A report of a novel technique: The comprehensive fibular autograft with double metal locking plate fixation (cFALP) for refractory post-operative diaphyseal femur fracture non-union treatment

Ternary regulation mechanism of Rhizoma drynariae total flavonoids on induced membrane formation and bone remodeling in Masquelet technique

CONTEXT

Rhizoma drynariae total flavonoids (RDTF) are used to treat fractures. CD31hiEmcnhi vessels induced by PDGF-BB secreted by osteoclast precursors, together with osteoblasts and osteoclasts, constitute the ternary regulatory mechanism of bone tissue reconstruction.

OBJECTIVE

This study aimed to determine whether RDTF can promote bone tissue remodeling and induce membrane growth in the rat Masquelet model and to explore its molecular mechanism based on the ternary regulation theory.

METHODS

Thirty-six SD rats were randomized to three groups: blank, induced membrane, and RDTF treatment (n = 12/group). The gross morphological characteristics of the new bone tissue were observed after 6 weeks. Sixty SD rats were also randomized to five groups: blank, induction membrane, low-dose RDTF, medium-dose RDTF, and high-dose RDTF (n = 12/group). After 4 weeks, immunohistochemistry and western blot were used to detect the expression of membrane tissue-related proteins. The mRNA expression of key factors of ternary regulation was analyzed by qRT-PCR.

RESULTS

RDTF positively affected angiogenesis and bone tissue reconstruction in the bone defect area. RDTF could upregulate the expression of key factors (PDGF-BB, CD31, and endomucin), VEGF, and HMGB1 mRNA and proteins in the ternary regulation pathway.

DISCUSSION AND CONCLUSION

Although the expected CD31hiEmcnhi vessels in the induction membrane were not observed, this study confirmed that RDTF could promote the secretion of angiogenic factors in the induced membrane. The specific mechanisms still need to be further studied.

A novel bone graft technique combined with plating for aseptic recalcitrant long bone nonunion

Background

To evaluate the outcomes and efficacy of a new technique of autogenous iliac crest bone grafting combined with locking compression plate (LCP) vertical fixation for aseptic recalcitrant long bone nonunion.

Methods

From July 2010 to September 2020, 36 aseptic recalcitrant long bone nonunions were treated with a bone-forming channel technique and internal LCP fixation. All the patients had received one or more failed treatments. The injury mechanism, nonunion type and duration, and prior treatments were recorded pre-operation. The routine treatment process included nonunion area exposure, previous implant removal, sclerotic bone debridement, LCP fixation, bone-forming channel creation, and iliac bone grafting, and a second LCP fixation when required. At follow-up, X-ray images were obtained to assess bone healing and implant failure. Visual analog scale (VAS), fracture site stability, limb function, activity, muscle strength, limb length, and complications were recorded.

Results

A total of 34 patients (24 males and 10 females) were finally enrolled, with a mean age of 49.8 ± 12.3 years. At a mean follow-up of 35.6 ± 22.0 months, 32 patients displayed bone union, with a healing rate of 94.1% and mean union time of 6.8 ± 2.4 months. The VAS score was 0.7 ± 1 at the final follow-up. The functional results showed that 19 patients were excellent, 11 patients were good, 2 patients were poor, and 2 patients did not heal.

Conclusion

Bone-forming channel technique combined with LCP vertical fixation is an excellent option to treat recalcitrant long bone nonunion.

Level of evidence

Therapeutic Level IV.

Finite element analysis of different medial fixation strategies in double-plate osteosynthesis for AO type 33-C2 fractures

OBJECTIVES

In this study, we evaluated the biomechanical characteristics of different locations of medial fixation strategies in double-plate osteosynthesis for fixing AO/ASIF type 33-C2 fractures by means of finite element analysis.

