Minimally invasive plate augmentation in the treatment of long-bone non-unions

Augmentation plate without bone graft in the management of distal tibial diaphyseal non-union

PURPOSE

The objective of this study was to assess the efficacy of augmentation plating with retaining of previous implant in situ in cases of non-united oligotrophic or atrophic aseptic distal tibial diaphyseal and metaphyseal fractures without bone grafting depending on the unified bone healing and non-union theory.

METHODS

Through the period between December 2019 and December 2022, twelve patients with distal third tibial non-unions who were fixed at time of fracture either by intramedullary interlocking nails (seven cases) or by minimally invasive plate osteosynthesis (five cases) were included. Non-union was diagnosed on basis of absence of any healing progression in three months period or absence of fracture healing after six months from index surgery. All patients had oligotrophic or atrophic non-union. Augmentation plating through an anterolateral approach was done on average of 7.25 months after initial surgery (6-9 months). Circumferential exposure of the fracture site and debridement of fibrous tissue were not necessary. No bone grafting was done as no cases had major bone defect.

RESULTS

All patients achieved complete radiological union with a mean time of 21.8 weeks (range 18-30 weeks) that mean full callus formation in all cortices. All patients were walking independently after three months (13weeks) from surgery and returned to work even in cases of absent complete radiological union. No cases had been complicated with wound healing problems (infection or dehiscence). One patient had incomplete ankle dorsiflexion (10°) due to tight calf muscles and one patient had paresthesia on the dorsum of the foot that was not improved at last follow up (one year after surgery).

CONCLUSION

Augmentation plating is a safe and effective option for management of distal tibial diaphyseal nonunion even in cases of oligotrophic or atrophic non-union.

Augmentative lag screws as a treatment for aseptic hypertrophic nonunion after internal fracture fixation

BACKGROUND

Hypertrophic nonunion after intramedullary (IM) nailing and plating is Uncommon and the treatment remained controversial. The aim of this study was to show the result of a simple augmentative lag screws technique for vital non-unions after internal fixation PATIENTS AND METHODS: We retrospectively reviewed the patients with nonunion after internal fixation between January 2016 to August 2022. Patients with unacceptable shortening or deformity were excluded as well as nonunion septic cases. All the patients were followed up for at least 6 months.

RESULTS

Seven patients achieved bony union in a median time of 12 weeks (IRQ 12-16). There was a failure case with persistent non-union and brokerage of the screws.

DISCUSSION

Various techniques have been described to treat non-union after intramedullary nailing or plating. The existing nail is frequently removed, and the non-union site is either re-reamed and re-nailed or fixed with a plate or external fixation devices or rechanged by a nail in the case of plates. In our study of non-union, augmentative lag screws were successfully applied to treat eight patients with aseptic nonunion, resulting in the healing of non-union in all cases except one.

CONCLUSION

Augmentative lag screws represent a simple technique for the management of aseptic hypertrophic nonunion after internal fixation with a significantly shorter operating time.

Augmentative Plating versus Exchange Intramedullary Nailing for the Treatment of Aseptic Non-Unions of the Femoral Shaft-A Biomechanical Study in a SawboneTM Model

BACKGROUND

Non-unions after intramedullary nailing of femoral shaft fractures are a significant problem. Treatment options such as augmenting with plates or exchange nailing have been proposed. The ideal treatment remains controversial.

METHODS

Augmentative plating using a 4.5 mm LCP or a 3.2 mm LCP leaving the nail in situ was tested biomechanically and compared to exchange intramedullary nailing in a Sawbone^TM model of a femoral shaft non-union.

RESULTS

The difference of fracture gap motion in axial testing was small. In rotational testing, the exchange nail allowed for the largest amount of motion. The 4.5 mm augmentative plate was the most stable construct in all loading conditions.

CONCLUSIONS

Augmentative plating using a 4.5 mm LCP plate while leaving the nail in situ is biomechanically superior to exchange intramedullary nailing. A small fragment 3.2 mm LCP is undersized and does not reduce fracture motion sufficiently in a femoral shaft non-union.

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.

