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Grünewald D, Dolt A, Barzen S, Rehme-Röhrl J, von Rüden C, Hoffmann R, Schweigkofler U. [Is the 95°blade plate still important in the treatment of proximal femoral pseudarthrosis?]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:589-596. [PMID: 38748217 DOI: 10.1007/s00113-024-01435-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/13/2024] [Indexed: 07/30/2024]
Abstract
Due to demographic changes, fractures and subsequently delayed fracture healing as well as pseudarthrosis of the proximal femur are on the increase. In the acute fracture situation, a load-stable treatment with an intramedullary implant (cephalomedullary nail) is generally sought. To date, there is no uniform consensus on the optimal treatment for complicated cases. The aim of this study was to evaluate the clinical and radiological outcome after revision of pseudarthrosis using a 95° blade plate in aseptic proximal femoral pseudarthrosis and to identify the specifications of blade plate treatment.The retrospective study design was used to evaluate data, some of which were prospectively collected. The study period covered January 2010 to December 2020 and 22 patients (10 women, 12 men) with an average age of 59 years were included in this single-center study. All patients showed pseudarthrosis after a femoral fracture type AO 31 A1-A3 or proximal femoral fracture type AO 32 A-C. Clinical and radiological follow-up were performed after 3, 6 and 12 months. Functional outcomes were assessed using the modified Harris hip score (mHHS), the numerical rating scale (NRS) and the short form health survey (SF-12).The postoperative radiological results after reosteosynthesis using a blade plate showed good results and 86.4% of the patient population were healed during the observation period. Pseudarthrosis persisted in four patients and was surgically revised.The functional results showed good results on average, albeit with a high dispersion of 17-91 points in the mHHS. The SF-12 averaged 42.6 (±10.4) points and the psychological score 49.4 (±9.6) points. The postoperative pain level was low both at rest and under stress.It was shown that reosteosynthesis with a blade plate is a surgically demanding but effective treatment option with a low potential for infection and safe bone consolidation, especially for the correction of high-grade axial deviation or varus malalignment.
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Affiliation(s)
- Dag Grünewald
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt, Friedberger Landstraße 430, 60389, Frankfurt am Main, Deutschland.
| | - Annika Dolt
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt, Friedberger Landstraße 430, 60389, Frankfurt am Main, Deutschland
| | - Stefan Barzen
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt, Friedberger Landstraße 430, 60389, Frankfurt am Main, Deutschland
| | - Julia Rehme-Röhrl
- Department of Trauma Surgery, BG Unfallklinik Murnau, 82418, Murnau, Deutschland
| | - Christian von Rüden
- Department of Trauma Surgery, BG Unfallklinik Murnau, 82418, Murnau, Deutschland
- Klinik für Unfallchirurgie, Orthopädie und Handchirurgie, Klinikum Weiden, 92637, Weiden in der Oberpfalz, Deutschland
| | - Reinhard Hoffmann
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt, Friedberger Landstraße 430, 60389, Frankfurt am Main, Deutschland
| | - Uwe Schweigkofler
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt, Friedberger Landstraße 430, 60389, Frankfurt am Main, Deutschland
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Whittaker BD, Balogh ZJ. Intraoperative diagnosis of rotational instability in femoral shaft fracture non-union revision surgery. ANZ J Surg 2024; 94:485-486. [PMID: 38044503 DOI: 10.1111/ans.18811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 11/08/2023] [Accepted: 11/23/2023] [Indexed: 12/05/2023]
Affiliation(s)
- Brent D Whittaker
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, New South Wales, Australia
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, New South Wales, Australia
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Devendra A, Patra SK, Velmurugesan P, Zackariya M, Ramesh P, Arun Kamal C, Dheenadhayalan J, Rajasekaran S. Results of a simple treatment protocol for aseptic femoral shaft nonunion in 330 patients. Injury 2024; 55:111412. [PMID: 38341997 DOI: 10.1016/j.injury.2024.111412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/21/2024] [Accepted: 01/27/2024] [Indexed: 02/13/2024]
Abstract
INTRODUCTION Our primary aim of the study was to assess the results of a treatment protocol for aseptic femoral shaft nonunion treated by three techniques - Exchange Nailing (EN), Plate Augmentation (PA), and Exchange Nailing combined with Plate augmentation (NP). The secondary objective was to assess the radiological outcome, duration of surgery (DOS) and need for blood transfusion (BT) in all the three groups. MATERIALS AND METHODS We analyzed 330 patients treated for AFNU between Jan 2007 and Dec 2019. Using a simple treatment algorithm, EN, PA and NP were performed in 24,183 and 123 patients respectively. Patients in all the three groups were assessed for radiological-union (union rate and time to union), DOS and BT. RESULTS Of these 330 patients, 327 (99 %) patients achieved radiological union at a mean duration of 6.07 months. Union rate is highest with NP followed by PA and EN. The union rate in patients with NP, PA and EN were 100 %, 99.5 % and 91.7 % respectively (p < 0.01). Time to union was lowest for NP followed by PA and EN (p < 0.001).The mean time to union for NP, PA and EN were 3.76, 7.2and 9.21 months respectively (p < 0.001). The mean DOS in minutes for NP, EN and PA was 107, 94 and 82 respectively (p < 0.01). The mean need for BT in the form of packed red blood cells for NP, PA and EN were 1.95, 1.87 and 1.38 units respectively (p < 0.01). CONCLUSION Following a simple algorithm to decide treatment protocol on a case-to case basis helps to achieve good results in an optimal time period. When compared with EN and PA, NP is associated with 100 % union rate with least time to union making NP a reasonably effective procedure with a very high success rate. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Agraharam Devendra
- Department of Orthopaedics and Trauma, Ganga Medical Centre & Hospitals Pvt Ltd, Tamil Nadu, India.