METHODS

We used 3-matic software and UG-NX software to construct AO/ASIF type 33-C2 fractures and lateral less invasive stabilization system (LISS) plates, medial plates (MPs), and medial support pads (MSPs), respectively. Then, the LISS, MP and MSP were assembled into the fracture model separately to form three fixation models: MSP+LISS, anteromedial plate (AMP+LISS), and MP+LISS. In the next procedure, we performed finite element analysis using ANSYS software after meshing the elements of the models in HyperMesh 11.0 software. Loading conditions including lateral-medial four-point bending, anterior-posterior four-point bending, axial loading, and torsional loading were applied to evaluate the biomechanical advantages among the three fixation types. We observed the peak Von Mises Stress (VMS) value, maximum displacement, bending angle in the coronal plane of the fracture, and torsional angle of the fracture to assess the degree of plate deformation and fixation stability.

RESULTS

Our results showed that in both lateral-medial four-point bending and anterior-posterior four-point bending, the calculations of MP+LISS were marginally better than those of AMP+LISS. However, with the action of axial loading and torsional loading, the deformation of MP+LISS was distinctly smaller than that of AMP+LISS, and the fixation stability of MP+LISS was also prominently better. Under lateral-medial four-point bending, the VMS on the lateral plate of MSP+LISS (59.977 MPa) was approximately half of the two double-plate models. Under anterior and posterior four-point bending, the 38.209 MPa peak VMS of MSP+LISS was still superior to the other two double-plate models. Under torsional loading, the peak VMS (347.75 MPa), the maximum torsional angle of the femoral head (7.852 °), and the torsional angle of fracture (0.036 °) of MSP+LISS preceded those of the other two models. However, under axial loading, the peak VMS (76.376 MPa) and the maximum displacement (3.1798 mm) of MSP+LISS were slightly higher than those of MP+LISS.

CONCLUSION

The MSP+LISS model showed better biomechanical performance than the double-plate models, which might be an effective solution for the treatment of comminuted distal femur fractures.

A 3D-printed, personalized, biomechanics-specific beta-tricalcium phosphate bioceramic rod system: personalized treatment strategy for patients with femoral shaft non-union based on finite element analysis

Background

Although double-plate fixation (DP), i.e., fixation with a combination of a main lateral plate (LP) and a support medial plate (MP), is a relatively mature method for treating femoral shaft non-union with bone defect causes complications. The purpose of this study was to evaluate LP fixation with a 3D-printed, personalized, biomechanics-specific β-TCP bioceramic rod system (LP + 3DpbsBRS) as an alternative with less collateral damage.

Methods

Structure-specific finite element modelling was used to simulate femoral shaft non-union with bone defects and treatment with an LP only as the blank control. Then, the peak von Mises stress (VMS), the VMS distribution, and the plate displacement were determined to compare the effectiveness of LP + CBG (cancellous bone grafting), DP + CBG, and LP + 3DpbsBRS under 850 N of axial force.

Results

Our results indicated that the peak VMS was 260.2 MPa (LP + 3DpbsBRS), 249.6 MPa (MP in DP + CBG), 249.3 MPa (LP in DP + CBG), and 502.4 MPa (LP + CBG). The bending angle of the plate was 1.2° versus 1.0° versus 1.1° versus 2.3° (LP + 3DpbsBRS versus MP in DP + CBG versus LP in DP + CBG versus LP + CBG).

Conclusion

The 3DpbsBRS in the LP + 3DpbsBRS group could replace the MP in the DP + CBG group by providing similar medial mechanical support. Furthermore, avoiding the use of an MP provides better protection of the soft tissue and vasculature.

J-bone graft with double locking plate: a symphony of mechanics and biology for atrophic distal femoral non-union with bone defect

Objective

Atrophic distal femur non-union with bone defect (ADFNBD) has been a worldwide challenge to treat due to the associated biological and mechanical problems. The purpose of this study was to introduce a new solution involving the use of a J-shaped iliac crest bone graft (J-bone) combined with double-plate (DP) in the treatment of femoral non-union.

