Treatment of femoral shaft aseptic nonunions: comparison between closed and open bone-grafting techniques

Surgical strategy of the treatment of atypical femoral fractures

The atypical femoral fracture (AFF) has been attracting significant attention because of its increasing incidence; additionally, its treatment is challenging from biological and mechanical aspects. Although surgery is often required to manage complete AFFs, clear guidelines for the surgical treatment of AFFs are currently sparse. We reviewed and described the surgical treatment of AFFs and the surveillance of the contralateral femur. For complete AFFs, cephalomedullary intramedullary nailing spanning the entire length of the femur can be used. Various surgical techniques to overcome the femoral bowing common in AFFs include a lateral entry point, external rotation of the nail, and the use of a nail with a small radius of curvature, or a contralateral nail. In the case of a narrow medullary canal, severe femoral bowing, or pre-existing implants, plate fixation may be considered as an alternative. For incomplete AFFs, prophylactic fixation depends on several risk factors, such as a subtrochanteric location, presence of a radiolucent line, functional pain, and condition of the contralateral femur; the same surgical principles as those in complete AFFs can be applied. Finally, once AFF is diagnosed, clinicians should recognize the increased risk of contralateral AFFs, and close surveillance of the contralateral femur is recommended.

Intramedullary bone pedestal formation contributing to femoral shaft fracture nonunion: A case report and review of the literature

BACKGROUND

Femoral shaft fracture is a commonly encountered orthopedic injury that can be treated operatively with a low overall delayed/nonunion rate. In the case of delayed union after antegrade or retrograde intramedullary nail fixation, fracture dynamization is often attempted first. Nonunion after dynamization has been shown to occur due to infection and other aseptic etiologies. We present a unique case of diaphyseal femoral shaft fracture nonunion after dynamization due to intramedullary cortical bone pedestal formation at the distal tip of the nail.

CASE SUMMARY

A 37-year-old male experienced a high-energy trauma to his left thigh after coming down hard during a motocross jump. Evaluation was consistent with an isolated, closed, left mid-shaft femur fracture. He was initially managed with reamed antegrade intramedullary nail fixation but had continued thigh pain. Radiographs at four months demonstrated no evidence of fracture union and failure of the distal locking screw, and dynamization by distal locking screw removal was performed. The patient continued to have pain eight months after the initial procedure and 4 mo after dynamization with serial radiographs continuing to demonstrate no evidence of fracture healing. The decision was made to proceed with exchange nailing for aseptic fracture nonunion. During the exchange procedure, an obstruction was encountered at the distal tip of the failed nail and was confirmed on magnified fluoroscopy to be a pedestal of cortical bone in the canal. The obstruction required further distal reaming. A longer and larger diameter exchange nail was placed without difficulty and without a distal locking screw to allow for dynamization at the fracture site. Post-operative radiographs showed proper fracture and hardware alignment. There was subsequently radiographic evidence of callus formation at one year with subsequent fracture consolidation and resolution of thigh pain at eighteen months.

CONCLUSION

The risk of fracture nonunion caused by intramedullary bone pedestal formation can be mitigated with the use of maximum length and diameter nails and close follow up.

Is open bone graft always necessary when treating aseptic subtrochanteric nonunion with a reamed intramedullary nail?

Background

This study aimed to compare the radiological results between closed nailing without bone graft (BG) and open nailing with BG for aseptic subtrochanteric nonunion and to determine when an open procedure with BG should be considered.

Methods

In this retrospective study, we investigated patients who underwent surgical intervention for subtrochanteric nonunion between January 2008 and March 2018 in two institutions. Patients with infection, large bone defect, pathologic fracture, open fracture, previous surgery using plate, and follow-up of less than 1 year were excluded. We compared the demographic details and radiological results between patients who underwent the open procedure with BG (BG group) and the closed procedure without BG (non-BG group) as a historical control, and risk factors for the failure of revision surgery were evaluated.

Results

Thirty-seven patients met the criteria and were divided into the following two groups: the BG group (n=19) who underwent open nailing with BG and the non-BG group (n=18) who underwent closed reamed nailing without BG. The mean degrees of correction of varus and flexion deformity were significantly different (p=0.001, respectively), 6.2° and 2.9° in the BG group and 4.1° and 0.6° in the non-BG group, respectively. Bony union was observed in 17 cases (89.5%) in an average of 7.4 months in the BG group and in 16 cases (88.9%) in 7.6 months in the non-BG group, with no significant differences. The factors that were significantly associated with failure of revision were atypical fracture, two or more previous surgeries, and varus and sagittal anterior angulation.

Conclusions

The radiological results of closed reamed nailing without BG for subtrochanteric nonunion were satisfactory. In the effort of percutaneous realignment, gap reduction, and intramedullary reaming, the radiological results of closed nailing without BG were not different from those of open nailing with BG; therefore, closed procedure without BG may be an acceptable option in appropriately selected patients.

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

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

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

Objective

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

Methods

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

Results

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

Conclusion

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

Augmentative antirotational plating provided a significantly higher union rate than exchanging reamed nailing in treatment for femoral shaft aseptic atrophic nonunion - retrospective cohort study

Background

Atrophic nonunion of femoral shaft fracture after intramedullary (IM) nailing is uncommon. The treatment for femoral shaft aseptic atrophic non-union remained controversial. The aim of this study was to compare the surgical results between exchanging reamed nailing (ERN) and augmentative antirotational plating (AAP) for femoral shaft aseptic atrophic nonunion.

Methods

We retrospectively reviewed the patients with femoral shaft nonunion between the year of 2014 and 2015. The patients with nonunion after plate osteosynthesis, septic nonunion, hypertrophic nonunion, additional surgery during revision surgery were excluded. All the patients were followed up at least 12 months.

