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Qiang H, Congming Z, Teng M, Kun Z, Chaofeng W. Plate augmentation and hybrid bone grafting are effective treatments for atrophic nonunion of the femur with the original intramedullary nail retained in situ. Sci Rep 2024; 14:7089. [PMID: 38528078 DOI: 10.1038/s41598-024-57809-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 03/21/2024] [Indexed: 03/27/2024] Open
Abstract
The purpose of this study is to evaluate the efficacy of plate augmentation and hybrid bone grafting for treating atrophic nonunion of the femur with original intramedullary nail retained in situ.In this study, 36 patients with atrophic nonunion of the femur who underwent surgery using the technique of plate augmentation and a hybrid bone grafting while retaining the original intramedullary nail in situ in Xi'an Honghui Hospital from January 2019 to December 2021 were enrolled. 28 patients who met the inclusion and exclusion criteria were ultimately included in the study. These 28 patients, consisting of 20 males and 8 females with a mean age of 38 years, were evaluated based on factors such as operation time, intraoperative blood loss, the average hospitalization days. Additionally, the results and function of these patients were evaluated by union time, Wu's scores of limb function and incidence of serious complications.All 28 patients achieved bone union at the 12 month follow-up, with an average follow-up time of 14.6 ± 4.2 months.The average operation time was 68.3 ± 11.2 min, and the average intraoperative blood loss was 140 ± 22.6 ml. Patients were hospitalized for an average of 5.8 ± 1.1 days. Full clinical and radiological bone union was achieved on average at 5.1 ± 1.9 months. The mean value of Wu's scores at the 12 month follow-up was significantly higher than before the operation. Limb function was excellent in 27 patients and good in one patient at the 12 month follow-up. However, five patients experienced the lower limb vein thrombosis, including one deep vein thrombosis and four lower limb intermuscular vein thromboses. One patient had a superficial infections of the surgical incision site, while three patients reported pain and numbness where their iliac bone graft was extracted at the 12 month follow-up. The technique of plate augmentation and hybrid bone grafting, combined with retaining the original intramedullary nail in situ has been shown to be a safe, effective, simply and standardizable practice for treating atrophic femoral nonunion with an intact original IMN fixation.
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Affiliation(s)
- Huang Qiang
- Department of Orthopaedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, No.76 Nanguo Road, Beilin District, Xi'an, 710054, Shaanxi, China
| | - Zhang Congming
- Department of Orthopaedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, No.76 Nanguo Road, Beilin District, Xi'an, 710054, Shaanxi, China
| | - Ma Teng
- Department of Orthopaedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, No.76 Nanguo Road, Beilin District, Xi'an, 710054, Shaanxi, China
| | - Zhang Kun
- Department of Orthopaedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, No.76 Nanguo Road, Beilin District, Xi'an, 710054, Shaanxi, China
| | - Wang Chaofeng
- Department of Orthopaedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, No.76 Nanguo Road, Beilin District, Xi'an, 710054, Shaanxi, China.
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Kook I, Oh CW, Shon OJ, Kim JW, Kim JW, Hwang KT, Park KC. Comparing outcomes of plate augmentation, nail exchange, and nail exchange with plate augmentation in the treatment of atrophic femoral shaft nonunion after intramedullary nailing: a multicenter retrospective study. Arch Orthop Trauma Surg 2024; 144:1259-1268. [PMID: 38372763 DOI: 10.1007/s00402-023-05183-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 12/11/2023] [Indexed: 02/20/2024]
Abstract
INTRODUCTION Intramedullary (IM) nailing is the treatment of choice for femoral shaft fractures, but nonunion rates have been reported to be as high as 12%. Surgical interventions for nonunion involve exchange nailing or plate augmentation. Recently, a combined treatment of exchange nailing and plate augmentation has demonstrated good results, but its comparative effectiveness remains unclear. This study aimed to compare the clinical and radiographic outcomes of three different surgical interventions for atrophic femoral shaft nonunion, and investigate the factors that affect bone healing after reoperation. MATERIALS AND METHODS A retrospective study was conducted at five university hospitals involving 149 patients with aseptic atrophic nonunion after IM nailing. These patients underwent reoperation with plate augmentation, exchange nailing, or combined treatment. Clinical and radiographic outcomes were assessed and compared according to reoperation procedure. Logistic regression analysis was performed to identify factors affecting persistent nonunion after reoperation. RESULTS Of the cohort, 57 patients underwent plate augmentation, 64 underwent exchange nailing, and 28 received combined treatment. There were no significant differences in patient demographics among the groups. Exchange nailing produced a significantly lower union rate than did the combined treatment (82.8% vs. 100%, p = 0.016), whereas no significant difference was observed in the union rate and time to the union between plate augmentation and the combined treatment. Combined treatment showed the longest operative time and the greatest transfusion requirements. The risk factors for persistent nonunion included age, absence of autogenous bone grafts, and use of an exchange nailing technique. CONCLUSIONS Exchange nailing as a treatment for atrophic femoral shaft nonunion after IM nailing resulted in a lower union rate. The efficacy of the combined treatment requires further study, and persistent nonunion may be influenced by age, bone grafting, and surgical techniques. A comprehensive approach targeting both biological environment and mechanical stability is crucial in the treatment of atrophic femoral shaft nonunion.