Methods

Clinically, 18 patients with ADFNBD were included in this retrospective study and were treated with a combination of J-bone graft and DP. The average follow-up time was 22.1 ± 5.5 months (range, 14 to 34 months). The imaging information and knee joint activity tests and scores were used to evaluate the time to weight-bearing, the time to non-union healing, and the knee joint mobility. A finite element analysis was used to evaluate the differences between the following: (1) the use of a lateral locking plate (LLP) only group (LLP-only), (2) a DP only group (DP-only), (3) a DP with a J-bone group (DP+J-bone), and (4) an LLP with a J-bone group (LLP+J-bone) in the treatment of ADFNBD. A finite element analysis ABAQUS 6.14 (Dassault systems, USA) was used to simulate the von Mises stress distribution and model displacement of the plate during standing and normal walking.

Result

All patients with non-union and bone defect in the distal femur achieved bone healing at an average of 22.1 ± 5.5 months (range, 14 to 34 months) postoperatively. The average healing time was 6.72 ± 2.80 months. The knee Lysholm score was significantly improved compared with that before surgery. Under both 750 N and 1800 N axial stress, the maximum stress with the DP+J-bone structure was less than that of the LLP+J-bone and DP-only structures, and the maximum stress of J-bone in the DP+J-bone was significantly less than that of the LLP+J-bone+on structure. The fracture displacement of the DP+J-bone structure was also smaller than that of the LLP+J-bone and DP-only structures.

Conclusion

J-bone combined with DP resulted in less maximum stress and less displacement than did a J-bone combined with an LLP or a DP-only graft for the treatment of ADFNBD. This procedure was associated with less surgical trauma, early rehabilitation exercise after surgery, a high bone healing rate, and a satisfactory rate of functional recovery. Therefore, a combination of J-bone and DP is an effective and important choice for the treatment of ADFNBD.

Design and Analysis of Customized Fixation Plate for Femoral Shaft

BACKGROUND

In the recent years, several techniques have been used to treat femur diaphyseal fracture. Among all the traditional fixation techniques, unstable fixation remains the biggest challenge for orthopedists. Researchers have recommended new approaches to deal with diaphyseal femur fracture. However, solely few had been successful in getting some better results. In the present work, a methodology comprising of design and finite-element analysis of a counter fit customized fixation plate has been suggested to provide a stable fixation.

MATERIALS AND METHODS

In the present work, reverse engineering (RE) approach has been invoked to create a 3D model of a fresh fractured femur diaphysis bone using the computed tomography (CT) scan data available in digital imaging and communications in medicine (DICOM) format. To provide stable fixation, a counter fit customized fixation plate at medial side has been designed and simulated under static physiological loading conditions for three different biocompatible materials, viz., titanium alloy (Ti6Al4V), stainless steel (SS-316L), and cobalt-chromium-molybdenum alloy (Co-Cr-Mo).

RESULTS

Static stress distribution and deformation analysis of the clinical setup have been performed for the aforementioned materials. It has been observed that the stresses and deformation developed in all the materials are quite low. It implies that customized fixation plates will provide stable fixation resulting in improved fracture union.

CONCLUSION

The proposed work will assist the medical practitioners regarding the design and analysis of customized implants. This will reduce the post surgical failures and residual pain due to non-union fractured region.

Does Supplemental Intramedullary Grafting Increase Stability of Plated Proximal Humerus Fractures?

OBJECTIVES

To investigate the biomechanical competence of locked plating augmented with supplemental intramedullary graft in comparison to conventional locked plate fixation in proximal humerus fractures (PHF).

METHODS

Complex four-part PHFs were set in 30 artificial humeri assigned to 3 study groups (n = 10 in each group). Group 1 was characterized by loss of medial support, group 2 by simulated severe cancellous bone damage due to osteoporosis, and group 3 by combination of the 2 features. After locked plating, each specimen underwent nondestructive quasi-static mechanical testing in 25 degrees lateral angulation under axial loading between 150 and 400 N in 50-N increments, accompanied by consecutive anteroposterior x-ray imaging. Subsequently, an additional 3D-printed intramedullary graft was inserted into each specimen and all tests were repeated.