| | - Sudipta Kumar Patra
- Department of Orthopaedics and Trauma, Ganga Medical Centre & Hospitals Pvt Ltd, Tamil Nadu, India
| | - P Velmurugesan
- Department of Orthopaedics and Trauma, Ganga Medical Centre & Hospitals Pvt Ltd, Tamil Nadu, India
| | - Mohd Zackariya
- Department of Orthopaedics and Trauma, Ganga Medical Centre & Hospitals Pvt Ltd, Tamil Nadu, India
| | - P Ramesh
- Department of Orthopaedics and Trauma, Ganga Medical Centre & Hospitals Pvt Ltd, Tamil Nadu, India
| | - Chandramohan Arun Kamal
- Department of Orthopaedics and Trauma, Ganga Medical Centre & Hospitals Pvt Ltd, Tamil Nadu, India
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Hackl S, von Rüden C, Trenkwalder K, Keppler L, Hierholzer C, Perl M. Long-Term Outcomes Following Single-Stage Reamed Intramedullary Exchange Nailing in Apparently Aseptic Femoral Shaft Nonunion with Unsuspected Proof of Bacteria. J Clin Med 2024; 13:1414. [PMID: 38592249 PMCID: PMC10933962 DOI: 10.3390/jcm13051414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 02/25/2024] [Accepted: 02/27/2024] [Indexed: 04/10/2024] Open
Abstract
Background: The aim of this study was to evaluate detection rates and risk factors for unsuspected proof of bacteria, as well as clinical and radiologic outcomes following femoral shaft nonunion without clinical signs of infection treated by a single-stage surgical revision procedure including reamed intramedullary exchange nailing. Methods: A retrospective cohort study was performed in a European level I trauma center between January 2015 and December 2022. Fifty-eight patients were included who underwent reamed intramedullary exchange nailing as a single-step procedure for surgical revision of posttraumatic diaphyseal femoral nonunion without any indications of infection in medical history and without clinical signs of local infection. Clinical details of the patients were analyzed and functional and radiologic long-term outcomes were determined. Results: In all patients, with and without proof of bacteria osseous, healing could be observed. The physical component summary of the SF-12 demonstrated significantly better results at least one year after the final surgical revision in case of a negative bacterial culture during exchange nailing. Conclusions: Clinical long-term outcomes demonstrated a trend towards better results following femoral shaft nonunion revision if there was no evidence for the presence of low-grade infected nonunion. In this case, a single-stage surgical procedure may be recommended.
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Affiliation(s)
- Simon Hackl
- Department of Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
- Institute for Biomechanics, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Christian von Rüden
- Institute for Biomechanics, Paracelsus Medical University, 5020 Salzburg, Austria
- Department of Trauma Surgery, Orthopedics and Hand Surgery, Weiden Medical Center, 92637 Weiden, Germany
| | - Katharina Trenkwalder
- Institute for Biomechanics, Paracelsus Medical University, 5020 Salzburg, Austria
- Institute for Biomechanics, BG Unfallklinik Murnau, 82418 Murnau, Germany
| | - Lena Keppler
- Department of Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
| | - Christian Hierholzer
- Department of Trauma Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Mario Perl
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, 91054 Erlangen, Germany
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Li W, Wang Y, Zhou S, Liu S, Di L, Chen W, Lv H. Development and validation of predictive nomogram for postoperative non-union of closed femoral shaft fracture. Sci Rep 2024; 14:3543. [PMID: 38347044 PMCID: PMC10861573 DOI: 10.1038/s41598-024-53356-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 01/31/2024] [Indexed: 02/15/2024] Open
Abstract
Closed femoral shaft fracture is caused by high-energy injuries, and non-union exists after operation, which can significantly damage patients' body and mind. This study aimed to explore the factors influencing postoperative non-union of closed femoral shaft fractures and establish a predictive nomogram. Patients with closed femoral shaft fractures treated at Hebei Medical University Third Hospital between January 2015 and December 2021 were retrospectively enrolled. A total of 729 patients met the inclusion criteria; of them, those treated in 2015-2019 comprised the training cohort (n = 617), while those treated in 2020-2021 comprised the external validation cohort (n = 112). According to multivariate logistic regression analysis, complex fractures, bone defects, smoking, and postoperative infection were independent risk factors. Based on the factors, a predictive nomogram was constructed and validated. The C-indices in training and external validation cohorts were 0.818 and 0.781, respectively; and the C-index of internal validation via bootstrap resampling was 0.804. The Hosmer-Lemeshow test showed good fit of the nomogram (P > 0.05) consistent with the calibration plot results. The clinical effectiveness was best at a threshold probability of 0.10-0.40 in decision curve analysis. The risk prediction for patients with fractures using this nomogram may aid targeted prevention and rehabilitation programs.