Fracture nonunion in long bones: A literature review of risk factors and surgical management

Nonunion following a long bone fracture causes considerable morbidity when it occurs. Risk factors depend on specific fractures but there is a complex interplay of injury severity, comorbidities, patient medication and infection. The majority of nonunions occur after long bone fractures with the tibia, femur, forearm, humerus and clavicle predominating. Despite interest in the biological augmentation of fracture healing, the majority of nonunions can be effectively managed with conventional surgical techniques. In this review we present a review of risk factors for nonunion and the outcome following surgical management.

Treatment of Infected Pseudoarthrosis in a Subtrochanteric Fracture in a Patient with Osteopetrosis

Osteopetrosis is a disease of osteoclasts that results in failure of bone remodeling. Despite the sclerotic radiographic appearance of the thickened cortices and its material hardness, osteopetrotic bone is weak and prone to fracture by minor trauma. We report a case of a subtrochanteric fracture in an osteopetrotic patient, with further pseudoarthrosis and infection. Several surgical procedures were required, with further complications. The outcome of each procedure and the final result are also described.

Comparing Augmentative Plating and Exchange Nailing for the Treatment of Nonunion of Femoral Shaft Fracture after Intramedullary Nailing: A Meta-analysis

Objective

The aim of this meta‐analysis was to systematically evaluate the efficacy of augmentative plating (AP) and exchange nailing (EN) in the treatment of nonunion of femoral shaft fracture.

Methods

For the present meta‐analysis, PubMed, EMBASE, and the Cochrane Library were searched to identify relevant articles up to April 2019. Two investigators independently evaluated the quality of original publications following the guidelines proposed by the Cochrane Handbook. Data were extracted from the studies and analyzed using Review Manager 5.3.

Results

Five studies were included in this meta‐analysis, with a total of 506 patients. There were 232 patients in the AP group and 276 patients in the EN group. The AP group was associated with higher union rate (OR, 11.66; 95% CI, 4.31–31.50; P < 0.01), shorter union time (SMD, −1.10; 95% CI, −2.09 to −0.11; P = 0.03), shorter operation time (SMD, −0.55; 95% CI, −0.88 to −0.21; P < 0.01), less blood loss (SMD, −1.72; 95% CI, −3.33 to −0.11; P < 0.01), and fewer complications (OR, −0.11; 95% CI, −0.16 to −0.07; P < 0.01) than the EN group.

Conclusion

The results of the meta‐analysis showed that AP is found to be superior for nonunion of femoral shaft fractures in both intraoperatively (ie, shorter operation time and less blood loss) and postoperatively (ie, higher union rate, shorter union time, and lower complication rate). Overall, AP was superior to EN in the treatment of nonunion of femoral shaft fractures after intramedullary nailing (IMN).

[Research progress of augmentation plate for femoral shaft nonunion after intramedullary nail fixation]

OBJECTIVE

To review the history, current situation, and progress of augmentation plate (AP) for femoral shaft nonunion after intramedullary nail fixation.

METHODS

The results of the clinical studies about the AP in treatment of femoral shaft nonunion after intramedullary nail fixation in recent years were widely reviewed and analyzed.

RESULTS

The AP has been successfully applied to femoral shaft nonunion after intramedullary nail fixation since 1997. According to breakage of the previous nailing, AP is divided into two categories: AP with retaining the previous intramedullary nail and AP with exchanging intramedullary nail. AP is not only suitable for simple nonunion, but also for complex nonunion with severe deformity. Compared with exchanging intramedullary nail, lateral plate, and dual plate, AP has less surgical trauma, shorter healing time, higher healing rate, and faster returning to society. However, there are still some problems with the revision method, including difficulty in bicortical screw fixation, lack of anatomic plate suitable for femoral shaft nonunion, and lack of postoperative function and quality of life assessment.

CONCLUSION

Compared with other revision methods, AP could achieve higher fracture healing rate and better clinical prognosis for patients with femoral shaft nonunion. However, whether patients benefit from AP in terms of function and quality of life remain uncertain. Furthermore, high-quality randomized controlled clinical studies are needed to further confirm that AP are superior to the other revision fixations.