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Affiliation(s)
- Incheol Kook
- Department of Orthopaedic Surgery, Hanyang University Hospital, Seoul, South Korea
| | - Chang-Wug Oh
- Department of Orthopaedic Surgery, Kyungpook National University Hospital, Daegu, South Korea
| | - Oog-Jin Shon
- Department of Orthopaedic Surgery, Yeungnam University Medical Center, Daegu, South Korea
| | - Joon-Woo Kim
- Department of Orthopaedic Surgery, Kyungpook National University Hospital, Daegu, South Korea
| | - Ji-Wan Kim
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Kyu Tae Hwang
- Department of Orthopaedic Surgery, Hanyang University Hospital, Seoul, South Korea
| | - Ki-Chul Park
- Department of Orthopaedic Surgery, Hanyang University Guri Hospital, 153, Gyeongchun-ro, Guri, Gyeonggi-do, 11923, South Korea.
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El Sewify O, Abi-Rafeh J, Legler J, Karimi S, Baradaran A, Efanov JI. Clinical, Radiologic, and Functional Outcomes following Bone Grafting for Metacarpal Non-Unions: A Systematic Review. J Clin Med 2024; 13:1148. [PMID: 38398461 PMCID: PMC10889921 DOI: 10.3390/jcm13041148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/12/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024] Open
Abstract
Objectives: Metacarpal non-unions are complex hand defects that can lead to severe hand impairment. Treatment may require the use of artificial or autologous bone grafts. This systematic review aims to describe the outcomes of bone grafting following metacarpal non-union in an attempt to establish an optimal therapeutic protocol for this complication. Methods: A systematic review was conducted in adherence with PRISMA guidelines. Data collection and analysis were performed in duplicate and confirmed by a third investigator. Our primary outcomes focused on radiological time to bone fusion and rates of non-union. Additionally, functional outcomes and complications were analyzed as means of central tendency. Results: Eighteen studies were included in the systematic review, accounting for a total of 47 patients. The average follow-up time was 12.4 months. Fourteen studies analyzed radiological outcomes, with atrophic non-union representing the most common type. The time to bone fusion, assessed radiologically, following bone graft was an average of 6.9 months (n = 14), with a 100% rate of union in 42 patients. Regarding patient-reported pain improvement, 76% of patients experienced pain relief. Moreover, all patients reported a complete subjective return to baseline hand function. Adverse events, limited to hematoma and seroma, were seen in three patients, representing a complication rate of 11.8% in the examined population. Conclusions: Metacarpal non-union can be treated successfully via vascularized and non-vascularized bone grafting. Based on the available evidence, bone grafts demonstrate favorable union rates, post-operative pain reduction, hand function recovery, earlier bone fusion times, and minimal complications in the context of metacarpal non-union management.
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Affiliation(s)
- Omar El Sewify
- Faculty of Medicine, Laval University, Quebec, QC G1V0A6, Canada
| | - Jad Abi-Rafeh
- Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, McGill University, Montreal, QC H3G2M1, Canada
| | - Jack Legler
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H3G2M1, Canada
| | - Shayan Karimi
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H3G2M1, Canada
| | - Aslan Baradaran
- Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, McGill University, Montreal, QC H3G2M1, Canada
| | - Johnny I. Efanov
- Plastic and Reconstructive Surgery, Department of Surgery, Centre hospitalier de l’Universite de Montreal (CHUM), Montreal, QC H2X3E4, Canada
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Özdemir A, Odabaşı E, Eravsar E, Safalı S, Acar MA. Treatment of recalcitrant femur nonunion with pedicled corticoperiosteal medial femoral condyle flap. Sci Rep 2023; 13:20326. [PMID: 37990029 PMCID: PMC10663536 DOI: 10.1038/s41598-023-47432-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 11/14/2023] [Indexed: 11/23/2023] Open
Abstract
Periosteal or osteoperiosteal medial femoral condyle (MFC) flaps may be good options for atrophic nonunion. The aim of this study was to evaluate the effectiveness and safety of pedicled MFC flap in the treatment of recalcitrant femur nonunion without bone defect. Thirteen patients (11 male and 2 female), who suffered recalcitrant femur nonunion and were treated with pedicled osteoperiosteal MFC flap between January 2014 and April 2018, were included in this study. Patient files were reviewed retrospectively. Atrophic or recalcitrant 2/3 distal femoral nonunion were the indications for this clinical procedure. Demographics and operative data, flap size, visual analog scale (VAS) score, time to union, and complications were evaluated. A total of 13 patients underwent femur nonunion treatment with MFC flap after an average of 3.4 previous surgical procedures. The median age was 34 (Q1: 32.5, Q3:43) years old. The mean flap size was 4.3 × 6.4 cm, all nonunions healed in a median 5 months (Q1: 4.5, Q3: 6). There were an intraoperative knee medial collateral ligament injury in a patient, hematoma in a patient, and seroma in two patients. The median length of the follow-up was 40 months (Q1: 30, Q3: 47). There wasn't any additional complication in long-term follow-up. Functional outcomes were satisfactory. The median preoperative VAS score was 7 (Q1: 6, Q3: 9.5), decreasing to 1 (Q1: 0, Q3: 1) at the 6-month follow-up, and further reducing to 0 (Q1: 0, Q3: 1) at the 24-month follow-up. The nonunion period ranged from 6 to 18 months. The pedicled MFC flap is a good option for recalcitrant femur nonunion where larger vascularized flaps are not warranted. It is easy to harvest, does not require microvascular anastomosis, is effective, and offers minimal donor site morbidity.