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Affiliation(s)
- Wenjing Li
- Hebei Provincial Key Laboratory of Orthopaedic Biomechanics, Hebei Orthopaedic Research Institute, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
- School of Public Health, Hebei Medical University, No.361 Zhongshan East Road, Shijiazhuang, 050017, China
- Trauma Emergency Center, Hebei Medical University Third Hospital, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
| | - Yan Wang
- Hebei Provincial Key Laboratory of Orthopaedic Biomechanics, Hebei Orthopaedic Research Institute, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
- School of Public Health, Hebei Medical University, No.361 Zhongshan East Road, Shijiazhuang, 050017, China
- Trauma Emergency Center, Hebei Medical University Third Hospital, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
| | - Shuai Zhou
- Hebei Provincial Key Laboratory of Orthopaedic Biomechanics, Hebei Orthopaedic Research Institute, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
- School of Public Health, Hebei Medical University, No.361 Zhongshan East Road, Shijiazhuang, 050017, China
- Trauma Emergency Center, Hebei Medical University Third Hospital, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
| | - Shihang Liu
- Hebei Provincial Key Laboratory of Orthopaedic Biomechanics, Hebei Orthopaedic Research Institute, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
- School of Public Health, Hebei Medical University, No.361 Zhongshan East Road, Shijiazhuang, 050017, China
- Trauma Emergency Center, Hebei Medical University Third Hospital, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
| | - Luqin Di
- Trauma Emergency Center, Hebei Medical University Third Hospital, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
| | - Wei Chen
- Hebei Provincial Key Laboratory of Orthopaedic Biomechanics, Hebei Orthopaedic Research Institute, No. 139 Ziqiang Road, Shijiazhuang, 050051, China.
- Trauma Emergency Center, Hebei Medical University Third Hospital, No. 139 Ziqiang Road, Shijiazhuang, 050051, China.
| | - Hongzhi Lv
- Hebei Provincial Key Laboratory of Orthopaedic Biomechanics, Hebei Orthopaedic Research Institute, No. 139 Ziqiang Road, Shijiazhuang, 050051, China.
- School of Public Health, Hebei Medical University, No.361 Zhongshan East Road, Shijiazhuang, 050017, China.
- Trauma Emergency Center, Hebei Medical University Third Hospital, No. 139 Ziqiang Road, Shijiazhuang, 050051, China.
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Srikant K, Soni A, Pradhan S, Gulia A, Sandeep B, Kafley R, Venkatesan V, S S, Mohanty SA. Ilizarov Fixator-Assisted Management of Neglected Femur Fractures by Open Intramedullary Nailing: A Case Series. Cureus 2023; 15:e50864. [PMID: 38259399 PMCID: PMC10801114 DOI: 10.7759/cureus.50864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2023] [Indexed: 01/24/2024] Open
Abstract
Femoral shaft fractures are major life- and limb-threatening injuries. Such injuries, when neglected for months or years, can lead to a range of debilitating consequences. In the Indian subcontinent, there are multiple such cases that are presented to tertiary care hospitals late due to a lack of awareness and low socioeconomic constraints. These neglected cases on presentation are usually in a state of nonunion or malunion, with gross shortening and deformity affecting adjacent joint mobility. The management of neglected femur shaft fractures (NFFs) demands uphill tasks, such as achieving mechanical stability, restoring length and alignment, and having strong rehabilitation schedules. The functional outcomes of these cases are always not proportional to their radiological counterparts and must be taken care of separately. In this study, intramedullary nailing of the fracture after initial distraction with the Ilizarov fixator aims to reduce deformity and shortening while restoring near-optimal functional life. The study aimed to evaluate the functional and radiological outcomes of NFFs operated with distraction by an Ilizarov fixator followed by intramedullary nailing. METHODS Fourteen cases of NFFs presented to Kalinga Institute of Medical Sciences, Bhubaneswar, India, between January 2020 and June 2022 were recruited for the study. After preoperative evaluation and explanation of available treatment options to patients, they were operated on with a two-stage procedure of Ilizarov fixator application, followed by intramedullary interlocking nailing, with a period of gradual distraction in between. They were then followed up for a minimum of 12 months to assess functional and radiological outcomes. RESULTS The average time for all of the fractures to heal was 25.2 weeks. The average knee flexion increased from 28.2 degrees before surgery to 87.1 degrees after surgery. All 14 patients could walk with complete weight bearing on the operated limb postoperatively after proper pain control measures were taken. The mean Tegner Lysholm knee score was 77.8. There was residual limping in six of the cases, which could be attributed to muscle atrophy and/or shortening in the affected limbs. In three cases, skin blisters were formed due to the acute nature of the distraction, but they all healed with a scab and scar, otherwise uneventfully. The shortening, in 13 cases, came down to 4 cm or less, which was managed with a shoe raise. The one case with a residual 5 cm shortening had a short, limping gait, and it was attributed to an extremely overriding osteopenic femur preoperatively. CONCLUSION A two-stage operation with distraction by an Illizarov fixator followed by an intramedullary fixation provides the basic advantage of not having to excise an excessive amount of bone, which may be required in primary open reduction and intramedullary fixation. It also allows the patient to carry on his daily activities as mobilization is not restricted, which is the case in an individual to whom skeletal traction is applied. Hence, in any NFF case, this algorithm of management can be considered a frontrunner in the comprehensive management of disability and deformity.
