Plate fixation of femoral nonunions over an intramedullary nail with autogenous bone grafting

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

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

Management of infected bone defects of the femoral shaft by Masquelet technique: sequential internal fixation and nail with plate augmentation

BACKGROUND

To evaluate the effectiveness of a sequential internal fixation strategy and intramedullary nailing with plate augmentation (IMN/PA) for bone reconstruction in the management of infected femoral shaft defects using the Masquelet technique.

METHODS

We performed a retrospective descriptive cohort study of 21 patients (mean age, 36.4 years) with infected bone defects of the femoral shaft treated by the Masquelet technique with a minimum follow-up of 18 months after second stage. After aggressive debridement, temporary stabilisation (T1) was achieved by an antibiotic-loaded bone cement spacer and internal fixation with a bone cement-coated locking plate. At second stage (T2), the spacer and the locking plate were removed following re-debridement, and IMN/PA was used as definitive fixation together with bone grafting. We evaluated the following clinical outcomes: infection recurrence, bone union time, complications, and the affected limb's knee joint function.

RESULTS

The median and quartiles of bone defect length was 7 (4.75-9.5) cm. Four patients required iterative debridement for infection recurrence after T1. The median of interval between T1 and T2 was 10 (9-19) weeks. At a median follow-up of 22 (20-27.5) months, none of the patients experienced recurrence of infection. Bone union was achieved at 7 (6-8.5) months in all patients, with one patient experiencing delayed union at the distal end of bone defect due to screws loosening. At the last follow-up, the median of flexion ROM of the knee joint was 120 (105-120.0)°.

CONCLUSIONS

For infected femoral shaft bone defects treated by the Masquelet technique, sequential internal fixation and IMN/PA for the reconstruction can provide excellent mechanical stability, which is beneficial for early functional exercise and bone union, and does not increase the rate of infection recurrence.

Mechanical evaluation of revision surgery for femoral shaft nonunion initially treated with intramedullary nailing: Exchange nailing versus augmentation plating

INTRODUCTION

Exchange nailing (EN) or augmentation plating (AP) has been employed to treat nonunions after intramedullary nailing for femoral shaft fractures. Although instability is a factor in hypertrophic nonunion, mechanical evaluations have been limited because the contribution of the callus to fracture site stability varies with healing. Our previous study illustrated the potential for evaluation using a finite element analysis (FEA) that incorporates callus material properties. This study aimed to mechanically evaluate revision surgery for nonunions using FEA.

MATERIALS AND METHODS

A quantitative computed tomography-based FEA was performed on virtual revision models of a patient with suspected nonunion after intramedullary nailing. In addition to the initial nailing model (IN) with an 11-mm diameter (D) and 360-mm length (L), four EN models with D12mm (EN1), D13mm (EN2), D12mm-L400mm (EN3), and D13mm-L400mm (EN4) nails and three AP models with 5- (AP1), 6- (AP2), and 7-hole (AP3) plates were created. As with bone, callus was assigned inhomogeneous material properties derived from density based on an empirical formula. The hip joint reaction force and muscle forces at maximum load during the gait cycle were applied. The volume ratio of the callus at the fracture site with a tensile failure risk of ≥1 (tensile failure ratio) and bone fragment movement were evaluated.

RESULTS

The tensile failure ratio was 11.6 % (IN), 10.1 % (EN1), 6.3 % (EN2), 10.9 % (EN3), 6.2 % (EN4), 6.4 % (AP1), 7.2 % (AP2), and 7.7 % (AP3), respectively. The bone fragment movement showed an opening on the lateral side with the initial intramedullary nailing. However, both revision surgeries reduced the opening, leading to compression except in the EN1 model. The proximal bone fragments were internally rotated relative to the distal fragments, and the rotational instability was more suppressed in models with lower tensile failure ratio.