Results

Overall, the union rate after revision surgery was 70.8%. The union rate was significantly higher in the AAP group than in the ERN group. Operating time was also significantly shorter in the AAP group. Regarding the location of nonunion, the union rate was comparable between groups for isthmic nonunions. However, for non-isthmic nonunions, the union rate was significantly higher and operating time was significantly shorter in the AAP group.

Conclusion

AAP showed an overall higher union rate for management of femoral shaft aseptic atrophic nonunion compared with ERN. Especially for non-isthmic femoral shaft atrophic nonunions, AAP provided a significantly higher union rate and significantly shorter operating time.

Uniting the un-united: should established non-unions of femoral shaft fractures initially treated with IM nails be treated by plate augmentation instead of exchange IM nailing? A systematic review

The majority of femoral fractures are surgically treated with intramedullary nails. Non-union rate is low but challenging and costly if it occurs. There have been encouraging results from the use of augmentative plating as a treatment for non-union of femoral fractures. We performed a systematic review of the literature to compare union rates, time to union and complications between exchange nailing and augmentative plating as a primary procedure following a diagnosis of femoral non-union following initial nailing. We found a total of 21 papers, which found the mean union rate of augmentative plating to be 99.8% compared to 74% (P = 2.05⁻¹²) found for exchange nailing. Times to union were comparable at 5.9 months for augmentative plating and 6.3 months for exchange nailing (P = 0.68916), and complication rate was 4% for augmentative plating compared to 20% for exchange nailing. From the evidence available, plate augmentation provides a more reliable union rate if used as the first operative intervention on a non-union of a femoral fracture compared to exchange nailing.

Level of Evidence IV Systematic review of therapeutic studies.

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.

Systematic review of dynamization vs exchange nailing for delayed/non-union femoral fractures

AIM

To analyze the literature on efficacy of dynamamization vs exchange nailing in treatment of delayed and non-union femur fractures.

METHODS

Ultimately, 31 peer-reviewed articles with 644 exchanged nailing patients and 131 dynamization patients were identified and analyzed. The following key words were inputted in different combinations in order to search the field of publications in its entirety: “non-union”, “delayed union”, “ununited”, “femur fracture”, “femoral fracture”, “exchange nailing”, “dynaiz(s)ation”, “secondary nailing”, “dynamic”, “static”, and “nail revision”. The initial search yielded over 150 results, and was refined based on the inclusion criteria: Only studies reporting on humans, non-unions and delayed unions, and the usage of exchange nailing and/or dynamization as a secondary treatment after failed IM nailing. The resulting 66 articles were obtained through online journal access. The results were filtered further based on the exclusion criteria: No articles that failed to report overall union rates, differentiate between success rates of their reported techniques, or articles that analyzed less than 5 patients.

RESULTS

Exchange nailing lead to fracture union in 84.785% of patients compared to the 66.412% of dynamization with statistically comparable durations until union (5.193 ± 2.310 mo and 4.769 ± 1.986 mo respectively). Dynamically locking exchange nails resulted in an average union time of 5.208 ± 2.475 mo compared to 5.149 ± 2.366 mo (P = 0.8682) in statically locked exchange nails. The overall union rate of the two procedures, statically and dynamically locked exchange nailing yielded union rates of 84.259% and 82.381% respectively. Therefore, there was no significant difference between the different locking methods of exchange nailing for union rate or time to union at a significance value of P < 0.05. The analysis showed exchange nailing to be the more successful choice in the treatment of femoral non-unions in respect to its higher success rate (491/567 EN, 24/57 dynam, P < 0.0001). However, there was no significant difference between the success rates of the two procedures for delayed union fractures (25/27 EN, 45/55 dynam, P = 0.3299). Nevertheless, dynamization was more efficient in the treatment of delayed unions (at rates comparable to exchange nailing) than in the treatment of non-unions.

CONCLUSION

In conclusion, after examination of factors, dynamization is recommended treatment of delayed femur fractures, while exchange nailing is the treatment of choice for non-unions.

Femoral non-union with malalignment: reconstruction and biological stimulation with the chipping technique

INTRODUCTION

The purpose of this study was to investigate the effectiveness of the chipping technique for the treatment of femoral non-unions associated with malalignment.

PATIENTS AND METHODS

A total of 21 femoral non-unions were managed with the chipping procedure and re-fixation. 15 of them had malalignment (angular or rotational deformity or limb length discrepancy). The deformities were simultaneously corrected by a combination of chipping and temporal external fixator. The median age of patients were 41 years (range, 19-73 years). The median time from injury or the final surgery to the initial chipping procedure was 24 months (range: 9-240 months). Femoral non-unions were classified as hypertrophic in 9, oligotrophic in 5 and atrophic in 7. Clinical and radiological assessment was performed.

RESULTS

All femoral non-unions radiographically healed with one (19 cases) or two (2 cases) chipping procedures without bone grafting. Pre-existing angular deformity was corrected from 14° to 2°, external rotation 27° to 0°, and limb length discrepancy 16-7 mm. There were no major complications, although swelling of thigh and anemia was common after surgery.

CONCLUSION

Chipping the non-union site was associated with a favorable outcome. It biologically enhances fracture healing and should be considered as a treatment option for femoral non-unions with malalignment.

Radiological assessment of the PRF/BMSC efficacy in the treatment of aseptic nonunions: A retrospective study on 90 subjects

BACKGROUND

Nonunion is a major orthopaedic concern because of treatment difficulty, high costs and devastating effects on the patients' life quality. Therefore, there is interest in the use of bone substitutes and cell-based strategies to augment fracture repair. We aimed to verify if Platelet Rich Fibrin (PRF) added with bone marrow stromal cells (BMSC) was able to improve the reparative process in the aseptic nonunion, and to establish whether it was worthwhile with atrophic nonunion. The primary outcome was radiological union. As secondary endpoint, the healing time was assessed, and the radiological consolidation grade at each follow-up.