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Affiliation(s)
- Konchada Srikant
- Orthopaedics, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | - Amar Soni
- Orthopaedics, Soni Hospital, Dahod, IND
| | - Sandeep Pradhan
- Orthopaedics, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | - Ankit Gulia
- Orthopaedics, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | - Bodanapu Sandeep
- Orthopaedics, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | - Rishab Kafley
- Orthopaedics, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | | | - Sayashi S
- Orthopaedics, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
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Concha JM, Osma JL, Fantín E, Concha C, Caicedo AJ. Augmentative lag screws as a treatment for aseptic hypertrophic nonunion after internal fracture fixation. Injury 2023; 54 Suppl 6:110805. [PMID: 38143134 DOI: 10.1016/j.injury.2023.05.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/05/2023] [Accepted: 05/11/2023] [Indexed: 12/26/2023]
Abstract
BACKGROUND Hypertrophic nonunion after intramedullary (IM) nailing and plating is Uncommon and the treatment remained controversial. The aim of this study was to show the result of a simple augmentative lag screws technique for vital non-unions after internal fixation PATIENTS AND METHODS: We retrospectively reviewed the patients with nonunion after internal fixation between January 2016 to August 2022. Patients with unacceptable shortening or deformity were excluded as well as nonunion septic cases. All the patients were followed up for at least 6 months. RESULTS Seven patients achieved bony union in a median time of 12 weeks (IRQ 12-16). There was a failure case with persistent non-union and brokerage of the screws. DISCUSSION Various techniques have been described to treat non-union after intramedullary nailing or plating. The existing nail is frequently removed, and the non-union site is either re-reamed and re-nailed or fixed with a plate or external fixation devices or rechanged by a nail in the case of plates. In our study of non-union, augmentative lag screws were successfully applied to treat eight patients with aseptic nonunion, resulting in the healing of non-union in all cases except one. CONCLUSION Augmentative lag screws represent a simple technique for the management of aseptic hypertrophic nonunion after internal fixation with a significantly shorter operating time.
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Affiliation(s)
- Juan Manuel Concha
- Departamento de Ciencias Quirúrgicas, Universidad del Cauca, Popayán Colombia; Hospital Susana López de Valencia, Popayán, Colombia.
| | - Jose Luis Osma
- Universidad Industrial de Santander, Bucaramanga, Colombia.
| | - Emilio Fantín
- IUCBC Instituto Universitario de Ciencias Biomédicas, Cordoba, Argentina.
| | - Carolina Concha
- Department Facultad de Medicina, Institution Pontificia, Universidad Javeriana, Bogotá, Colombia.
| | - Alvaro Jose Caicedo
- Department Facultad de Medicina, Institution Pontificia, Universidad Javeriana, Cali, Colombia.
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Kavanagh AM, Schumann J, Burgess BJ. Intramedullary Nail Fixation for the Treatment of Symptomatic Fibular Nonunion: A Case Series. Foot Ankle Spec 2023:19386400231193620. [PMID: 37608750 DOI: 10.1177/19386400231193620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Ankle fractures are a relatively common injury in the lower extremity. They can be treated with conservative management if they are nondisplaced and only involve the fibula. Nonunions at the fracture site, however, are a potential complicating factor during treatment. There is growing literature supporting the use of intramedullary fixation for fracture care. Not only does it have the advantages of using smaller incisions to preserve periosteum while providing improved biomechanical outcomes, but intramedullary reaming can help stimulate cells to promote bone healing. Few articles discuss the use and success of intramedullary reaming in revision surgery of the distal fibula. We present 3 cases of computed tomography-confirmed fibular nonunion following conservative fracture care, which underwent revision surgery with fibular nail fixation technique. These cases illustrate clinical and image findings as well as highlight the surgical technique used for each patient. At follow-up, all patients were asymptomatic and radiographs confirmed healing of the previous nonunion site. These cases are examples of successful revision for fibular fracture nonunion using intramedullary nail fixation.Level of Evidence: Level IV: Case series.
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Affiliation(s)
- Amber M Kavanagh
- Division of Hinsdale Orthopaedics, Illinois Bone & Joint Institute, Joliet, Illinois
| | - Jaclyn Schumann
- Division of Hinsdale Orthopaedics, Illinois Bone & Joint Institute, Joliet, Illinois
| | - Brian J Burgess
- Division of Hinsdale Orthopaedics, Illinois Bone & Joint Institute, Joliet, Illinois
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Bianco Prevot L, Nannini A, Mangiavini L, Bobba A, Buzzi S, Sinigaglia F, Peretti G. What Is the Best Treatment of the Femoral Shaft Nonunion after Intramedullary Nailing? A Systematic Review. Life (Basel) 2023; 13:1508. [PMID: 37511883 PMCID: PMC10381168 DOI: 10.3390/life13071508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/30/2023] [Accepted: 07/03/2023] [Indexed: 07/30/2023] Open
Abstract
Nonunion (NU) is one of the most feared complications of femoral shaft fracture treatment. Femoral shaft fracture treatment is often linked with poor bone stock and reduced bone metabolism. In this paper, the goal is to carefully analyze the best treatment options for patients who developed nonunion after the intramedullary nailing of a femoral shaft fracture. A systematic review of the literature available in the PubMed, EMBASE and Cochran library databases was carried out, and 16 studies were included. Exclusion criteria included case reports and case series that do not have data about clinical outcomes or functional outcomes and included fewer than 10 patients. The reviewed data provide evidence for very good results about the treatment of this pathology with exchanging intramedullary nails or the implantation of a plate and screws (general healing rate of 96.3%). Moreover, the data support the utilization of autologous bone graft in order to stimulate the healing process. In conclusion, the choice between these two types of treatment must be guided by the type of pseudarthrosis that the patient presents. Additionally, bone grafting or growth factors promote bone regenerative processes, especially in patients with oligo-atrophic pseudoarthrosis.