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Affiliation(s)
- Ali Özdemir
- Department of Orthopaedics and Traumatology and Hand Surgery Konya, Selcuk University, Konya, Turkey.
| | - Egemen Odabaşı
- Department of Orthopaedics and Traumatology, Konya Beyhekim Training and Research Hospital, Konya, Turkey
| | - Ebubekir Eravsar
- Department of Orthopaedics and Traumatology, Konya City Hospital, Konya, Turkey
| | - Selim Safalı
- Department of Orthopaedics and Traumatology and Hand Surgery Konya, Selcuk University, Konya, Turkey
| | - Mehmet Ali Acar
- Department of Orthopaedics and Traumatology and Hand Surgery Konya, Selcuk University, Konya, Turkey
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Metwaly RG, Younis AS. Augmentation plate without bone graft in the management of distal tibial diaphyseal non-union. Injury 2023; 54:111057. [PMID: 37752033 DOI: 10.1016/j.injury.2023.111057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 09/17/2023] [Indexed: 09/28/2023]
Abstract
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.
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Concha JM, Osma JL, Fantín E, Concha C, Caicedo AJ. Augmentative lag screws as a treatment for aseptic hypertrophic nonunion after internal fracture fixation. Injury 2023; 54 Suppl 6:110805. [PMID: 38143134 DOI: 10.1016/j.injury.2023.05.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/05/2023] [Accepted: 05/11/2023] [Indexed: 12/26/2023]
Abstract
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.
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Affiliation(s)
- Juan Manuel Concha
- Departamento de Ciencias Quirúrgicas, Universidad del Cauca, Popayán Colombia; Hospital Susana López de Valencia, Popayán, Colombia.
| | - Jose Luis Osma
- Universidad Industrial de Santander, Bucaramanga, Colombia.
| | - Emilio Fantín
- IUCBC Instituto Universitario de Ciencias Biomédicas, Cordoba, Argentina.
| | - Carolina Concha
- Department Facultad de Medicina, Institution Pontificia, Universidad Javeriana, Bogotá, Colombia.
| | - Alvaro Jose Caicedo
- Department Facultad de Medicina, Institution Pontificia, Universidad Javeriana, Cali, Colombia.
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Walcher MG, Day RE, Gesslein M, Bail HJ, Kuster MS. Augmentative Plating versus Exchange Intramedullary Nailing for the Treatment of Aseptic Non-Unions of the Femoral Shaft-A Biomechanical Study in a Sawbone TM Model. J Pers Med 2023; 13:jpm13040650. [PMID: 37109036 PMCID: PMC10142865 DOI: 10.3390/jpm13040650] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/06/2023] [Accepted: 04/08/2023] [Indexed: 04/29/2023] Open
Abstract
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 SawboneTM 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.
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Affiliation(s)
- Matthias Georg Walcher
- OC Würzburg, Oeggstr. 3, 97070 Würzburg, Germany
- Department of Orthopedics and Traumatology, Paracelsus Medical University, Breslauer Straße 201, 90471 Nuremberg, Germany
| | - Robert E Day
- Health Technology Management Unit, Royal Perth Hospital, University of Western Australia, 197 Wellington Street, Perth 6000, Australia
| | - Markus Gesslein
- Department of Orthopedics and Traumatology, Paracelsus Medical University, Breslauer Straße 201, 90471 Nuremberg, Germany
| | - Hermann Josef Bail
- Department of Orthopedics and Traumatology, Paracelsus Medical University, Breslauer Straße 201, 90471 Nuremberg, Germany
| | - Markus S Kuster
- Perth Orthopaedic Sports Medicine Centre, The University of Western Australia, 31 Outram Street, Perth 6005, Australia
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Çimen O, Öner A, Köksal A, Dırvar F, Mert M, Kargın D. A comparison of exchange nailing and plate augmentation over a retained intramedullary nail in aseptic oligotrophic and atrophic femoral shaft pseudoarthrosis. Jt Dis Relat Surg 2023; 34:121-129. [PMID: 36700273 PMCID: PMC9903120 DOI: 10.52312/jdrs.2023.788] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 11/22/2022] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES This study aims to evaluate the success of plate augmentation over a retained intramedullary nail (IMN) against exchange nailing performed with autologous bone grafting in oligotrophic and atrophic pseudoarthrosis of the femoral shaft. PATIENTS AND METHODS Between May 2005 and October 2020, a total of 42 of 56 patients (28 males, 14 females; mean age: 47.3±17.2 years; range, 19 to 84 years) with aseptic atrophic or oligotrophic femoral nonunion were retrospectively analyzed. The patients, 20 were operated with plate over a retained IMN, and the rest (n=22) by exchange nailing. Data including demographic and clinical characteristics of the patients, treatment success, duration of surgery, blood loss during surgery, infection rates, length of hospital stay, time to bridging of the nonunion site, and time to obliteration of the fracture line (solid union) were recorded. RESULTS The mean follow-up was 23.8±20.4 (range, 12 to 96) months in the plate over an IMN group and 34.7±27.4 (range, 12 to 90) months in the exchange nailing group. At the final follow-up, solid union occurred in all of the patients in the plate augmentation over a retained IMN group, and 21 of 22 (95.45%) patients in the exchange nailing group. Blood loss during surgery was significantly less in the plate augmentation over IMN group (p=0.027). There was no statistically significant difference in the other variables between the two groups (p>0.05). CONCLUSION Our study results demonstrate that plate over a retained IMN is effective as exchange nailing in the surgical treatment of oligotrophic and atrophic pseudoarthrosis of the femoral shaft. However, it can be speculated that plate application over IMN is more advantageous in terms of blood loss during surgery.