METHODS

We identified 113 subjects with tibia or femur nonunion and retrospectively created two groups. Group A was constituted by 56 subjects who underwent the standard procedure, i.e. Judet decortication with/out internal fixation devices, and opposite cortical homoplastic stick. In 57 patients, the standard procedure was modified by adding PRF and BMSC carried by homologous lyophilised bone chips (group B). The same surgeon performed all the operations. To our knowledge, no data are reported in the literature about such application. Since a "gold standard" for healing quantification does not exist, a new scoring radiological system was applied, at 1.5, 3, 6, 12 and 24 months after treatment.

RESULTS

At the final 24-month follow-up, the radiological union percentage was 94,12 in group B and 95,12% in group A. A decreased healing time was demonstrated in the presence of PRF/BMSC in comparison with the standard procedure. When we compared the radiological scores at each follow-up, we found that the PRF/BMSC combination significantly improved the consolidation grade at 1.5-, 3- and 6-month follow-up in femurs and at 1.5-month follow-up in tibiae. Furthermore, an improved consolidation grade was demonstrated in the atrophic subjects treated with adjuvants compared to atrophic patients treated with the standard procedure at 1.5-month follow-up.

CONCLUSIONS

This study supports the concept that the use of PRF/BMSC, during the standard procedure, is effective in shortening nonunion healing time. It could allow an early mobilization of patients, minimizing suffering, and could be an effective tool to reduce the health-care costs resulting from this issue.

LEVEL OF EVIDENCE

Therapeutic level III.

Exchange nailing for femoral diaphyseal fracture non-unions: Risk factors for failure

The aim of this study was to identify risk factors for failure of exchange nailing for femoral diaphyseal fracture non-unions. The study cohort comprised 40 patients with femoral diaphyseal non-unions treated by exchange nailing, of which six were open injuries. The median time to exchange nailing from primary fixation was 8.4 months. The main outcome measures were union, number of secondary fixation procedures required to achieve union and time to union. Multiple causes for non-union were found in 16 (40%) cases, with infection present in 12 (30.0%) patients. Further surgical procedures were required in nine (22.5%) cases, one of whom (2.5%) required the use of another fixation modality to achieve union. Union was ultimately achieved with exchange nailing in 34/37 (91.9%) patients. The median time to union after the exchange nailing was 9.4 months. Cigarette smoking and infection were risk factors for failure of exchange nailing. Multivariate analysis found infection to be the strongest predictor of exchange failure (p<0.05). Exchange nailing is an effective treatment for aseptic femoral diaphyseal fracture non-union. However, 50% of patients undergoing exchange nailing in the presence of infection required at least one further procedure. It is important to counsel patients of this so that they can plan for it and do not consider that the first exchange operation has failed.

Management of a humeral shaft non-union after a Gustilo III C fracture

A 25-year-old man was admitted to our Department with an open humeral shaft fracture (Gustilo III C); two large wounds were noticed with ulnar artery and median nerve completely dissected. Initial primary treatment included irrigation, debridement and fracture stabilization with a monolateral external fixator followed by vascular and nerve repair and wound closure. At 6 months follow up the patient was able to use his arm without any painful stimuli and a CT scan showed the presence of postero-medial callus formation. Consequently, the external fixator was removed and the patient was discharged to physiotherapy. After 7 months, the patient presented with severe pain and functional impairment with no history of trauma. X rays showed recent re-fracture on a background of oligotrophic nonunion. Revision surgery included debridement of the non-union bone edges, reaming of the medullary canal and insertion of a humeral nail. Six months later osseous healing was noted with complete restoration of shoulder and elbow movement and partial recovery of the median nerve.

Management of hypertrophic nonunion with failure of internal fixation by distraction osteogenesis

INTRODUCTION AND AIM

Distraction osteogenesis is employed in the management of hypertrophic nonunion associated with angular deformity and shortening. This study was aimed at evaluating the outcomes of Ilizarov apparatus without bone graft or open osteotomy in cases of hypertrophic nonunion not responding to treatment with internal fixation.

METHODS

We retrospectively reviewed the data of 12 patients (mean age, 46.5 years) treated for hypertrophic nonunion at our institution. All patients had two-plane angular deformities (mean, 19° and 23.5° in sagittal and frontal plane, respectively) and limb-length discrepancy (mean, 3.8cm). The Ilizarov apparatus was used to simultaneously treat the nonunion, malalignment, and limb-length discrepancy.

RESULTS

The mean follow-up duration after the removal of the apparatus was 42 months. In all cases, bone union had been achieved within an average of 8 months after a single surgery, without the need for any additional procedure. Additionally, none of the patients had recurrence of limb-length discrepancy or malalignment during the follow-up period. Complications of superficial pin-tract infections and mild Achilles tendon contracture were observed, but they resolved over time. All patients were satisfied with the outcome of the surgery.

CONCLUSION

Patients with hypertrophic nonunion associated with internal fixation failure can be treated by using the Ilizarov apparatus, thereby eliminating the need for bone graft or open osteotomy. Distraction osteogenesis appears to be effective as a minimally invasive percutaneous procedure in the treatment of hypertrophic nonunion with deformity and shortening.