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Affiliation(s)
- Luca Bianco Prevot
- IRCCS Galeazzi-S. Ambrogio Institute, EUORR University Equip of Regenerative and Reconstructive Orthopedics, Via Cristina Belgioioso 173, 20157 Milan, Italy
| | - Alessandra Nannini
- IRCCS Galeazzi-S. Ambrogio Institute, EUORR University Equip of Regenerative and Reconstructive Orthopedics, Via Cristina Belgioioso 173, 20157 Milan, Italy
| | - Laura Mangiavini
- IRCCS Galeazzi-S. Ambrogio Institute, EUORR University Equip of Regenerative and Reconstructive Orthopedics, Via Cristina Belgioioso 173, 20157 Milan, Italy
| | - Andrea Bobba
- IRCCS Galeazzi-S. Ambrogio Institute, EUORR University Equip of Regenerative and Reconstructive Orthopedics, Via Cristina Belgioioso 173, 20157 Milan, Italy
| | - Sara Buzzi
- IRCCS Galeazzi-S. Ambrogio Institute, EUORR University Equip of Regenerative and Reconstructive Orthopedics, Via Cristina Belgioioso 173, 20157 Milan, Italy
| | - Federico Sinigaglia
- IRCCS Galeazzi-S. Ambrogio Institute, EUORR University Equip of Regenerative and Reconstructive Orthopedics, Via Cristina Belgioioso 173, 20157 Milan, Italy
| | - Giuseppe Peretti
- IRCCS Galeazzi-S. Ambrogio Institute, EUORR University Equip of Regenerative and Reconstructive Orthopedics, Via Cristina Belgioioso 173, 20157 Milan, Italy
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Çimen O, Öner A, Köksal A, Dırvar F, Mert M, Kargın D. A comparison of exchange nailing and plate augmentation over a retained intramedullary nail in aseptic oligotrophic and atrophic femoral shaft pseudoarthrosis. Jt Dis Relat Surg 2023; 34:121-129. [PMID: 36700273 PMCID: PMC9903120 DOI: 10.52312/jdrs.2023.788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 11/22/2022] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES This study aims to evaluate the success of plate augmentation over a retained intramedullary nail (IMN) against exchange nailing performed with autologous bone grafting in oligotrophic and atrophic pseudoarthrosis of the femoral shaft. PATIENTS AND METHODS Between May 2005 and October 2020, a total of 42 of 56 patients (28 males, 14 females; mean age: 47.3±17.2 years; range, 19 to 84 years) with aseptic atrophic or oligotrophic femoral nonunion were retrospectively analyzed. The patients, 20 were operated with plate over a retained IMN, and the rest (n=22) by exchange nailing. Data including demographic and clinical characteristics of the patients, treatment success, duration of surgery, blood loss during surgery, infection rates, length of hospital stay, time to bridging of the nonunion site, and time to obliteration of the fracture line (solid union) were recorded. RESULTS The mean follow-up was 23.8±20.4 (range, 12 to 96) months in the plate over an IMN group and 34.7±27.4 (range, 12 to 90) months in the exchange nailing group. At the final follow-up, solid union occurred in all of the patients in the plate augmentation over a retained IMN group, and 21 of 22 (95.45%) patients in the exchange nailing group. Blood loss during surgery was significantly less in the plate augmentation over IMN group (p=0.027). There was no statistically significant difference in the other variables between the two groups (p>0.05). CONCLUSION Our study results demonstrate that plate over a retained IMN is effective as exchange nailing in the surgical treatment of oligotrophic and atrophic pseudoarthrosis of the femoral shaft. However, it can be speculated that plate application over IMN is more advantageous in terms of blood loss during surgery.
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Affiliation(s)
- Osman Çimen
- Metin Sabancı Baltalimanı Kemik Hastalıkları Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, Araştırma Hastanesi, 34470 Sarıyer, İstanbul, Türkiye.