CONCLUSIONS

For EN, the increase in diameter, not length, is important to suppress instability. AP reduces instability, comparable to a 2 mm increase in nail diameter, and screw fixation closer to the fracture site reduces instability. This study suggest that AP is mechanically equivalent to EN and could be an option for revision surgery for femoral shaft nonunions.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

ON Path: outpatient nonunion pathway for lower-extremity nonunions

Objectives

The purpose of this study was to assess the safety and efficacy of outpatient and short-stay surgical nonunion treatment by incorporating minimally invasive surgical techniques, multimodal pain control, and a modernized postoperative protocol.

Design

Retrospective case series.

Setting

Tertiary referral hospital and hospital outpatient department.

Patients

All consecutive nonunion surgeries performed by 1 surgeon between 2014 and 2019 were identified. Outpatient and short-stay surgeries for patients with nonunion of the tibia and femur were eligible (n = 50).

Intervention

Outpatient and short-stay surgical nonunion treatment by incorporating minimally invasive surgical techniques, multimodal pain control, and a modernized postoperative protocol.

Main Outcome Measurements

Length of stay, postoperative emergency department visits, all complications, reoperations, and time to union.

Results

Fifty patients were eligible, with 32 male patients (64%) and an average age of 46.5 years. The patient cohort consisted of 28 femur (56%) and 22 tibia (44%) nonunions. The average length of stay was 0.36 days. Seven patients (14%) required reoperation, 6 patients because of deep infection and 1 patient because of painful implant removal. Four patients (8%) presented to the emergency department within 1 week of surgery. One patient requiring amputation and patients lost to follow-up were excluded from the union rate calculation. For the remaining patients (46/50), 100% (46/46) united their nonunion. The average time to radiographic union was 7.82 months.

Conclusions

An outpatient pathway is safe and effective for medically appropriate patients undergoing nonunion surgery. Outpatient nonunion surgery is a reasonable alternative that achieves similar outcomes compared with inpatient nonunion studies in the published literature.

Level of Evidence

IV.

Concomitant intramedullary nailing and plate augmentation as a single-stage procedure in treating complicated nonunited femoral shaft fractures

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.

Clinical Outcomes of Treatment Strategies for Postoperative Plate Fracture and In Situ Fracture of the Femoral Shaft

Objective

To investigate the treatment and clinical efficacy of postoperative plate fracture and in situ fracture of the femoral stem.

Methods

We have retrospectively analyzed the clinical data, revised surgery information, and clinical efficacy of patients with postoperative plate fracture of the femoral stem in our hospital. A total of 33 cases were included whose original fractures were located in the upper and cadaveric femur and treated with paralleling intramedullary pins for revision surgery, as well as patients whose original fractures were located in the lower femur which were fixed with retrograde intramedullary nailing or anatomical locking and compression splints in the distal femur. For the selection of bone grafting, the original fracture site with Fernadez-Esteve scab grades I and II was treated with an autologous iliac bone graft. Postoperatively, patients were evaluated for fracture healing time, the clinical outcome of the affected limb, and complications in the iliac bone donor area.

Results

All patients were followed up until fracture healing, and all patients achieved clinical healing with a healing rate of 100% and a mean healing time of 6.3 months. No internal fixation failure such as rebreakage or loosening of the internal fixation occurred in all patients during the follow-up period. According to the Tohner-Wrnch criteria, 23 cases were excellent, 10 cases were good, and 0 cases were poor, with an excellent rate of 100%. Complications in the autologous iliac bone donor area amounted to 36.7%.

Conclusion

For patients with original fractures located in the upper femoral segment or cadre, it is recommended to perform revision surgery with a paralleling intramedullary pin, while patients with original fractures located in the lower femoral segment are fixed with the retrograde intramedullary nailing or an anatomical type of distal femoral locking and compression splint. Patients with postoperative plate fractures of the femoral stem do not require routine autologous bone grafting for revision surgery.

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

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Results of combining intramedullary nailing and plate fixation for treating segmental femoral fractures

BACKGROUND

Intramedullary nailing (IMN) is generally accepted as the standard treatment for femoral shaft fractures. However, segmental femoral fractures are considered to be a special injury type associated with high complication rates. Combined IMN and plate is proved to be a reliable method for treating complex tibia fractures with less operation time and high union rates. Therefore, the purpose of our study is to evaluate the outcome of following combined IMN and plate fixation for segmental femoral fractures.