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Affiliation(s)
- Osman Çimen
- Metin Sabancı Baltalimanı Kemik Hastalıkları Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, Araştırma Hastanesi, 34470 Sarıyer, İstanbul, Türkiye.
| | - Ali Öner
- Department of Orthopedics and Traumatology, Ministry of Health Metin Sabancı Baltalimanı Bone and Joint Diseases Training and Research Hospital, İstanbul, Türkiye
| | - Alper Köksal
- Department of Orthopedics and Traumatology, Ministry of Health Metin Sabancı Baltalimanı Bone and Joint Diseases Training and Research Hospital, İstanbul, Türkiye
| | - Ferdi Dırvar
- Department of Orthopedics and Traumatology, Ministry of Health Metin Sabancı Baltalimanı Bone and Joint Diseases Training and Research Hospital, İstanbul, Türkiye
| | - Muhammed Mert
- Department of Orthopedics and Traumatology, Ministry of Health Metin Sabancı Baltalimanı Bone and Joint Diseases Training and Research Hospital, İstanbul, Türkiye
| | - Deniz Kargın
- Department of Orthopedics and Traumatology, Ministry of Health Metin Sabancı Baltalimanı Bone and Joint Diseases Training and Research Hospital, İstanbul, Türkiye
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The role of an augmentative plating in the management of femoral subtrochanteric nonunion. Arch Orthop Trauma Surg 2023:10.1007/s00402-023-04767-4. [PMID: 36624207 DOI: 10.1007/s00402-023-04767-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 01/03/2023] [Indexed: 01/11/2023]
Abstract
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.
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Wu T, Zhang W, Chang Z, Zhu Z, Sun L, Tang P, Chen H. 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. Orthop Surg 2022; 15:169-178. [PMID: 36411511 PMCID: PMC9837237 DOI: 10.1111/os.13581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 10/05/2022] [Accepted: 10/11/2022] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Taoguang Wu
- Department of Orthopedic Surgerythe fourth medical center, Chinese PLA General hospitalBeijingChina
| | - Wei Zhang
- School of Sports EngineeringBeijing Sport UniversityBeijingChina
| | - Zuhao Chang
- Department of Orthopedic Surgerythe fourth medical center, Chinese PLA General hospitalBeijingChina
| | - Zhengguo Zhu
- Department of Orthopedic Surgerythe fourth medical center, Chinese PLA General hospitalBeijingChina
| | - Lijun Sun
- Department of Orthopedic Surgerythe fourth medical center, Chinese PLA General hospitalBeijingChina
| | - Peifu Tang
- Department of Orthopedic Surgerythe fourth medical center, Chinese PLA General hospitalBeijingChina
| | - Hua Chen
- Department of Orthopedic Surgerythe fourth medical center, Chinese PLA General hospitalBeijingChina
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Khalifa AA, Fadle AA, Elsherif ME, Said HG, Elsherif E, Said G, Refai O. Concomitant intramedullary nailing and plate augmentation as a single-stage procedure in treating complicated nonunited femoral shaft fractures. TRAUMA-ENGLAND 2022; 24:286-293. [DOI: 10.1177/14604086211007037] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Background and Purpose: Complicated femur fracture represents a major challenge for the orthopedic surgeon, with failed internal fixation, nonunion with broken intramedullary nail (IMN), and infected nonunion among the complications. Mechanical instability, as well as the poor biological environment, is considered as a concern when treating these cases. The purpose of this study was to evaluate concomitant IMN and plate augmentation as a single-stage procedure for the management of multiply operated nonunited femoral shaft fractures. Materials and Methods: Between January 2015 and May 2018, nine patients (eight men) with an average age of 40.8 years (range 25–70) diagnosed as nonunion femoral fractures after an average of four previous surgeries (range 2–6). All patients were available for follow-up with an average of 22 months (range 12–36). Results: The average time for fracture union was 6.7 months (range 3–12); five patients needed bone grafting to compensate for the bone defect encountered during the initial procedure, and two patients required secondary bone grafting after 6 months follow-up. Two patients presented with surgical site infection which was treated by antibiotics and daily dressing. The average leg length discrepancy at last follow-up was 1 cm (range 0.5–1.5). No patient had a metalwork failure or needed removal of the implants. Conclusion: In treating complicated multiply operated nonunited femoral shaft fractures, we believe that this technique can provide a robust mechanical foundation as well as an improved biological environment for such nonunited fractures to heal.
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Affiliation(s)
- Ahmed A Khalifa
- Orthopaedic Department, Assiut University Hospital, Assiut, Egypt
- Orthopaedic Department, Qena Faculty of Medicine and University Hospital, South Valley University, Qena, Egypt
| | - Amr A Fadle
- Orthopaedic Department, Assiut University Hospital, Assiut, Egypt
| | | | - Hatem G Said
- Orthopaedic Department, Assiut University Hospital, Assiut, Egypt
| | - Essam Elsherif
- Orthopaedic Department, Assiut University Hospital, Assiut, Egypt
| | - Galal Said
- Orthopaedic Department, Assiut University Hospital, Assiut, Egypt
| | - Omar Refai
- Orthopaedic Department, Assiut University Hospital, Assiut, Egypt
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Nonoperative Management of Closed Displaced Tibia Shaft Fractures in Patients Under 18 Years of Age: Low Failure Rate. J Pediatr Orthop 2022; 42:421-426. [PMID: 35793788 DOI: 10.1097/bpo.0000000000002206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Tibial shaft fractures are the third most common pediatric long bone fracture pattern. Historically, these fractures have been initially treated with closed reduction and casting (CRC). Recently, there has been an increasing trend toward surgical intervention as an initial treatment for these injuries. In an effort to better understand whether this trend is warranted, this study seeks to characterize the clinical and radiographic outcomes of a large number of children who underwent nonoperative treatment with CRC as their initial treatment for pediatric tibial shaft fractures at a single tertiary care center. METHODS Outcomes measured included final alignment, other procedures performed, length of time to full radiographic healing, and length of time in each method of immobilization before progressing to full weight-bearing status. Patients were separated by ages into the following cohorts during statistical analysis: 4 to 8 years, 9 to 12 years, and 13+ years. Differences between continuous variables were analyzed with independent-samples t tests. χ 2 tests were used to analyze differences in categorical variables. An α<0.05 was considered statistically significant. RESULTS A total of 137 patients met our inclusion criteria. The median age was 10.19 years (4.03 to 17.43). The average initial displacement among all age groups was 27.42% (±15.05%). After the initial intervention with CRC, all age groups demonstrated an average of <5 degrees of residual angulation and <20% of residual displacement. Complete radiographic healing was seen in 127 (92.7%) patients by 3 months. Loss of reduction requiring additional clinical intervention was seen in 30 (21.9%) patients with only 5% requiring surgical intervention, whereas malunion was seen in a total of 16 (11.7%) patients at the final visit. There were no cases of compartment syndrome or deep wound infection. Male and initial angulation were the only factors predictive of loss of reduction. CONCLUSION Initial intervention with CRC is a safe and effective treatment for the majority of children in all age groups presenting with tibial shaft fractures demonstrating minimal angulation and displacement with surgical intervention being required in only 5% of patients. Further studies are warranted to elucidate the characteristics of patients who may benefit most from initial surgical intervention. LEVEL OF EVIDENCE Level III-retrospective study.