Treatment of the femoral shaft nonunion with double plate fixation and bone grafting: A case series of 14 patients

INTRODUCTION

The management of femoral shaft nonunion still remains a challenge in orthopaedic surgery. It represents a serious postoperative problem for the patient, associated with plate breakage and loosening, bone defect, shortening deformity and infection. A double plate fixation combined with bone grafting may become a promising therapeutic strategy for the treatment of patients with femoral shaft nonunion. In this study, our goal was to evaluate the clinical outcome of a novel approach for 14 consecutive patients with femoral shaft nonunion using double plate fixation with bone grafting.

METHODS

Retrospective data from June 2010 to August 2012 were obtained from records for 14 consecutive femoral shaft aseptic nonunion patients treated with double plate fixation combined with bone grafting. Nine patients were men and five patients were woman and average age of the patients was 26 years (range from 22 to 32 years). The mean time since injury was 26.2 months. The nonunion had resulted from repeated internal fixation failure (including plate or intramedullary nail fixation) in nine cases and primary internal fixation in five cases.

RESULTS

All the 14 patients were followed up for an average of 14.8 (10-25) months. All cases achieved bony union without wound infection or fixation failure and the mean time to union was 5.2 months (range 4-7 months).

CONCLUSION

Double plate fixation and bone grafting are a promising method for femoral shaft nonunion. In addition, this strategy is useful for such a nonunion caused by a repeated plate or intramedullary nail fixation failure with bone defect due to its strong stability with three-dimensional fixation and fully bone graft availability.

Results of a systematic approach to exchange nailing for the treatment of aseptic femoral nonunions

OBJECTIVES

To evaluate the radiographic and clinical outcomes of a systematic approach to exchange nailing for the treatment of aseptic femoral nonunions previously treated with an intramedullary nail.

DESIGN

Retrospective cohort.

SETTING

Tertiary referral center.

PATIENTS

Fifty aseptic femoral nonunions in 49 patients who presented with an intramedullary nail in situ an average of 25 months after the initial fracture nailing were evaluated.

INTERVENTION

Our systematic approach includes inserting an exchange nail at least 2 mm larger in diameter than the in situ nail, using a different manufacturer's nail, static interlocking, correction of any metabolic and endocrine abnormalities, and secondary nail dynamization in cases showing slow progression toward healing.

MAIN OUTCOMES MEASUREMENTS

The outcome measures were radiographic and clinical evidence of nonunion healing and time to union.

RESULTS

All 50 femoral nonunions (100%) healed after this systematic approach to exchange nailing. The average time to achieve union was 7 months (range, 3-26 months).

CONCLUSIONS

Utilization of this systematic approach of exchange nailing for the treatment of aseptic femoral nonunions resulted in a 100% healing rate.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The effect of autologous concentrated bone-marrow grafting on the healing of femoral shaft non-unions after locked intramedullary nailing

The aim of this study was to assess the union rates in a series of patients with failed femoral shaft aseptic non-union who were treated with percutaneous concentrated autologous bone marrow grafting. Bone marrow harvesting and cell injection were performed under general anaesthesia in a single surgical procedure. Radiographic union was diagnosed in fractures with a score ≥ 10 according to the radiographic union scale in tibial fractures (RUST) and confirmed by clinical examination. Eight out of 16 patients progressed to consolidation (RUST score ≥ 10). Radiographic evidence of fracture union was observed at an average of 4.75 ± 1.75 months (range 3 to 8 months). All eight patients who did not progress to union within 12 months following the cell grafting procedure had a RUST score ≤ 10 (range 4 to 9). There were no differences in age, number of previous surgeries, duration of nonunion and preoperative RUST score between the patients that developed solid union and those with failed consolidation. However, a relationship between the number of osteoprogenitors injected and the rate of union was noted, 20.2 ± 8.6 × 10(8) versus 9.8 ± 4.3 × 10(8), p<0.005, between the patients with and without union, respectively. The efficacy of percutaneous autologous concentrated bone marrow grafting seems to be related to the number of osteoprogenitors available in the aspirates. Optimisation of the aspiration technique and concentration process is of paramount importance to increase the incidence of a successful outcome.

Reamed intramedullary exchange nailing: treatment of choice of aseptic femoral shaft nonunion

BACKGROUND

The aim of this study was to evaluate a standardized method of treatment of femoral nonunion of the isthmal femur excluding non-united metaphyseal fractures.

METHODS

Between 2003 and 2010, 72 consecutive patients with nonunion of the femoral shaft were operated using a standardized protocol in our trauma department and followed up for successful union and functional result.

RESULTS

Osseous healing was observed in 71 patients (98%). Only one patient was lacking bone healing following a time period of 24 months after the first exchange nailing and 5 months after the second exchange nailing. In 59 patients (82%), uneventful and timely bone healing after exchange nailing was detected. In 18% of patients (n = 13), delayed bone healing was observed and required additional therapy. In the majority of patients (61%), bone healing occurred within the first 2 to 5 months, only 18% of patients' duration of bone healing exceeded 8 months. In 62 patients (86%), no relevant or clinically apparent leg-length discrepancy prior to and after exchange nailing was detected as well as no significant axis deviation or malrotation. Functional studies including simple clinical gait and standing analysis, return to activities of daily life, return to sports activities, and return to work were all reached on a satisfying level.

DISCUSSION

Reamed intramedullary exchange nailing as described in this study is the treatment of choice for aseptic femoral shaft nonunion with a high rate of bone healing and a low rate of complications including length discrepancy or malrotation and a good functional outcome.