RESULTS

Grafting resulted in significantly higher axial stiffness compared with no graft in groups 1 and 3 (P < 0.01) but not in group 2 (P = 0.12). Nongrafted specimens represented significantly higher stiffness in group 2 compared with groups 1 and 3 (P < 0.01), whereas no significant differences were detected among the 3 groups in the grafted state (P > 0.99). Varus deformation decreased significantly in each group after graft insertion (P ≤ 0.04). Nongrafted specimens in group 2 showed significantly lower varus deformation compared with groups 1 and 3 (P ≤ 0.04). No significant differences were registered among the 3 groups after grafting (P ≥ 0.65).

CONCLUSIONS

From a biomechanical perspective, locked plating augmented with intramedullary graft has the potential to increase significantly the stability against varus collapse in unstable PHFs when compared with conventional locked plate fixation.

Masquelet technique to treat a septic nonunion after nailing of a femoral open fracture

Septic nonunion is one of the most serious complications after an open fracture because both the infection and the bone defect need to be dealt with. Treatment is always protracted and expensive, and the result is uncertain. In the 1980s, Masquelet first described the technique of the induced membrane and autologous bone grafting to manage critical size bone defects. In septic nonunions, the described approach, characterised by two different surgical steps, allows a radical approach to manage the infection, and gives a significant biological stimulus to bone healing. In this case, we present a 35-year-old male patient with an open grade II femoral shaft fracture (AO / OTA 32C3). The patient was initially treated with an intramedullary nail and the resulting septic nonunion was subsequently managed with the induced membrane technique and a double-plate osteosynthesis to protect the biological chamber.

Is augmented LISS plating biomechanically advantageous over conventional LISS plating in unstable osteoporotic distal femoral fractures?

Treatment of complex osteoporotic distal femur fractures with the Less Invasive Stabilization System (LISS) has been associated with high complication rates. The aim of this study was to investigate the biomechanical competence of two different techniques of augmented versus conventional LISS plating. Unstable distal femoral fracture AO/OTA 33-A3 was created via osteotomies in artificial femora simulating osteoporotic bone. Three study groups, consisting of 10 specimens each, were created for fixation with either LISS plate, LISS plate with additional polylactide intramedullary graft, or LISS plate plus medial locking plate (double plating). All specimens were non-destructively tested under axial (20-150 N) and torsional (0-4 Nm) quasi-static loading. Each bone-implant construct was tested with two different working length (WL) configurations (long and short) of the LISS plate. Relative movements between the most medial superior and inferior osteotomy aspects were investigated via three-dimensional motion tracking analysis. Double plating revealed significantly smaller longitudinal and shear displacement than the other two techniques (p ≤ 0.001). In addition, LISS plus graft fixation was with significantly less longitudinal displacement in comparison to conventional LISS plating (p < 0.001). Long WL resulted in significantly higher longitudinal and shear displacement compared to short WL for LISS and LISS plus graft (p ≤ 0.032), but not for double plating (p > 0.999). In conclusion, intramedullary grafting resulted in significantly increased fracture stability under axial loading in comparison to conventional LISS plating. Although it was not efficient enough to provide comparable stability to double plating, intramedullary grafting may be considered as a useful biological alternative to the latter in a surgeon's armamentarium. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2604-2611, 2018.

Finite Element Analysis of Different Double-Plate Angles in the Treatment of the Femoral Shaft Nonunion with No Cortical Support opposite the Primary Lateral Plate

Objectives

We evaluated the biomechanical outcome of different plate fixation strategies (the single plate construct, 45° double-plate construct, 90° double-plate construct, 135° double-plate construct, and 180° double-plate construct) used for the fixation of the femoral shaft nonunion with no cortical support opposite the primary lateral plate. This may help surgeons choose the optimal therapy to the femoral shaft nonunion.

Methods

The femoral shaft nonunion with no medial support and the models of lateral plate and medial plate was constructed in 3-matic software and UG-NX software, respectively. We then assembled the single plate and different double plates to the fracture model separately to form the fixation models. After meshing the models' elements, we used the ABAQUS software to perform the finite element analysis. Values of the von Mises Stress (VMS) distribution of the implant, peak VMS, and model displacement and deformation were used to capture the mechanical factors in this study.