METHODS

Between February 2013 and January 2016, 18 consecutive patients with femoral shaft fracture with AO/OTA type 32-C2 were treated via combined IMN and plate. Surgical details, operative and postoperative complications, the rate of union and time to union were evaluated.

RESULTS

There were 14 men and four women with a mean age of 37.8 years (range 27-52 years). All patients were followed up for a minimum of 12 months. Of the patients, 13 were closed fractures, three were Gustilo type I open fractures and two were Gustilo type II open fractures. All patients achieved union within 18.9 weeks (range 12-28 weeks) and none of them had malunion. There were no deep infections, and two patients with superficial wound infections were successfully treated with antibiotics.

CONCLUSION

Combining IMN and plate fixation appears to be a reliable method for the treatment of segmental femoral shaft fractures with less operation time, high union rates and ability to maintain alignment, therefore it provides another choice for treating segmental femoral fractures.

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.

Failed osteosynthesis of cemented B1 periprosthetic fractures

BACKGROUND

Periprosthetic fractures about the hip are increasingly common. The literature estimates a failure rate of approximately 10% in Vancouver B1 type fractures which have undergone fixation. There is currently no guidance available on the next step of management for this patient group. This study presents a series of nine Vancouver B1 fractures with failed osteosynthesis and proposes that repeated fixation has poorer results than revision.

METHODS

A total of nine patients (five women, four men) with a mean age of 71.2 years (52-83) underwent operative treatment for failed osteosynthesis of periprosthetic fractures of Vancouver type B1. Three patients were revised to a long revision stem while six patients had repeated osteosythesis. Failure was defined as the need for further operative intervention.

RESULTS

The three patients revised to a long revision stem at first failure of osteosynthesis required no further surgical intervention. All six patients who had repeat osteoynthesis failed again. Five patients were subsequently successfully treated with revision of the primary stem, three were revised to a long revision stem while two patients required proximal femoral replacement. One patient died prior to revision. The mean follow up following initial B1 fracture was 49.3 months and following definitive operative intervention was 37.7 months. Six patients had died at 1st July 2017.

CONCLUSION

Failed osteosynthesis of B1 fractures may necessitate revision rather than repeat fixation, regardless of how well fixed the stem appears. Revision to a long stem provided good results in this cohort.

Endosteal Substitution With an Intramedullary Rod in Fractures of the Femur

BACKGROUND

Morbid obesity and segmental fracture/bone loss are challenging problems in the treatment of fractures and nonunions of the distal femur. The use of an intramedullary rod as an endosteal substitute for a deficient medial cortex along with a lateral locked plate is 1-tool to combat these problems. This article describes the technique used and its results at a single Level 1 trauma center.

METHODS

Retrospective chart and radiographic review of all patients treated for acute fractures and nonunions of the distal femur using endosteal substitution with an intramedullary nail and a lateral locked plate. Fixation construct was determined at the surgeon's discretion and was strongly influenced by bone loss and patient body habitus.

RESULTS

Seven of 8 acute fractures and 8 of 8 nonunions healed without an unplanned reoperation. There were no cases of secondary displacement after fixation, and only 1 unplanned reoperation in the study group.

CONCLUSION

Endosteal substitution with an intramedullary rod and the use of a lateral locked plate provides the stability needed to allow bone healing under prolonged or supraphysiologic loads seen in morbid obesity or segmental bone loss.

LEVEL OF EVIDENCE

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

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

INTRODUCTION

Exchange nailing is most acceptable for treating hypertrophic non-union of the long bones, requiring the removal of previously fixed implant. However, its main effect of mechanical stabilization is controversial in non-isthmal area. We hypothesized that minimally invasive plate augmentation over the non-union site may have a better option, without the need of bone grafting or removing pre-existing implants.

