimensional cross locking plate (MDC-LP) compared with a locking compression plate (LCP) as the augmentation plate (AP) over an intramedullary nail (IMN) for the treatment of femoral shaft nonunion by using finite element analysis. A finite element model of the femur was developed to analyze the maximum stress, stress distribution, displacement of fixation and nonunion site under increasing axial and torsional loads. Some differences in the stress distribution and stress values on the fixations were observed in the five fixation models. The MDC-LP with eight screw fixation showed the lowest variety of nonunion site displacement under the increasing axial and torsional loads. Models of the MDC-LP were more stable with regard to the bending and torsional forces. The short MDC-LP with eight screw insertion as an augmentation plate over intramedullary nail shows biomechanical advantages compared to the LCP. The MDC-LP may be an appropriate and effective treatment option for femoral shaft nonunion.

Augmentation plating leaving the nail in situ is an excellent option for treating femoral shaft nonunion after IM nailing: a multicentre study

PURPOSE

In recent years, plate augmentation over a retained intramedullary (IM) nail has been shown to be an effective option for managing femur fracture nonunions because it improves the biomechanical environment of the fracture site without causing additional biological damage. In the current study, we present outcome data from 22 consecutive patients treated with plate augmentation for femoral shaft nonunion leaving the nail in situ.

PATIENTS AND METHODS

Between 2015 and 2018, 22 consecutive patients with femoral shaft aseptic nonunion after IM nailing were treated with plate augmentation over a retained nail at four different institutions. Nonunion was categorized based on its anatomical location and was classified according to the Weber and Cech classification. Cortical defects greater than 1.0 cm, the type of nailing procedure, and the number of previous interventions were recorded. Patients were assessed clinically and radiographically to measure the healing of nonunion sites. The time to fracture union and complications were recorded. Descriptive statistics were used when applicable.

RESULTS

One site location was supra-isthmic, 12 were isthmic, and 9 were infra-isthmic. There were 10 cases of vascular nonunion and 12 cases of avascular nonunion. A cortical defect greater than 1.0 cm was observed in three patients. Antegrade nailing was performed in 11 patients, and retrograde nailing was performed in 11 patients. Reaming was performed in 12 patients. In eight patients, the fracture was openly reduced during the IM nailing index procedure. The average number of previous interventions before augmentation plating was 1.6 (1-4). Bone union was achieved in 19 patients after augmentation plating with an average follow-up of 23.5 months (12-51 months). Excellent and good clinical results were observed in all patients. There was no plate or screw breakage, and no patient developed infection.

CONCLUSION

Augmentation plating leaving the nail in situ is an excellent option for treating femoral shaft nonunion after IM nailing, with a high union rate and few complications. We believe the technique should gradually replace exchange nailing as the standard of care for the majority of femoral shaft nonunions that occur after IM nailing.

Treatment of atrophic nonunion via autogenous ilium grafting assisted by vertical fixation of double plates: A case series of patients

OBJECTIVE

To investigate the efficacy of the treatment of atrophic nonunion using structural autogenous ilium bone grafting in combination with vertical fixation of double plates.

METHODS

This retrospective study analysed the clinical data from consecutive patients with atrophic nonunion who underwent autogenous ilium grafting in combination with double-plate vertical fixation. The injury type and the bone affected by nonunion, the duration of nonunion and the outcomes following surgery were recorded for all patients.

RESULTS

The study enrolled 43 patients with atrophic nonunion of the upper and lower limbs: 17 patients with tibial nonunion, 21 with femoral nonunion, four with humeral nonunion and one with radial shaft nonunion. The mean duration of postoperative follow-up was 14.5 months (range, 8-28 months). A total of 43 of 43 patients (100%) achieved a healed nonunion fracture without the occurrence of complications such as infection, fracture of internal fixation or pain in the harvesting site. Comprehensive postoperative assessments of bone healing and function were observed to be good and/or excellent in all 43 patients.

CONCLUSION

Structural autogenous ilium grafting used in combination with double-plate vertical fixation can provide a stable structural environment for near optimal bone healing in patients with atrophic nonunion.

Effectiveness of exchange K-nail and augmented plating in aseptic femoral diaphyseal non-union

BACKGROUND

Femoral diaphyseal non-unions present difficult scenario to manage. There are multiple options but most of them still report varying incidences of failure. We combined the principles of augmented plating and exchange nailing and aim to study the effectiveness of this technique.

METHOD

A retrospective study at a tertiary trauma centre was conducted. Seventy patients (60 men, 10 women), average age 40.7±15.27 years (range 18-81 years) with diaphyseal femoral fracture non-unions treated between July 2010 and January 2015 were reviewed. The average interval between first and the last surgery was 18.07±17.65 months (range 4-96 months). Forty six patients had hypertrophic non-union and 24 patients had atrophic non-union. Twenty one patients had undergone a prior surgery for non-union, 13 dynamisation, 4 bone grafting, 1 augmented plating and 3 exchange nailing. Non-unions were treated with implant removal, freshening of bone edges and exchange K-nailing and augmented plating. Autologous bone grafting and raising of osteoperiosteal flaps was done in all cases. Outcome measures were radiographic evidence of fracture union at minimum three out of four cortices, knee range of motion as compared to opposite knee, and study of complications.

RESULTS

All patients demonstrated radiographic evidence of fracture union with an average time of 16.77±2.38 weeks (range 12-26 weeks). Mean knee range of motion of unaffected limb was 126±9.76° (range 90-140°) while in operated limb it was 121.1±11.36° (range 80-140°), p>0.01. Patients with hypertrophic non-unions, prior surgery for non-union and supra- or infra-isthmal non-unions had shorter union time. Two patients had superficial infection which was managed by superficial debridement and two patients had pain at proximal nail tip site which was managed by anti-inflammatory medication. None of the patients required additional surgery for implant removal.

CONCLUSION

Exchange K nailing with Bone graft and additional plating technique for non-union diaphyseal femur fracture achieved good union rates with minimal complication. In our series none of the patient required revision and the technique probably will further minimise the revision rates compared to current options for non-union femur.

Treatment of aseptic non-union after intramedullary nailing without removal of the nail

Failure of bone healing after intramedullary nailing of a diaphyseal long bone fracture is a severe complication that requires an effective management to ensure the best chances for successful bone-union and termination of a long period of incapacity and morbidity for the sufferers. Traditional procedures require removal of the existing nail and re-fixation with wider nail, plate or external fixation constructs. The concept that bone union can be obtained with the existing nail in situ is gaining popularity as its removal adds trauma and potential complications and prolongs the operating time. This article reviews all techniques that have been proposed for the management of aseptic diaphyseal long bone non-unions that stimulate bone healing without removing the existing nail.