Operative treatment for femoral shaft nonunions, a systematic review of the literature

The objective of this article is to systematically review the currently available literature to formulate evidence-based guidelines for the treatment of femoral shaft nonunions for clinical practice and to establish recommendations for future research. Articles from PubMed/MEDLINE, Cochrane Clinical Trial Register, and EMBASE, that presented data concerning treatment of nonunions of femoral shaft fractures in adult humans, were included for data extraction and analysis. The search was restricted to articles from January 1970 to March 2011 written in the English, German, or Dutch languages. Articles containing data that were thought to have been presented previously were used once. Reports on nonunion after periprosthetic fractures, review articles, expert opinions, abstracts from scientific meetings, and case reports on 5 or fewer patients were excluded. The data that were extracted from the relevant articles included: type of nonunion, type of initial and secondary treatments, follow-up, union rate, and general complications. Most studies had different inclusion criteria and outcome measures, thus prohibiting a proper meta-analysis. Therefore, only the union rate and number of complications were compared between the different treatments. Methodological quality was assessed by assigning levels of evidence as previously defined by the Centre for Evidence-Based Medicine. This systematic review provides evidence in favour of plating if a nail is the first treatment; after failed plate fixation, nailing has a 96 % union rate. After failed nailing, augmentative plating results in a 96 % union rate compared to 73 % in the exchange nailing group.

Relevance of deep decortication and vascularization in a case of post-traumatic femoral non-union treated with grafts, platelet gel and bone marrow stromal cells

PURPOSE

A male patient suffering from non-union of the femoral diaphysis after a traumatic fracture was treated with deep decortication and grafted with lyophilized bone, platelet gel (PG) and autologous bone marrow stromal cells (BMSCs). After 40 days from surgery, he was re-operated, due to fracture secondary displacement, caused by inappropriate load during sports activity. In addition to radiographs, two bone biopsies were retrieved: this allowed for a histological evaluation of the early response of host bone to the graft. To our knowledge, there is no report describing such early tissue response.

METHODS

A clinical-radiographic evaluation of the patient and a histomorphometric analysis of the bone biopsies were performed.

RESULTS

An early reparative bone formation was observed adjacent to the osteointegrated graft. Non-resorbed bone chips and large islands of non-vital bone particles, surrounded by fibrous tissue, were observed in a zone of sclerotic diaphyseal bone, that is the process was delayed despite decortication.

CONCLUSIONS

These findings support the concept, until now evidenced only by imaging, that bone chips added with PG and BMSCs are effective in shortening the healing time in fracture non-union. The clinical relevance of deep decortication and vascularization is emphasized.

LEVEL OF EVIDENCE

Therapeutic studies-investigating the results of treatment, Level V.

Diagnostic and treatment modalities in nonunions of the femoral shaft: a review

Nonunions of the femoral shaft represent a treatment challenge for the orthopaedic surgeon and a serious socioeconomic problem for the patient. Inadequate fracture stability, insufficient blood supply, bone loss or presence of infection are the main reasons for the development of a nonunion. Careful classification and exclusion of infection are crucial for the choice of the proper treatment alternative. Nail dynamization, primary intramedullary nailing or nail exchange, plate osteosynthesis and external fixation along with bone grafting, usage of bone substitutes and electrical stimulation can stimulate osseous union. A review of the aetiology, classification and treatment should prove helpful managing this serious complication.

Intramedullary nailing for the treatment of aseptic femoral shaft non-unions after plating failure: effectiveness and timing

This retrospective, multicentre study aimed to evaluate reamed intramedullary nailing (IMN) for the treatment of 30 cases of aseptic femoral shaft non-union after plating failure. Following nailing, 29 non-unions had healed by a mean 7.93 months. In one case a hypertrophic non-union required renailing after 8 months, using a nail of greater diameter, and united within five further months. Healing times were not related to whether the fracture was open or closed, the type non-union or the type of fracture. The delay from the initial plating to intramedullary nailing had a statistically significant effect on healing time and final outcome. This treatment is cost effective and should be implemented as soon as the non-union is diagnosed.

Human hypertrophic nonunion tissue contains mesenchymal progenitor cells with multilineage capacity in vitro

Hypertrophic nonunion usually results from insufficient fracture stabilization. Therefore, most hypertrophic nonunions simply require the stabilization of the nonunion site. However, the reasons why union occurs without treating the nonunion site directly is not well understood biologically. In this study, we hypothesized that the intervening tissue at the hypertrophic nonunion site (nonunion tissue) could serve as a reservoir of mesenchymal progenitor cells and investigated whether the cells derived from nonunion tissue had the capacity for multilineage mesenchymal differentiation. After nonunion tissue was obtained, it was cut into strips and cultured. Homogenous fibroblastic adherent cells were obtained. Flow cytometry revealed that the adherent cells were consistently positive for mesenchymal stem cell related markers CD13, CD29, CD44, CD90, CD105, CD166, and negative for the hematopoietic markers CD14, CD34, CD45, and CD133, similar to control bone marrow stromal cells. In the presence of lineage-specific induction factors, the adherent cells differentiated in vitro into osteogenic, chondrogenic, and adipogenic cells. These results demonstrated for the first time that hypertrophic nonunion tissue contains multilineage mesenchymal progenitor cells. This suggests that hypertrophic nonunion tissue plays an important role during the healing process of hypertrophic nonunion by serving as a reservoir of mesenchymal cells that are capable of transforming into cartilage and bone forming cells.

Intramedullary fixation of failed plated femoral diaphyseal fractures: are bone grafts necessary?

BACKGROUND

Nonunited fracture shaft femur after plate fixation is a common problem in third world countries because of economic reasons. Management of such a problem is still controversial and is associated with many surgical details, due not only to the nonunited fracture itself, but also to the broken implant which is not easy to remove.

METHODS

This study is a randomized prospective study presenting 40 patients with aseptic nonunited fracture shaft femur associated with failed plating managed by the removal of hardware, and intramedullary fixation using an interlocking nail with or without autogenous iliac bone graft.