| | - Ali Öner
- Department of Orthopedics and Traumatology, Ministry of Health Metin Sabancı Baltalimanı Bone and Joint Diseases Training and Research Hospital, İstanbul, Türkiye
| | - Alper Köksal
- Department of Orthopedics and Traumatology, Ministry of Health Metin Sabancı Baltalimanı Bone and Joint Diseases Training and Research Hospital, İstanbul, Türkiye
| | - Ferdi Dırvar
- Department of Orthopedics and Traumatology, Ministry of Health Metin Sabancı Baltalimanı Bone and Joint Diseases Training and Research Hospital, İstanbul, Türkiye
| | - Muhammed Mert
- Department of Orthopedics and Traumatology, Ministry of Health Metin Sabancı Baltalimanı Bone and Joint Diseases Training and Research Hospital, İstanbul, Türkiye
| | - Deniz Kargın
- Department of Orthopedics and Traumatology, Ministry of Health Metin Sabancı Baltalimanı Bone and Joint Diseases Training and Research Hospital, İstanbul, Türkiye
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11
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Wu T, Zhang W, Chang Z, Zhu Z, Sun L, Tang P, Chen H. Augmented Stability in Leaving Original Internal Fixation with Multidimensional Cross Locking Plate through Mini-Open Femoral Anterior Approach for Aseptic Femoral Shaft Nonunion: A Retrospective Cohort Study. Orthop Surg 2022; 15:169-178. [PMID: 36411511 PMCID: PMC9837237 DOI: 10.1111/os.13581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 10/05/2022] [Accepted: 10/11/2022] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Aseptic femoral shaft nonunion constitutes approximately 1%-10% of all femoral shaft fractures treated with intramedullary nail (IMN) fixation, possibly attributable to the lack of anti-rotational stability. Although a lateral locking plate (LP) with retainment of original IMN has shown the most success, lateral LP inflicts significant surgical trauma on patients. Therefore, the Multidimensional Cross Locking Plate (MDC-LP) was designed based on a mini-open femoral anterior approach. We aim to report and compare the technical aspects and clinical outcomes of using anterior MDC-LP or lateral LP with retention of original IMN for the treatment of aseptic femoral shaft nonunion. METHODS In this single center retrospective cohort study, records of 49 patients who had undergone revision of femoral shaft aseptic nonunion with anterior MDC-LP or lateral LP while retaining the original IMN from January 2015 to October 2019 were retrospectively reviewed. Information on patients' demographics, clinical data, and surgical outcomes were gathered and analyzed. X-ray and CT scans were used for bone union evaluation and the lower extremity functional scale (LEFS) was used for follow-up functional evaluation. For quantitative data, the Student's t-test was used if the data were normally distributed. The Mann-Whitney U-test was used for non-normally distributed data. For qualitative data, the Chi-square test was used for comparisons. RESULTS Twenty-seven patients were treated with anterior MDC-LP, and 22 patients were treated with lateral LP. There are no significant differences in age, sex, BMI, time since initial femoral shaft fracture, initial fracture type (close/open), nonunion type, or nonunion location between patients' group. Among patients treated with anterior MDC-LP, an average of 2-months advantage in time to union was observed (4.09 months vs. 6.8 months in the lateral LP group: P = 0.000), smaller incision was required for MDC-LP installment (7.7 cm vs 17.1 cm in lateral LP group: P = 0.000). CONCLUSIONS For the treatment of aseptic femoral shaft nonunion with retainment of original IMN, anterior MDC-LP via mini-open femoral anterior approach described in this study is a better option than lateral LP for achieving faster bone union and satisfactory functional outcome with less surgical trauma.
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Affiliation(s)
- Taoguang Wu
- Department of Orthopedic Surgerythe fourth medical center, Chinese PLA General hospitalBeijingChina
| | - Wei Zhang
- School of Sports EngineeringBeijing Sport UniversityBeijingChina
| | - Zuhao Chang
- Department of Orthopedic Surgerythe fourth medical center, Chinese PLA General hospitalBeijingChina
| | - Zhengguo Zhu
- Department of Orthopedic Surgerythe fourth medical center, Chinese PLA General hospitalBeijingChina
| | - Lijun Sun
- Department of Orthopedic Surgerythe fourth medical center, Chinese PLA General hospitalBeijingChina
| | - Peifu Tang
- Department of Orthopedic Surgerythe fourth medical center, Chinese PLA General hospitalBeijingChina
| | - Hua Chen
- Department of Orthopedic Surgerythe fourth medical center, Chinese PLA General hospitalBeijingChina
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12
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Najafi A, Shahbazi P, Azarsina S, Zargar D, Kahrizi MS, Hadavi D, Minaei-Noshahr R. Cortical bridging a union predictor: A prospective study after intramedullary nailing of the femoral shaft fractures. Eur J Transl Myol 2022; 32:10835. [PMID: 36305702 PMCID: PMC9830402 DOI: 10.4081/ejtm.2022.10835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 10/12/2022] [Indexed: 01/13/2023] Open
Abstract
Early prediction of the union helps for timely intervention, reduction of hospitalization, treatment costs, and disability in cases of nonunion. With this in mind, we tried to find how long any cortical bridging predicts the union in femoral shaft fractures. A prospective study of 113 femoral shaft fractures treated with reamed, locked intramedullary nailing was performed. Radiographs were taken during months 2 to 4, 6, 9, and one-year follow-up. The cortical bridging (presence and number) was assessed by anterior-posterior and lateral views. The ROC curve provides the prediction of the union. The overall nonunion rate was 10.6% (12 of 113 fractures). Age and diabetes mellitus were statistically significant with nonunion (p value < 0.001). The final analysis demonstrated that any cortical bridging at four months postoperatively was the most accurate and earlier indicator (105 of 113, 92.9% accuracy), while it was 84.9% at six months in bicortical and 80.5% accuracy at nine months in tricortical bridging. Low-cost and simple radiographic imaging presents cortical bridging in any form 4 months after surgery that precisely predicts a union in femoral shaft fractures.