MATERIALS AND METHODS

Seventeen patients with hypertrophic non-union of the long bones between 2010 and 2014 on radiography who previously underwent intramedullary (IM) nailing or plate osteosynthesis for long-bone fractures were included. A locking compression plate was inserted with at least three mono- or bicortical screws at each proximal and distal segment. Broken or loosened interlocking screws of IM nail were simultaneously re-fixed. Fracture site exposure, pre-fixed implant removal, and bone grafting were not performed. We investigated whether union occurred and analyzed functional outcomes and complications.

RESULTS

Eleven femoral and six tibial non-unions were prospectively included. In the pre-existing implants, 13 nails and 4 plates were found. All cases achieved union at a mean 22.7 weeks. One case of superficial infection was managed with oral antibiotics. Deep infection or implant failure did not occur.

CONCLUSIONS

Minimally invasive plate augmentation can achieve additional stability and promote healing of hypertrophic non-union of the long bones. When indicated, this technique is the least invasive alternative to exchange nailing and reduces surgical risks in the treatment of diaphyseal non-union.

Outcomes of Distal Femur Nonunions Treated With a Combined Nail/Plate Construct and Autogenous Bone Grafting

In this study, we sought to retrospectively evaluate union and infection rates after treatment of distal femur nonunions using a combined nail/plate construct with autogenous bone grafting obtained from the ipsilateral femur using a reamer irrigator aspirator system. Ten (10) patients treated at a Level I trauma center for nonunion of a femoral fracture using a combined nail/plate construct from 2004 to 2014 were included in the study. Union rate and postoperative infection rates were recorded. Mean interval from index surgery to nonunion repair was 12 months (range 4-36 months). Follow-up at 24 months indicated that the entire cohort of 10 patients achieved clinical union and radiographic union based on radiograph union score in tibias (RUST) criteria. Treatment of distal femur nonunions with a combined nail/plate construct and autogenous bone grafting results in a high rate of union with a low complication rate.

Femoral Nonunion With Iliac Crest Bone Graft

PURPOSE

Fracture nonunion is a common problem for today's orthopaedic surgeon. However, many techniques are currently available for the treatment of long-bone nonunion. This video demonstrates the use of iliac crest bone graft and plate stabilization in the setting of a hypertrophic femoral nonunion.

METHODS

Treatment of femoral nonunion after intramedullary nail fixation using compression plating and bone grafting is a reliable technique for reducing pain, improving function, and achieving radiographic union. Furthermore, the use of autologous bone graft, in particular iliac crest bone graft, has provided reliable clinical results.

RESULTS

In this video, we present the case of a hypertrophic femoral nonunion treated with supplemental bone grafting in addition to plate and screw fixation.

CONCLUSIONS

Although femoral nonunions are a relatively rare occurrence, they can be reasonably treated using stabilization and supplemental bone grafting. Iliac crest bone graft provides for excellent results when used for treatment of a fracture nonunion.

Augmentation plating in management of failed femoral nailing

INTRODUCTION

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Augmentative locking plate with autologous bone grafting for distal femoral nonunion subsequent to failed retrograde intramedullary nailing

Objective

To explore the indications and efficacy of augmentative locking compression plate (LCP) or less invasive stabilization system (LISS)with autogenous bone grafting (BG) in treating distal femoral nonunion subsequent to failed retrograde intramedullary nailing (RIN).

Methods

A retrospective study was performed for 21 patients with distal femoral nonunion subsequent to failed RIN, who received therapy with either augmentative LCP (n = 11) or LISS with autogenous BG (n = 13). Operation time, time to union, union rate, time to renonunion, complication rate and SF-36 scores a year after hardware removal were compared between the two groups.

Results

The bone union occurred in 13/13 (100%) cases in augmentative LISS group versus 9/11 (81.8%) cases in augmentative LCP group [odds ratio (OR) = 3.21, 95% confidence interval (CI) 0.7–13]. Time to union, time to renonunion, complication rate of the augmentative LCP group were significantly more than that of the augmentative LISS with autogenous BG group (p = 0.023, p = 0.021 and p = 0.033). No significant difference was found in the average operation time of two groups (p = 0.121). At the follow-up a year after hardware removal, statistically significant HRQOL improvement in the augmentive LISS group was measured at the level of pain (p = 0.003) and general health perception (p = 0.011), as compared to the augmentive LCP group.