RESULTS

There was no statistically significant difference between patients with and without iliac autogenous bone graft regarding the demographic data, the preoperative condition, and the postoperative course including time needed for bone union and return to work. The statistically significant difference was in the intraoperative blood loss and the duration of surgery with less blood loss and shorter duration of surgery occurring in the group treated by reamed intramedullary nail without iliac bone graft.

CONCLUSION

In cases with aseptic nonunited fracture shaft femur after failed plating, intramedullary reamed nailing without autogenous bone graft produced similar results as with bone graft, but with less operating time and blood loss.

Femoral nonunion: risk factors and treatment options

Despite advances in surgical technique, fracture fixation alternatives, and adjuncts to healing, femoral nonunion continues to be a significant clinical problem. Femoral fractures may fail to unite because of the severity of the injury, damage to the surrounding soft tissues, inadequate initial fixation, and demographic characteristics of the patient, including nicotine use, advanced age, and medical comorbidities. Femoral nonunion is a functional and economical challenge for the patient, as well as a treatment dilemma for the surgeon. Surgeons should understand the various treatment alternatives and their role in achieving the goals of deformity correction, infection management, and optimization of muscle strength and rehabilitation. Used appropriately, nail dynamization, exchange nailing, and plate osteosynthesis can help minimize pain and disability by promoting osseous union. A review of the potential risk factors and treatment alternatives should provide insight into the etiology and required treatment of femoral nonunion.

Exchange nailing of ununited fractures

Exchange nailing is most appropriate for a nonunion without substantial bone loss. There is no clear consensus regarding the use of exchange nailing in the presence of active, purulent infection. The exchange nail should be at least 1 mm larger in diameter than the nail being removed, and it has been recommended that it be up to 4 mm larger when the nail being removed was greatly undersized. Canal reaming should progress until osseous tissue is observed in the reaming flutes. Exchange nailing is an excellent choice for aseptic nonunions of noncomminuted diaphyseal femoral fractures, with union rates reported to range from 72% to 100%. On the basis of the available literature, exchange nailing cannot be recommended for distal femoral nonunions at this time. Exchange nailing is an excellent choice for aseptic nonunions of noncomminuted diaphyseal tibial fractures, with union rates reported to range from 76% to 96%. On the basis of the available literature, exchange nailing is generally not indicated for humeral nonunions.

Exchange nailing of ununited fractures

Exchange nailing is most appropriate for a nonunion without substantial bone loss. There is no clear consensus regarding the use of exchange nailing in the presence of active, purulent infection. The exchange nail should be at least 1 mm larger in diameter than the nail being removed, and it has been recommended that it be up to 4 mm larger when the nail being removed was greatly undersized. Canal reaming should progress until osseous tissue is observed in the reaming flutes. Exchange nailing is an excellent choice for aseptic nonunions of noncomminuted diaphyseal femoral fractures, with union rates reported to range from 72% to 100%. On the basis of the available literature, exchange nailing cannot be recommended for distal femoral nonunions at this time. Exchange nailing is an excellent choice for aseptic nonunions of noncomminuted diaphyseal tibial fractures, with union rates reported to range from 76% to 96%. On the basis of the available literature, exchange nailing is generally not indicated for humeral nonunions.

Treatment of femoral nonunions by using cyclic compression and distraction

Eleven patients with femoral diaphyseal nonunions after intramedullary nailing were treated with cyclic compression and distraction with an external fixator over the nail. We evaluated the limitations of this technique and whether patients having this closed procedure could achieve union without additional operative procedures. Patients with hypertrophic nonunions (n = 4) were treated with gradual compression of the nonunion site. Cyclic compression and distraction was done in patients with oligotrophic (n = 2) or atrophic nonunions (n = 5) to stimulate consolidation. The average age of the patients was 32.9 years (range, 21-48 years), and the average followup was 40.5 months (range, 24-64 months). Union was achieved in an average of 5.8 months in all patients after one operation and without additional surgical intervention. However, pain necessitating strong analgesic agents and pin-related complications consisting of osteomyelitis, septic arthritis, and pin breakage in the atrophic nonunion group were a major limitation of this technique. Based on our study, the cyclic compression and distraction technique can be used in hypertrophic and oligotrophic nonunions that have failed one or more prior exchange nailings. However, it might not be an option for treatment of patients with atrophic nonunions unless pin-site problems are resolved.

LEVEL OF EVIDENCE

Therapeutic study, Level IV (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

One-stage lengthening using a locked nailing technique for distal femoral shaft nonunions associated with shortening

OBJECTIVE

To assess the effectiveness of a one-stage lengthening using a locked nail technique for the treatment of distal femoral shaft nonunions associated with shortening.

DESIGN

Retrospective.

SETTING

University hospital.

PATIENTS AND METHODS

During a 6-year period, 36 distal femoral shaft nonunions associated with shortening (>1.5 cm) were treated by the one-stage lengthening technique. Indications for this technique were distal femoral shaft aseptic or quiescent infected nonunions, 1.5-5 cm shortening, and a fracture level suitable for the insertion of two distal locked screws. The surgical technique involved skeletal traction using the femoral condyle, local débridement, lengthening by <or=4 cm aided by a laminar spreader, insertion of a static locked nail, and grafting of corticocancellous bone. Mize's classification for clinical function was used for final patient evaluation.

RESULTS

A total of 32 nonunions were followed-up for at least 1 year (median 3.8 years; range 1.2-6.9 years), and 29 fractures healed. The median union period was 4.5 months (range 3-6 months). Three fractures persistently failed to heal. One was treated successfully with exchange nailing, and the remaining two patients were followed annually and had no symptoms. At the latest follow-up, all 32 patients had achieved a satisfactory outcome. The average lengthening was 2.5 cm (range 1.5-3.5 cm).