Results

Our results indicated that the peak von Mises Stress (VMS) of the lateral plate was concentrated in middle surface of the lateral plate near the fragment of each group. The peak VMS was 5201.0 MPa (the single-plate construct), 3490.0 MPa (45° double-plate construct), 1754.0 MPa (90° double-plate construct), 1123.0 MPa (135° double-plate construct), and 816.5 MPa (180° double-plate construct). The additional short plate dispersed some stress leading to the decrease in the peak VMS of the lateral plate. As angle formed by the double plates increased, the dispersed function of the additional plate was becoming obvious. The bending angles of the lateral plate were 18° versus 12° versus 3° versus 2° versus 1° (the single-plate construct versus 45° double-plate construct versus 90° double-plate construct versus 135° double-plate construct versus 180° double-plate construct).

Conclusions

Our study indicated that increasing the angle between the plates in a double-plate construct improves the stability of the construct over a single lateral plate when there is no cortical support opposite to the lateral plate. The strongest fixation occurred when the angle between the two plates was greater than ninety degrees.

Interlocking Intramedullary Nailing Versus Locked Dual-Plating Fixation for Femoral Shaft Fractures in Patients with Multiple Injuries: A Retrospective Comparative Study

PURPOSE

Intramedullary nailing (IMN) is a popular method in the management of femoral shaft fractures (FSFs). However, whether the association of IMN with pulmonary fat emboli can compromise the pulmonary and nervous systems is debatable. The purpose of this study is to compare IMN with the locked dual plating (LDP) method by assessing the clinical outcomes of FSF patients with head or chest injury.

METHOD

A total of 126 FSF patients were included in this study between January 2010 and July 2016 and divided into LDP and IMN groups. Patient demographic characteristics, operative time, blood loss, Harris Hip Score, Lysholm Knee Score, radiological outcomes, and systemic complications were collected and compared between the two treatment groups. Patients were followed up for at least 12 months.

RESULTS

The LDP group performed better than IMN in terms of operative time, estimated blood loss amount, and malunion rate. Differences in function scores, fracture union rate, overall pulmonary complication rate, and in-hospital mortality between the two groups were not significant. Average radiographic union time was significantly longer in the LDP group (36.3 weeks) than in the IMN group (32.5 weeks). One case of fixation failure occurred postoperatively in the LDP group, whereas one case of fracture nonunion took place in the IMN group.

CONCLUSION

Our findings suggest that dual-plating fixation is a promising method for FSFs with multiple injuries. However, the retrospective nature of this study necessitates high-quality trials to be performed to assess the clinical efficiency of dual plating.

Recalcitrant aseptic atrophic non-union of the shaft of the humerus after failure of surgical treatment: management by excision of non-union, bone grafting and stabilization by LCP in different modes

Non-union of the humeral shaft is infrequently noticed after surgical fixation. Sixty eight patients whose osteosynthesis of humeral shaft had failed leading to non-union were identified over a duration of 10 years from (January 2006 to December 2015). Clinical and radiographical follow-up was available for 64 patients (4 patients were lost for follow-up), with a mean age of 58 years (range 25-78 years). All patients had aseptic atrophic non-union of either: proximal shaft (n=12), mid shaft (n=38), and lower shaft (n=14). All these patients had failure of primary fixation, with a minimum duration from 36 to 110 weeks. Non-unions were operated by excision of non-union, autogenous bone grafting and osteosynthesis by locking compression plating. Adequate fixation of non-union with bone grafting was achieved in all patients. All non-unions healed well at an average of 16 weeks (range 6-36 weeks). The mean length of follow-up was 120 weeks (range 60-250 weeks). The mean range of movements following healing of non-union was forward flexion of 140°, external rotation and internal rotation of 30° at shoulder and average fixed flexion deformity of 10° and flexion of 130° at elbow. Two patients had postoperative radial nerve palsy because of neuropraxia, which recovered in eight weeks. Three patient developed superficial infections at the iliac crest, which settled with antibiotics, dressings in 3 weeks time and two patients had some discomfort over the fibular graft harvest site. In all patients complete clinical and radiological union was achieved with satisfactory outcome in terms of relief of symptoms and functional improvement in the range of movements. The main points in surgical treatment were complete excision of non-union, correction of deformity, use of plenty of corticocancellous graft, furthermore the use of intramedullary fibula and osteosynthesis by long locking compression plating in different modes of fixation provided good to excellent results and clinical outcome.