Conclusions

We suggest augmentative LCP, for distal femoral nonunios after RIN, may be optimal for that of typeAO33A fractures, whereas augmentative LISS for that of typeAO33C fractures more.

Nonunion of the Femur and Tibia: An Update

Delayed union and nonunion of tibial and femoral shaft fractures are common orthopedic problems. Numerous publications address lower extremity long bone nonunions. This review presents current trends and recent literature on the evaluation and treatment of nonunions of the tibia and femur. New studies focused on tibial nonunion and femoral nonunion are reviewed. A section summarizing recent treatment of atypical femoral fractures associated with bisphosphonate therapy is also included.

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

OBJECTIVE

The aim of the current study was to determine whether plate augmentation was a successful treatment algorithm for selected femoral nonunions initially managed with intramedullary nailing.

MATERIALS AND METHODS

A total of 30 femoral nonunion cases were managed using the plate augmentation strategy with 13 primary cases and 17 multi-operated femurs (avg 2.8 ineffective procedures). Adjunctive strategies included autologous bone grafting and/or BMP for atrophic/oligotrophic and bone defect cases. Deformity correction was performed when required.

RESULTS

Osseous union occurred in 29 of 30 cases. One multi-operated case with bone defect and prior infection required repeat autologous grafting prior to union.

CONCLUSION

Plate augmentation should be added to the armamentarium for management of selected femoral nonunion that have failed initial intramedullary nailing.

Management of Aseptic Tibial and Femoral Diaphyseal Nonunions Without Bony Defects

An evidence-based description of aseptic tibial and femoral diaphyseal nonunions without segmental defects is based on a systematic search of MEDLINE. Aseptic nonunion of the femoral or tibial diaphysis without segmental defects and with an in situ nail, treated with reamed exchange nailing or augmentative plating and bone grafting, has consistently high union rates. Aseptic nonunion without segmental defects and with in situ plate and screw fixation is best managed with revision plate and screw fixation and autogenous bone graft. Various techniques and methods of biological stimulation have relatively high union rates.

Atypical Femoral Fracture Despite Prophylactic Intramedullary Nailing: A Case Report

CASE

A forty-three-year-old woman on bisphosphonate therapy sustained an atypical femoral fracture that was successfully treated with an intramedullary nail. After she developed radiographic and clinical signs of an impending stress fracture of the contralateral femur, prophylactic nailing was performed. However, seven months postoperatively, she sustained a spontaneous, complete fracture of the prophylactically nailed femur at the site of the lateral cortical stress lesion.

CONCLUSION

To our knowledge, progression of a bisphosphonate-associated stress lesion to a complete fracture months after initially successful prophylactic intramedullary nailing has not been previously reported. Implications regarding treatment and prognosis are discussed.

Trends in bone graft use in the United States

Bone graft and bone graft substitutes are used to provide structural support and enhance bone healing. Autogenous, allogeneic, and artificial bone grafts each have advantages and drawbacks. The development of allografts, synthetic bone grafts, and new operative techniques may have influenced the use of bone grafts in recent years. The goal of this study was to analyze the use of bone grafts and bone graft substitutes in the United States during a 16-year period. Using data from the National Hospital Discharge Survey, the authors analyzed the use of autogenous and artificial bone grafts in almost 2 million patients in the United States between 1992 and 2007 using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes in 4 periods (1992-1995, 1996-1999, 2000-2003, and 2004-2007). Among an estimated almost 2 million bone graft procedures (83% autogenous, 17% artificial), the use of both types of grafts decreased. The main diagnoses for which bone grafts were used did not change; however, cervical spine diseases and lower-limb fractures decreased more remarkably. Although sex (52% male in the early 1990s to 47% in 2000-2003) and discharge status (more discharges to a short-term or long-term-care facility) significantly changed, age increased from 47 to 53 years and inpatient days decreased significantly from 6 to 5 days during the study period. The use of bone grafts and bone graft substitutes is decreasing in the United States, with a slight shift from autogenous to substitute grafts.