CONCLUSIONS

One-stage lengthening using the locked nailing technique to treat distal femoral shaft nonunions associated with shortening can achieve a high success rate and low complication rate. The key to successful treatment is the patient's complete cooperation with strictly protected weight bearing until the fracture has healed.

Reaming bone grafting to treat tibial shaft aseptic nonunion after plating

OBJECTIVE

To investigate the effects of using intramedullary reaming to provide cancellous bone graft, and reamed intramedullary nail stabilisation to provide fragment stability on treating tibial shaft aseptic nonunions after plating.

METHODS

31 consecutive patients with tibial shaft aseptic nonunions after plating were prospectively treated. Indications for this technique included a tibial shaft nonunion with an inserted plate, a fracture level fit for traditional or locked nail stabilisation, absence of suspected infection and segmental bony defect at the time, and shortening of less than 2 cm. The plate was removed and the marrow cavity was reamed as widely as possible. A stable unlocked or locked intramedullary nail was then inserted. No extra cancellous bone graft was supplemented.

RESULTS

28 patients were followed up for a median period of 2.2 years (range, 1.0-5.2 years). All patients achieved solid union. The median union period was 4.5 months (range, 3.0-7.5 months). There were no significant complications.

CONCLUSION

When reamed intramedullary nails are used to treat tibial shaft aseptic nonunions after plating, supplemented cancellous bone grafting can be spared. Despite the technique being simplified, the success rate is high. We therefore recommend its wide use to treat all suitable cases.

Femoral exchange nailing for aseptic non-union: not the end to all problems

We report the results of a single centre prospective study of exchange nailing for aseptic non-union of a femoral fracture. Eighteen patients with 19 aseptic femoral non-unions had exchange nailing performed in our institution. We collected data on mechanism of injury, original fracture type, and indication for exchange nailing, further surgery and major complications. In 11 non-unions (58%), the exchange nail procedure alone resulted in fracture union with a mean time to radiographic union of 9 months (range 3-24 months). The non-union did not heal in five patients, two patients developed an infected non-union, and one patient required dynamisation of the exchange nail. Fracture healing was eventually achieved in 18 non-unions (95%). Complications following exchange nailing occurred in 11 fractures (58%), in which further surgery was required (four repeat exchange nailings, two Ilizarov frame applications and five nail removals). The role of reamed exchange nailing in the treatment of femoral non-union needs to be re-evaluated. Although fracture healing is eventually achieved in most patients, a significant number of them required additional surgery to achieve union or to deal with complications arising from the exchange nailing.

The treatment of nonunions following intramedullary nailing of femoral shaft fractures

OBJECTIVE

To assess the effectiveness of different surgical options in the treatment of nonunion of a femoral shaft fracture after initial intramedullary nailing.

DESIGN

Retrospective.

SETTING

University hospital.

PATIENTS AND METHODS

During a seven-year period a total of 278 skeletally mature patients with 280 fresh femoral shaft fractures were treated by intramedullary nailing. Of these patients, a subgroup of consecutive patients with nonunion of the fracture were subjected to a detailed analysis and were followed until the fracture was united (mean thirty-three months). Injury mechanism, fracture pattern using various established classifications, any possible concomitant injuries, complications, and subsequent surgical interventions were recorded.

RESULTS

Of the total of 280 fractures, nonunion was observed in thirty-four patients with thirty-five fractures (12.5 percent). To achieve solid union, one reoperation was sufficient in twenty-five fractures, six fractures had to be operated on twice, and four needed three operations. There were five patients with autogenous bone grafting alone, and all five required a further reoperation for the nonunion. After a dynamization procedure, four of seventeen patients required a further reoperation. After eight exchange nailing procedures, further surgery for nonunion was necessary in only one case. Solid union was achieved within six months after the final successful reoperation. A marked shortening of the femur developed as a local complication in six cases, four of which had undergone dynamization as final treatment before solid union.

CONCLUSIONS

Exchange nailing without extracortical bone grafting seems to be the most effective method to treat a disturbed union of a femoral shaft fracture after intramedullary nailing. Autogenous extracortical bone grafting alone proved to be insufficient. Dynamization predisposed to shortening of the bone.

Treatment of femoral shaft aseptic nonunion associated with plating failure: emphasis on the situation of screw breakage

BACKGROUND

Femoral shaft aseptic nonunions associated with plating failure resulting from screw breakage are rare, and the treatment is complex and yet to be defined. The aim of this prospective study was to develop a better technique for the treatment of this complication.

METHODS

Eight consecutive adult patients who sustained femoral shaft aseptic nonunions associated with plating failure resulting from screw breakage were treated. The procedure involved skeletal traction in the femoral condyle, removal of the broken screws after making a bony window in the lateral cortex, with or without lengthening the femur, stabilization with a static locked nail, and finally, corticocancellous bone grafting. Postoperatively, ambulation with protected weight bearing was encouraged as early as possible.

RESULTS

All eight patients were followed up for at least 1 year (range, 1.1-4.7 years), and seven nonunions healed. The median union period was 4 months (range, 3-6 months). One patient had a persistent nonunion, and the locked nail broke at 6 months. The nonunion healed 4 months after closed revision with a new locked nail.

CONCLUSION

The described technique has both theoretical and clinical merits. All abnormalities can be corrected concomitantly. The success rate is high and the complication rate is low. Whenever possible, therefore, it may be used to treat all indicated cases of nonunion.