Augmentation plating in management of failed femoral nailing

INTRODUCTION

Non-union following interlocking nailing is a troubling complication in treatment of shaft femur fractures. There is no clear consensus on the treatment of this problem. This research was undertaken to study the role of augmentation plating combined with exchange nailing in such cases.

PATIENTS AND METHODS

A prospective clinical study was undertaken from January 2010 to December 2015. Patients with aseptic femoral shaft non-union, with or without implant failure following intramedullary nailing were included in the study. Augmentation plating combined with Exchange Nailing with a 4.5mm LCP was done.

RESULTS

Fifteen patients (nine male and six female) with an average age of 43.7 years (range 18-67 years) were treated. Average timing from the first surgery was 7.3 months. Complete clinical and radiological union was achieved in all cases in a mean duration of 5.2 months. Average duration of follow up was 12.6 months. All the patients retained the preoperative hip and knee range of motion till the last follow up.

CONCLUSION

Augmentation plating combined with exchange nailing in non-unions following intramedullary nailing of femur shaft fractures is a reasonably good and effective procedure with a very high success rate.

Management of resistant distal femur non-unions with allograft strut and autografts combined with osteosynthesis in a series of 22 patients

INTRODUCTION AND PURPOSE

Challenges to the surgeon in managing cases of resistant non-union of the distal femur include poor bone stock, disuse osteopenia and joint contractures. Procedures varying from simple bone grafting to megaprosthesis revision have been described. We successfully managed such cases using our technique of combining cortical allograft struts to augment the defect in the femoral condyle coupled with autogenous iliac crest bone grafting and locking plate osteosynthesis.

MATERIALS AND METHODS

Between April 2012 and May 2014, 22 patients who presented with resistant nonunions of the distal femur following initial surgery were managed using this technique. Cortical allograft struts were taken from the tissue bank of our institution. All patients were followed up post operatively and their time to union was noted. Functional outcome was calculated using LEFS (Lower extremity functional score). The average follow up of all our patients was 24 months.

RESULTS

All patients went on to achieve complete bony union. The average union time was 6.2 months (5 to 8 months). One patient who was a diabetic had superficial infection post operatively which was treated successfully with IV antibiotics. Average knee flexion was 110 degrees (80 to 130 degrees). The mean LEFS score was 72 (59 to 79).

CONCLUSION

Combing a locking plate fixation with the bone grafting technique of using an allograft strut to support the metaphyseal medial bone defect and autografts gives a good union and a good functional outcome in the management of resistant non-unions of the distal femur by enhancing the biology and providing a good structural support to the distal femur.

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.

Double-plating fixation of comminuted femoral shaft fractures with concomitant thoracic trauma

Objective This study was performed to evaluate the clinical outcomes in adult polytraumatized patients with thoracic injury and femoral shaft fractures treated with double-plating fixation. Methods From November 2010 to October 2014, 15 polytraumatized patients with femoral shaft fractures were enrolled in this retrospective study. Radiographic findings and functional outcomes were assessed at 1, 3, 6, and 12 months postoperatively. Results Fourteen (93%) of the 15 femoral shaft fractures achieved bony union, with a mean time to union of 9.2 months. The mean Nonarthritic Hip Score and Lysholm Knee Score was 89.4 and 87.2 points, respectively. The range of motion of the knee joint was comparable between the injured and uninjured legs (116° and 121°, respectively). Conclusions Our findings suggest that lower limb function returns to normal after orthogonal double-plating fixation, which is an alternative technique to intramedullary nailing for femoral diaphyseal fractures in patients with severe chest injury.