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Affiliation(s)
- Arvin Najafi
- Department of Orthopedic Surgery, Shahid Madani Hospital, Alborz University of Medical Sciences, Karaj, Iran
| | - Parmida Shahbazi
- Department of Orthopedic Surgery, Shahid Madani Hospital, Alborz University of Medical Sciences, Karaj, Iran
| | - Salman Azarsina
- Department of Orthopedic Surgery, Shahid Madani Hospital, Alborz University of Medical Sciences, Karaj, Iran
| | - Danoosh Zargar
- Department of Orthopedic Surgery, Shahid Madani Hospital, Alborz University of Medical Sciences, Karaj, Iran
| | - Mohammad Saeed Kahrizi
- Department of Orthopedic Surgery, Shahid Madani Hospital, Alborz University of Medical Sciences, Karaj, Iran
| | - Dorsa Hadavi
- Department of Orthopedic Surgery, Shahid Madani Hospital, Alborz University of Medical Sciences, Karaj, Iran
| | - Reza Minaei-Noshahr
- Bone, Joint and Related Tissues Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran,Assistant Professor of orthopedic surgery, Bone, Joint and Related Tissues Research Center, Shahid Beheshti University of Medical Sciences, Velenjak St., Shahid Chamran Highway Tehran, Iran. Phone: +98912 857 6268. ORCID iD: 0000-0002-7851-842X
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13
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Nonunion of the femoral shaft associated with limb shortening treated with a combined technique of external fixation over an intramedullary nail versus the Ilizarov method. Arch Orthop Trauma Surg 2022; 142:2185-2192. [PMID: 33651147 DOI: 10.1007/s00402-021-03804-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 01/25/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Post-traumatic nonunion of the femur remains a challenging problem even for experienced orthopedic surgeons. The main question is the choice of the optimal surgical tool. MATERIALS AND METHODS Management of 20 patients with nonunion of the femoral diaphysis associated with anatomical shortening was retrospectively analyzed. Group A (n = 14) was treated with a hybrid technique that combined the Ilizarov external fixation and intramedullary nailing. The Ilizarov bone transport was used in group B (n = 6). Patients of both groups had aseptic post-traumatic nonunion. Mean shortening was 4.5 ± 0.4 cm in group A and 4.8 ± 1.0 cm in group B (p = 0.459959). RESULTS Union was achieved in 85.7% of group A and 100% of group B patients. External fixation was repeated in two cases of group A and achieved consolidation. Deep infection developed in one case of group A after 15 months post-frame with the nail in. It was resolved by nail removal, surgical debridement and external fixation. Limb shortening was fully eliminated in eleven cases of group A and four patients of group B. The average duration of distraction was 35.3 ± 1.7 days in group A and 47.8 ± 9.3 days in group B. The total duration of external fixation was 49.1 ± 3.5 and 177.2 ± 21.9 days with an external fixation index of 13.1 ± 1.2 and 52.4 ± 6.4 days/cm, respectively. Distraction regenerate consolidated in all the cases. CONCLUSION Hybrid technique provides bone union with compensation of limb shortening and reduces the treatment period as compared with the Ilizarov method used alone. However, deep infection may happen.
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14
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Hackl S, Trenkwalder K, Militz M, Augat P, Stuby FM, von Rüden C. [Infected nonunion: diagnostic and therapeutic work-up]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2022; 125:602-610. [PMID: 35750886 DOI: 10.1007/s00113-022-01204-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/02/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Septic nonunion is one of the major complications in fracture healing. The challenge is to identify the infection as the cause of nonunion first and then to achieve healing of the infection and the bone. OBJECTIVE Because of the more heterogeneous appearance of an infected nonunion, the prevalence of germ detection in surgical nonunion revision is often underestimated. MATERIAL AND METHODS In a retrospective study between 2010 and 2017, 86 patients with radiologically confirmed femoral shaft nonunion without clinical evidence and unremarkable medical history of a florid infection as the cause of nonunion, who had undergone primary single-stage surgical nonunion revision were analyzed. At least four intraoperatively obtained samples were evaluated for microbiological diagnosis. A distinction was made between tissue samples with subsequent 48‑h short-term incubation and tissue samples with 14-day long-term cultivation. The finding "germ detection" was made if at least two of the samples demonstrated bacterial growth. RESULTS In 18 of 86 patients with a nonunion preoperatively judged to be aseptic, positive bacterial evidence was obtained after short-term incubation. After long-term cultivation, positive bacterial detection was possible in 38 of 86 patients with a femoral shaft nonunion initially classified as aseptic. Regarding potential risk factors, the two groups demonstrated no relevant differences. In 29 patients, 1 pathogen was isolated from the obtained samples, whereas in the remaining 9 patients, a mixed culture with an average of 2.9 ± 0.5 different bacteria was detected. Identification revealed mainly low-virulence bacteria, most commonly Staphylococcus epidermidis. CONCLUSION If the preoperative diagnostics including clinical, laboratory and radiological examination as well as a careful anamnesis reveal indications of a possible infectious event, the surgical nonunion revision should be performed in two stages with specimen collection before definitive nonunion revision. For microbiological diagnosis, several representative tissue samples should independently be obtained from the nonunion site and incubated for 14 days. Only in the absence of evidence of septic nonunion is a single-stage procedure suggested.
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Affiliation(s)
- Simon Hackl
- Abteilung Unfallchirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland.
- Universitätsinstitut für Biomechanik, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich.
| | - Katharina Trenkwalder
- Institut für Biomechanik, BG Unfallklinik Murnau, Murnau, Deutschland
- Universitätsinstitut für Biomechanik, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich
| | - Matthias Militz
- Abteilung Unfallchirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland
| | - Peter Augat
- Institut für Biomechanik, BG Unfallklinik Murnau, Murnau, Deutschland
- Universitätsinstitut für Biomechanik, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich
| | - Fabian M Stuby
- Abteilung Unfallchirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland
| | - Christian von Rüden
- Abteilung Unfallchirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland.
- Universitätsinstitut für Biomechanik, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich.