A revised protocol for more clearly classifying a nonunion

Classifying a nonunion solely on the extent of callus formation on a radiograph is insufficient. We have conducted a study with a revised protocol to classify a nonunion more clearly, which uses both radiographic observation and fixation stability. 47 consecutive femoral shaft nonunions were studied using this protocol and 42 nonunions were followed up for at least one year after discovery (range, 1-3 years). 40 nonunions healed after treatment with a union rate of 95.2% (40/42) and a union period of 4.7 plus or minus 0.9 months. The 2 cases of failure were due to implant failure and both healed after reoperation. We recommend this revised protocol as a pretreatment assessment for all nonunions because of its integrity and effectiveness.

Success of exchange reamed intramedullary nailing for femoral shaft nonunion or delayed union

OBJECTIVES

To investigate the success of exchange reamed femoral nailing in the treatment of femoral nonunion after intramedullary (IM) nailing, and to analyze factors that may contribute to failure of exchange reamed femoral nailing.

DESIGN

Retrospective consecutive clinical series.

SETTING

Level I trauma center and tertiary university hospital.

PATIENTS

Twenty-three patients were identified whose radiographs failed to show progression of healing for four months after treatment with a reamed IM femoral nail. Nineteen patients had undergone primary IM nailing of an acute femoral shaft fracture, one patient had been converted to an IM nail after initially being treated in an external fixator, and three patients had previously undergone an unsuccessful exchange reamed nailing.

INTERVENTION

All patients were treated by exchange reamed femoral nailing. The diameter of the new nail was one to three millimeters larger than that of the previous nail (the majority were two millimeters larger). The intramedullary canal was overreamed by one millimeter more than the diameter of the nail. Most of the nails were statically locked, and care was taken to avoid distraction of the nonunion site by reverse impaction after distal interlocking was performed or by applying compression with a femoral distractor.

MAIN OUTCOME MEASUREMENTS

Radiographic evaluation of union was determined by the presence of healing on at least three of four cortices. Factors reviewed included the patient's age, smoking history, mechanism of injury, associated injuries, whether the initial fracture was open or closed, the pattern and location of the fracture, the type of nonunion, the increase in nail diameter, whether the nail was dynamically or statically locked, and the results of any intraoperative cultures.

RESULTS

Tobacco use was found to have a detrimental impact on the success of exchange reamed nailing. All eight of the nonsmokers healed after exchange reamed nailing, whereas only ten of the fifteen smokers (66.7 percent) healed after exchange reamed nailing. Overall, exchange reamed femoral nailing was successful in eighteen cases (78.3 percent). Three patients achieved union with additional procedures. Intramedullary cultures were positive in five cases; all of these achieved successful union.

CONCLUSIONS

Exchange reamed nailing remains the treatment of choice for most femoral diaphyseal nonunions. Exchange reamed IM nailing has low morbidity, may obviate the need for additional bone grafting, and allows full weight-bearing and active rehabilitation. Tobacco use appears to have an adverse effect on nonunion healing after exchange reamed femoral nailing.

Treatment of ununited femoral shaft fractures associated with locked nail breakage: comparison between closed and open revision techniques

OBJECTIVES

To investigate and compare closed and open revision techniques in the treatment of ununited femoral shaft fractures associated with locked nail breakage.

DESIGN

Retrospective.

SETTING

University hospital.

METHODS

Ununited femoral shaft fractures associated with locked nail breakage were treated with either closed or open revision (nine or eighteen cases, respectively). The closed technique entailed closed removal of the broken nail and reinsertion of a stable intramedullary nail after reaming the marrow cavity. The open technique included open removal of the broken nail, reinsertion of a stable intramedullary nail or plate, and cancellous bone graft supplementation. Union rate, union period, perioperative course, and complications were compared.

RESULTS

Eight closed and fifteen open technique cases were followed for at least one year (median two years). Cases treated with the closed technique had a union rate of 100 percent, a union period of 4.4+/-0.9 months, an operating time of 1.5+/-0.4 hours, no blood transfusion, and no complications. Open technique cases demonstrated a union rate of 100 percent, a union period of 5.7+/-1.5 months (p = 0.033), an operating time of 2.4+/-0.4 hours (p < 0.001), blood transfusion of 1,000+/-500 milliliters (p < 0.001), and no complications.

CONCLUSIONS

We recommend the closed revision technique because its union period and operating time are shorter, and it does not require a blood transfusion. Because there is no local wound dissection, infection rates should also be lower. However, the procedure is technically demanding. If it cannot be completed successfully, using the open technique can still achieve a satisfactory outcome.

High success rate with exchange nailing to treat a tibial shaft aseptic nonunion

OBJECTIVE

To investigate the effects of tibial exchange nailing in treating a tibial shaft aseptic nonunion and to establish optimal indications for using this technique.

DESIGN

Prospective, consecutive.

SETTING

University hospital.

METHODS

Twenty-five consecutive tibial shaft aseptic nonunions were prospectively treated with the exchange nailing technique. Indications for this procedure were a tibial shaft aseptic nonunion that had previously been treated with an inserted nonreamed or reamed intramedullary nail, displayed less than one centimeter of shortening, was with or without rotational or angular deformity, exhibited no segmental bony defects, and was anatomically suited for conventional or locked reamed intramedullary nail stabilization. The marrow cavity was reamed as extensively as possible, and a rigid intramedullary nail with stable fixation was inserted.

RESULTS

During a follow-up period of two to four years (median thirty-two months), twenty-four nonunions healed, on average, in four months (range three to six months). The one remaining nonunion healed four months after a cancellous bone grafting procedure. No wound infection or malunion was noted.

CONCLUSION

Because of its high union rate, low complication rate, and simplicity of method, we believe that the exchange nailing technique should be considered preferentially for all indicated cases.