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Fukase N, Duke VR, Lin MC, Stake IK, Huard M, Huard J, Marmor MT, Maharbiz MM, Ehrhart NP, Bahney CS, Herfat ST. Wireless Measurements Using Electrical Impedance Spectroscopy to Monitor Fracture Healing. SENSORS (BASEL, SWITZERLAND) 2022; 22:s22166233. [PMID: 36016004 PMCID: PMC9412277 DOI: 10.3390/s22166233] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 08/12/2022] [Accepted: 08/16/2022] [Indexed: 05/05/2023]
Abstract
There is an unmet need for improved, clinically relevant methods to longitudinally quantify bone healing during fracture care. Here we develop a smart bone plate to wirelessly monitor healing utilizing electrical impedance spectroscopy (EIS) to provide real-time data on tissue composition within the fracture callus. To validate our technology, we created a 1-mm rabbit tibial defect and fixed the bone with a standard veterinary plate modified with a custom-designed housing that included two impedance sensors capable of wireless transmission. Impedance magnitude and phase measurements were transmitted every 48 h for up to 10 weeks. Bone healing was assessed by X-ray, µCT, and histology. Our results indicated the sensors successfully incorporated into the fracture callus and did not impede repair. Electrical impedance, resistance, and reactance increased steadily from weeks 3 to 7-corresponding to the transition from hematoma to cartilage to bone within the fracture gap-then plateaued as the bone began to consolidate. These three electrical readings significantly correlated with traditional measurements of bone healing and successfully distinguished between union and not-healed fractures, with the strongest relationship found with impedance magnitude. These results suggest that our EIS smart bone plate can provide continuous and highly sensitive quantitative tissue measurements throughout the course of fracture healing to better guide personalized clinical care.
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Affiliation(s)
- Naomasa Fukase
- Linda and Mitch Hart Center for Regenerative & Personalized Medicine at the Steadman Philippon Research Institute, Vail, CO 81657, USA
| | - Victoria R. Duke
- Linda and Mitch Hart Center for Regenerative & Personalized Medicine at the Steadman Philippon Research Institute, Vail, CO 81657, USA
| | - Monica C. Lin
- UCSF Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
- Department of Bioengineering, University of California, Berkeley, CA 94720, USA
| | - Ingrid K. Stake
- Linda and Mitch Hart Center for Regenerative & Personalized Medicine at the Steadman Philippon Research Institute, Vail, CO 81657, USA
- Department of Orthopaedic Surgery, Ostfold Hospital Trust, 1714 Graalum, Norway
| | - Matthieu Huard
- Linda and Mitch Hart Center for Regenerative & Personalized Medicine at the Steadman Philippon Research Institute, Vail, CO 81657, USA
| | - Johnny Huard
- Linda and Mitch Hart Center for Regenerative & Personalized Medicine at the Steadman Philippon Research Institute, Vail, CO 81657, USA
| | - Meir T. Marmor
- UCSF Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Michel M. Maharbiz
- Department of Bioengineering, University of California, Berkeley, CA 94720, USA
- Department of Electrical Engineering and Computer Sciences, University of California, Berkeley, CA 94720, USA
- Chan Zuckerberg Biohub, San Francisco, CA 94158, USA
| | - Nicole P. Ehrhart
- Department of Clinical Sciences, Flint Animal Cancer Center, College of Veterinary Medicine, Colorado State University, Fort Collins, CO 80523, USA
| | - Chelsea S. Bahney
- Linda and Mitch Hart Center for Regenerative & Personalized Medicine at the Steadman Philippon Research Institute, Vail, CO 81657, USA
- UCSF Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
- Correspondence: (C.S.B.); (S.T.H.)
| | - Safa T. Herfat
- UCSF Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
- Correspondence: (C.S.B.); (S.T.H.)