Effectiveness of exchange nailing and augmentation plating for femoral shaft nonunion after nailing

PURPOSE

We assessed indications and outcomes of exchange nailing and augmentation plating for femoral shaft nonunion following femoral nail failure.

METHODS

We retrospectively reviewed the records of 21 consecutive patients with femoral shaft nonunion treated with femoral nailing from August 2008 to June 2013. Nonunion cases with infection were excluded from this study. The study population consisted of nine men and 12 women, with an average age of 40 (range 21-61) years. All patients received internal fixation using exchange nailing and an augment plate coupled with decortication and bone graft.

RESULTS

All patients in our study obtained osseous union with a mean time of six (range four to12) months. Mean operation time was three hours (range two to five hours), and mean blood loss was 800 ml (range 500-950 ml). There were no postoperative complications. At the last follow-up, all patients could flex their knees > 110°.

CONCLUSIONS

Exchange nailing and augment plating coupled with decortication and bone graft is an effective treatment option for femoral shaft nonunion and has more indications and higher union rate than the popular exchange nailing treatment.

Indications and outcomes of augmentation plating with decortication and autogenous bone grafting for femoral shaft nonunions

INTRODUCTION

Though augmentation plating (AP) with decortication and bone grafting (BG) reportedly has excellent outcomes for femoral shaft nonunions, there are no established indications of AP with decortication and BG. The purpose of this study was to evaluate the results of AP with decortication and autogenous BG for femoral shaft nonunions, focussing on the indications of AP with decortication and BG.

METHODS

Thirty-nine patients treated with AP combined with decortication and BG for femoral shaft nonunions after femoral nail failure between November 1996 and October 2010 were retrospectively reviewed. Indications of AP with decortication and BG at the time of surgery and outcomes (bony union) were evaluated.

RESULTS

The mean follow-up duration was 24.8 months (range 12-81 months). Thirty-eight (97%) of 39 femoral shaft nonunions achieved bony union. One incompliant patient showed screw breakage, which was healed uneventfully with subsequent cast application. The mean time to union was 6.1 months (range 3-16 months). Primary indications at the time of surgery were nonisthmal femoral nonunions in 17 patients, isthmal nonunions in 10 patients (cortical bone defect in five and widened canal in five), failed exchange nail in seven patients, nonunions with malrotation in two patients and difficult removal in three patients.

CONCLUSIONS

AP with decortication and autogenous BG is a good option for nonisthmal femoral shaft nonunions, such as supra-isthmal and infra-isthmal nonunions. In addition, this option is useful for selected cases of isthmal femoral shaft nonunions in which failure of exchange nailing is expected due to lack of a tight fit between the new larger nail and femoral cortices.

Nonunion of distal femoral fractures: a systematic review

Nonunions of the distal femur are inherently difficult to treat and associated with significant patient disability. An extensive search of published reports was conducted and identified articles reviewed to determine the prevalence of various fracture patterns, initial treatment methods, reported risk factors, and definitive treatment methods. The definitive treatment modalities for distal femoral nonunions were then analyzed according to union rate, time to union and complications. The purpose of this review was to determine the risk factors that predispose to nonunion of the distal femur and the most effective treatment methods to implement after nonunion has occurred. The current review assesses 19 studies published over the last 12 years in which there were patients with nonunion of the distal femur and treatment specific to those patients was described. It was found that the most common fracture pattern involved metaphyseal comminution, most common initial treatment was open reduction and internal fixation with plating, most common reported risk factor was an open fracture, and most common definitive treatment was fixed angle plating combined with cancellous autografting. Taken together, the reviewed reports suggest that this form of treatment has a successful union rate of 97.4% and average time to heal of 7.8 months.