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Mohamed MA, Noaman HH, Soroor YO, Elsayed M. Plate augmentation and bone grafting in treatment of femoral shaft nonunion initially fixed by intramedullary nail. SICOT J 2022; 8:19. [PMID: 35608412 PMCID: PMC9128607 DOI: 10.1051/sicotj/2022020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 05/01/2022] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
| | - Hassan H. Noaman
- Orthopaedic Department, Sohag University Hospital 82524 Sohag Egypt
| | - Yasser O. Soroor
- Orthopaedic Department, Sohag University Hospital 82524 Sohag Egypt
| | - Moustafa Elsayed
- Orthopaedic Department, Sohag University Hospital 82524 Sohag Egypt
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Hu S, Ge Q, Xia C, Ying J, Ruan H, Shi Z, Xu R, Xu T, Lv S, Fang L, Zou Z, Xu H, Xiao L, Tong P, Wang PE, Jin H. Bushenhuoxue formula accelerates fracture healing via upregulation of TGF-β/Smad2 signaling in mesenchymal progenitor cells. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2020; 76:153256. [PMID: 32534359 DOI: 10.1016/j.phymed.2020.153256] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 05/10/2020] [Accepted: 05/29/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Although Bushenhuoxue formula (BSHXF) is successfully used as a non-traumatic therapy in treating bone fracture in China, the molecular mechanism underlying its effects remains poorly understood. PURPOSE The present study aims to explore the therapeutic effects of BSHXF on fracture healing in mice and the underlying mechanism. METHODS We performed unilateral open transverse tibial fracture procedure in C57BL/6 mice which were treated with or without BSHXF. Fracture callus tissues were collected and analyzed by X-ray, micro-CT, biomechanical testing, histopathology and quantitative gene expression analysis. Tibial fracture procedure was also performed in Cre-negative and Gli1-CreER; Tgfbr2flox/flox conditional knockout (KO) mice (Tgfbr2Gli1ER) to determine if BSHXF enhances fracture healing in a TGF-β-dependent manner. In addition, scratch-wound assay and cell counting kit-8 (CCK-8) assay were used to evaluate the effect of BSHXF on cell migration and cell proliferation in C3H10T1/2 mesenchymal stem cells, respectively. RESULTS BSHXF promoted endochondral ossification and enhanced bone strength in wild-type (WT) or Cre- control mice. In contrast, BSHXF failed to promote bone fracture healing in Tgfbr2Gli1ER conditional KO mice. In the mice receiving BSHXF treatment, TGF-β/Smad2 signaling was significantly activated. Moreover, BSHXF enhanced cell migration and cell proliferation in C3H10T1/2 cells, which was strongly attenuated by the small molecule inhibitor SB525334 against TGF-β type I receptor. CONCLUSION These data demonstrated that BSHXF promotes fracture healing by activating TGF-β/Smad2 signaling. BSHXF may be used as a type of alternative medicine for the treatment of bone fracture healing.
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Affiliation(s)
- Songfeng Hu
- Institute of Orthopaedics and Traumatology, the First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang, China; The First College of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang, China; Department of Orthopaedics and Traumatology, Shaoxing Hospital of Traditional Chinese Medicine, Shaoxing 312000, Zhejiang, China
| | - Qinwen Ge
- Institute of Orthopaedics and Traumatology, the First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang, China; The First College of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang, China
| | - Chenjie Xia
- Institute of Orthopaedics and Traumatology, the First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang, China; The First College of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang, China
| | - Jun Ying
- Institute of Orthopaedics and Traumatology, the First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang, China; The First College of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang, China
| | - Hongfeng Ruan
- Institute of Orthopaedics and Traumatology, the First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang, China
| | - Zhenyu Shi
- Institute of Orthopaedics and Traumatology, the First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang, China; The First College of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang, China
| | - Rui Xu
- Institute of Orthopaedics and Traumatology, the First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang, China; The First College of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang, China
| | - Taotao Xu
- Institute of Orthopaedics and Traumatology, the First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang, China; Department of Orthopaedic Surgery, the First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang, China
| | - Shuaijie Lv
- Institute of Orthopaedics and Traumatology, the First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang, China; The First College of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang, China; Department of Orthopaedic Surgery, the First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang, China
| | - Liang Fang
- Institute of Orthopaedics and Traumatology, the First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang, China; The First College of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang, China
| | - Zhen Zou
- Institute of Orthopaedics and Traumatology, the First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang, China; The First College of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang, China
| | - Huihui Xu
- Institute of Orthopaedics and Traumatology, the First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang, China; The First College of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang, China
| | - Luwei Xiao
- Institute of Orthopaedics and Traumatology, the First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang, China
| | - Peijian Tong
- Institute of Orthopaedics and Traumatology, the First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang, China; Department of Orthopaedic Surgery, the First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang, China
| | - Ping-Er Wang
- Institute of Orthopaedics and Traumatology, the First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang, China.
| | - Hongting Jin
- Institute of Orthopaedics and Traumatology, the First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang, China.
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Szelerski Ł, Żarek S, Górski R, Mochocki K, Górski R, Morasiewicz P, Małdyk P. Surgical treatment outcomes of the Ilizarov and internal osteosynthesis methods in posttraumatic pseudarthrosis of the tibia-a retrospective comparative analysis. J Orthop Surg Res 2020; 15:179. [PMID: 32430044 PMCID: PMC7236123 DOI: 10.1186/s13018-020-01697-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 05/05/2020] [Indexed: 11/10/2022] Open
Abstract
Introduction This study compared surgical treatment outcomes of the Ilizarov and internal osteosynthesis methods in posttraumatic pseudarthrosis of the tibia. Material and methods In a retrospective comparative study, 75 patients were treated with the Ilizarov technique for aseptic posttraumatic pseudarthrosis of the tibia in the period 2000–2016. We compared them with the 51 patients from the control group, treated for tibial bone union disturbances using internal osteosynthesis methods, i.e., internal-fixation plates and intramedullary nails. The study groups were compared in terms of the rates of union, time to union, and the baseline-to-postoperative difference in lower leg deformity. Results Union rate in the Ilizarov group was 100% and the control group was 51.92% (p < 0.001). The median time to union suggests that patients from the Ilizarov group needed a shorter time to achieve bone union (203.00 days vs. 271.00 days) (p = 0.091). The effect size in the Ilizarov group was larger both in terms of reducing both limb deformity and shortening (it is worth noting, however, that the Ilizarov treatment was used in patients with higher baseline values of both these parameters). We observed no significant difference in terms of time to union between the group of patients with at least one risk factor for disturbance in fracture healing and the group with no risk factors. The following risk factors were considered: diabetes mellitus, corticosteroid therapy, smoking, alcohol dependence, and advanced lower-extremity vascular disease (p = 0.827). Discussion Our study demonstrated a high effectiveness of the Ilizarov method in the treatment of aseptic posttraumatic pseudarthroses of the tibia. The Ilizarov method seems to be worth considering in all cases where either the patient or the nature of injury is associated with additional risk factors and whenever there is a need for leg deformity correction or leg elongation.
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Affiliation(s)
- Łukasz Szelerski
- Department of Orthopedics and Musculoskeletal Traumatology, Medical University of Warsaw, Lindleya 4, 02-005, Warsaw, Poland.
| | - Sławomir Żarek
- Department of Orthopedics and Musculoskeletal Traumatology, Medical University of Warsaw, Lindleya 4, 02-005, Warsaw, Poland
| | - Radosław Górski
- Department of Orthopedics and Musculoskeletal Traumatology, Medical University of Warsaw, Lindleya 4, 02-005, Warsaw, Poland
| | - Karol Mochocki
- Department of Orthopedics and Musculoskeletal Traumatology, Medical University of Warsaw, Lindleya 4, 02-005, Warsaw, Poland
| | - Ryszard Górski
- Department of Orthopedics and Musculoskeletal Traumatology, Medical University of Warsaw, Lindleya 4, 02-005, Warsaw, Poland
| | - Piotr Morasiewicz
- Department and Clinic of Orthopaedic and Traumatologic Surgery, Wroclaw Medical University, Borowska 213, 50-556, Wroclaw, Poland
| | - Paweł Małdyk
- Department of Orthopedics and Musculoskeletal Traumatology, Medical University of Warsaw, Lindleya 4, 02-005, Warsaw, Poland
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``Sandwich technique" with dual strut allograft in surgical treatment of femoral nonunion. Injury 2020; 51:1057-1061. [PMID: 32107008 DOI: 10.1016/j.injury.2020.02.090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 02/12/2020] [Accepted: 02/17/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The treatment of femoral nonunion is challenging for both the surgeon and the patient. Strut allografts increase the bone stock, enhance fracture healing and increase stability by acting as a biological plate. In this study, we aimed to report the results of the sandwich technique with two-strut allograft in the treatment of oligotrophic or atrophic femoral nonunions. METHODS Medical records of the patients who were treated due to femoral nonunion in a single center were retrospectively reviewed. Twenty-one patients (10 males, 11 females) with a mean age of 49 (range: 21 to 79) years were included in the study. The left side was affected in 11 patients, whereas the right side was affected in ten. The patients had 11 femoral shaft fractures, seven proximal femoral fractures and three distal femoral fractures. The mean time from the previous operation to the nonunion surgery was 9.6 (range: 6 to 22) months. RESULTS Union was achieved in all patients after a mean period of 6.2 (range: 4 to 10) months. The mean follow-up time was 46.8 (range: 12 to 86) months. One patient had superficial surgical site infection in the autologous graft donor site. CONCLUSION The sandwich technique with two-strut allograft provides good results in the treatment of femoral nonunion. The technique can be used on any type of nonunion, at any segment of the femur and can be combined with different fixation techniques.
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Immediate weightbearing after intramedullary fixation of extra-articular distal tibial fractures reduces the nonunion rate compared with traditional weight-bearing protocol: A cohort study. Int J Surg 2020; 76:132-135. [DOI: 10.1016/j.ijsu.2020.02.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 02/02/2020] [Accepted: 02/28/2020] [Indexed: 01/01/2023]
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Uliana CS, Bidolegui F, Kojima K, Giordano V. Augmentation plating leaving the nail in situ is an excellent option for treating femoral shaft nonunion after IM nailing: a multicentre study. Eur J Trauma Emerg Surg 2020; 47:1895-1901. [PMID: 32107562 DOI: 10.1007/s00068-020-01333-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 02/15/2020] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
| | | | - Kodi Kojima
- Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Vincenzo Giordano
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro, Hospital Municipal Miguel Couto, Rua Mário Ribeiro 117, Rio de Janeiro, RJ, 22430-160, Brazil. .,Clínica São Vicente, Rede D'or São Luiz, Rio de Janeiro, Brazil.
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Zhang W, Zhang Z, Chen H. [Research progress of augmentation plate for femoral shaft nonunion after intramedullary nail fixation]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 33:1467-1473. [PMID: 31823542 PMCID: PMC8355795 DOI: 10.7507/1002-1892.201903073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 09/23/2019] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Wei Zhang
- Department of Orthopedics, General Hospital of Chinese PLA, Beijing, 100853, P.R.China
| | - Zhuo Zhang
- Department of Orthopedics, General Hospital of Chinese PLA, Beijing, 100853, P.R.China
| | - Hua Chen
- Department of Orthopedics, General Hospital of Chinese PLA, Beijing, 100853,
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Abstract
Diaphyseal tibia fractures in the pediatric population have dynamic treatment strategies that depend on injury pattern, mechanism, patient skeletal maturity and size. Treatment strategies include closed reduction and cast immobilization, flexible nails, uniplanar or multiplanar external fixation or plate osteosynthesis. Accepted parameters for sagittal and coronal alignment vary based on age and potential for remodeling, although all fractures should have minimal rotational malalignment and less than 1 cm of shortening. Stable union generally occurs in 3 to 4 weeks for the common toddler's fracture and 6 to 8 weeks in other fracture patterns. Complications such as compartment syndrome are possible with both open and closed injuries, and nonunions, although rare, are more common in patients treated with external fixation or flexible nailing. Overall, treatment should be predicated on a full evaluation of the patient, fracture, local soft tissues, and any concomitant injuries.
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Zhang W, Zhang Z, Li J, Zhang L, Chen H, Tang P. Clinical outcomes of femoral shaft non-union: dual plating versus exchange nailing with augmentation plating. J Orthop Surg Res 2018; 13:295. [PMID: 30458810 PMCID: PMC6247613 DOI: 10.1186/s13018-018-1002-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 11/12/2018] [Indexed: 12/04/2022] Open
Abstract
Background By comparing clinical outcomes between dual plating (DP) and exchange nailing with augmentation plating (EN/AP), we aimed to provide better treatment strategies for femoral shaft non-union. Methods We retrospectively reviewed 30 patients with aseptic femoral shaft non-union at our level 1 trauma center between January 2014 and January 2017. All patients underwent a one-stage, definitive revision procedure, including DP for 16 patients and EN/AP for 14 patients. Perioperative surgical trauma, fracture healing, complications, and the time to return to work were evaluated. Results Twenty-nine patients achieved fracture healing. In the EN/AP group, the fracture healing rate was 100%, the healing time was 5.7 ± 1.7 months, and the time of return to work was 8.2 ± 2.9 months. In the DP group, the fracture healing rate was 94%, the healing time was 8.4 ± 4.1 months, and the time of return to work was 18.4 ± 10.3 months. In terms of fracture healing and return to work, the patients in the EN/AP group required less time than those in the DP group, and the differences were statistically significant (p = 0.024 and p < 0.01 respectively). Except for the length of the incision, the two groups showed no statistically significant differences in operative time, postoperative deformity, and complications. Conclusions Both EN/AP and DP are important surgical options for femoral shaft non-union. Compared to DP, EN/AP resulted in a shorter incision, faster fracture healing, and a shorter time to return to work. Trial registration ChiCTR-ORC-17014062
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Affiliation(s)
- Wei Zhang
- Department of Orthopedic Surgery, General Hospital of Chinese People's Liberation Army, 28 Fu-Xing Road, Beijing, 100853, People's Republic of China
| | - Zhuo Zhang
- Department of Orthopedic Surgery, General Hospital of Chinese People's Liberation Army, 28 Fu-Xing Road, Beijing, 100853, People's Republic of China
| | - Jiantao Li
- Department of Orthopedic Surgery, General Hospital of Chinese People's Liberation Army, 28 Fu-Xing Road, Beijing, 100853, People's Republic of China
| | - Licheng Zhang
- Department of Orthopedic Surgery, General Hospital of Chinese People's Liberation Army, 28 Fu-Xing Road, Beijing, 100853, People's Republic of China
| | - Hua Chen
- Department of Orthopedic Surgery, General Hospital of Chinese People's Liberation Army, 28 Fu-Xing Road, Beijing, 100853, People's Republic of China
| | - Peifu Tang
- Department of Orthopedic Surgery, General Hospital of Chinese People's Liberation Army, 28 Fu-Xing Road, Beijing, 100853, People's Republic of China.
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Zhang W, Chen H, Tang P. [Recent advances in treatment of aseptic femoral shaft nonunion]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2018; 32:519-525. [PMID: 29806336 PMCID: PMC8430007 DOI: 10.7507/1002-1892.201712089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 03/30/2018] [Indexed: 11/03/2022]
Abstract
Objective To review the recent advances in treatment of aseptic femoral shaft nonunion. Methods The clinical studies about the treatments of aseptic femoral shaft nonunion in recent years were widely reviewed and analyzed. Results There are several surgical methods for aseptic femoral shaft nonunion. Due to uncertain clinical outcome, dynamization of nail should be carefully selected. The exchange nailing is suitable for the hypertrophic nonunion of the isthmal femoral shaft fracture. The exchange lateral plating is suitable for nonunion with obvious malformation. However, wave plate or dual plate should be chosen when the bone nonuinon is combined with the medial defect. The augmentation plating improves the success rate of nailing for femoral shaft nonunion, but it should be carefully selected for patients with obvious deformity or bone defect. Ilizarov technique is suitable for various bone nonunion, especially with complicated or large segmental bone defects. Induced membrane technique is also an important method for the treatment of bone nonunion with large bone defects. The clinical efficacy of the blocking screw remains to be supported by further evidence. Biological stimulants are mainly used for atrophic nonunion, and the clinical efficacy of them alone are still controversial. Conclusion Due to lack of comparative studies between different surgical methods, the orthopedist should choose the appropriate treatment according to the individual situations of the patient and the types of bone nonunion.
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Affiliation(s)
- Wei Zhang
- Department of Orthopedics, General Hospital of Chinese PLA, Beijing, 100853, P.R.China
| | - Hua Chen
- Department of Orthopedics, General Hospital of Chinese PLA, Beijing, 100853, P.R.China
| | - Peifu Tang
- Department of Orthopedics, General Hospital of Chinese PLA, Beijing, 100853,
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