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15
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Wu CC. Aseptic femoral nonunion treated with exchange locked nailing with intramedullary augmentation cancellous bone graft. J Orthop Surg Res 2022; 17:339. [PMID: 35794570 PMCID: PMC9258056 DOI: 10.1186/s13018-022-03229-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/26/2022] [Indexed: 11/20/2022] Open
Abstract
Background Closed reamed locked intramedullary nailing has been the treatment of choice for most of femoral shaft fractures. A high union rate with a low complication rate is generally predictable. For an aseptic femoral shaft nonunion with a prior inserted intramedullary nail, exchange nailing is one of favored surgical techniques for treatment. However, a greatly varied success rate of 72–100% has been reported. To improve the success rate of exchange femur nailing, a modified bone grafting technique was developed. The purpose of this retrospective study intended to evaluate outcomes of such a revised technique. Methods From July 2011 to March 2019, 48 consecutive adult patients (average, 38 years; range, 19–67 years) with aseptic femoral shaft nonunions after intramedullary nailing treatment were studied. All femoral shaft fractures were initially caused by traffic accidents, which were treated by a closed or open intramedullary nailing technique at various hospitals. The current revision treatment was performed after an average of 2.2 years (range 1.1–6.2 years) from initial injuries. In the surgery, the prior nail was removed and the marrow cavity was reamed widely (at least 2 mm as possible). Sufficient cancellous bone grafts harvested on the trochanteric marrow wall from the inside were placed in the marrow cavity of the junction of nonunion fragments. A new 1-mm smaller size locked intramedullary nail was inserted. Whether the dynamic or static mode of nails were used mainly depended on the nonunion level. Postoperatively, protected weight bearing with crutches was allowed for all patients. Results Forty-one patients were followed for an average of 2.8 years (85.4%; range, 1.9–4.5 years) and all fractures healed. The union rate was 100% (41/41, p < 0.001) with a union time of an average of 3.4 months (range, 2.5–5.0 months). There were no complications of deep infection, nonunions, malunions, implant failures or an avulsed trochanter tip fracture. The satisfactory knee function improved from 73.2% (30/41) preoperatively to 92.7% (38/41) at the latest follow-up (p = 0.019). Conclusions The described modified bone grafting technique may effectively improve a union rate of exchange femur nailing while the surgical procedure is not complicated. It may therefore be used concomitantly in all aseptic femoral shaft nonunions when exchange nailing is performed.
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16
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Pasque CB, Pappas AJ, Cole Jr CA. Intramedullary bone pedestal formation contributing to femoral shaft fracture nonunion: A case report and review of the literature. World J Orthop 2022; 13:528-537. [PMID: 35633740 PMCID: PMC9124995 DOI: 10.5312/wjo.v13.i5.528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 11/28/2021] [Accepted: 04/25/2022] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Charles B Pasque
- Department of Orthopaedic Surgery and Rehabilitation, University of Oklahoma College of Medicine, Oklahoma City, OK 73104, United States
| | - Alexander J Pappas
- Department of Orthopaedic Surgery and Rehabilitation, University of Oklahoma College of Medicine, Oklahoma City, OK 73104, United States
| | - Chad A Cole Jr
- University of Colorado School of Medicine, Aurora, CO 80045, United States
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17
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Risk Factors for Development of a Recalcitrant Femoral Nonunion: A Single Surgeon Experience in 122 Patients. J Orthop Trauma 2021; 35:619-625. [PMID: 34596060 DOI: 10.1097/bot.0000000000002276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The goals of the study were (1) to document the healing rates of femoral nonunions stratified by those that healed as intended, healed after a subsequent intervention, and those that did not heal; (2) to report the prevalence of recalcitrant femoral nonunions and (3) to identify specific demographic, injury, and treatment-related risk factors for the development of a recalcitrant nonunion. DESIGN Longitudinal observational cohort study. SETTING Academic Level 1 trauma center. PATIENTS/PARTICIPANTS One hundred twenty-two femoral nonunions treated with either a plate or intramedullary nail by a single surgeon between 1991 and 2018. INTERVENTION Bivariate and multivariate regression analysis were performed to identify specific demographic, injury, and treatment factors in patients who developed a recalcitrant nonunion. RESULTS Although 83.6% of the femoral nonunions eventually healed, only 66% "healed as intended" with 17.2% requiring 1 or more additional procedures to consolidate and 16.4% of nonunions failing to unite. There were no statistically significant differences in the recalcitrance rate when we compared treatment with conventional versus locked plates or primary versus exchange nailing. Risk factors for developing a recalcitrant nonunion were deep infection, current smokers, metabolic bone disease, and patients who had undergone 3 or more prior surgical procedures. CONCLUSIONS The use of both intramedullary nails and modern plates were associated with a high rate of recalcitrance. Infection, current smokers, metabolic bone disease, and 3 or more prior surgical procedures were predictors for the development of a recalcitrant nonunion. LEVEL OF EVIDENCE Therapeutic Leve IV. See Instructions for Authors for a complete description of levels of evidence.
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18
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Gönder N, Demir İH, Öğümsöğütlü E, Kılınçoğlu V. Collagen/Nano-hydroxyapatite Composite Scaffold Application with Exchange Reamed Nailing Accelerates Bone Union and Improves Quality of Life in Atrophic Femoral Shaft Nonunions: A Retrospective Comparative Study. Indian J Orthop 2021; 56:412-420. [PMID: 35251504 PMCID: PMC8854517 DOI: 10.1007/s43465-021-00545-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 10/10/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Our aim in this study was to evaluate the effect of exchange intramedullary nailing in femoral shaft atrophic nonunions and the use of collagen/nano-hydroxyapatite composite scaffold applied in addition to the cancellous iliac crest autograft on the union, return to work, and quality of life. MATERIALS AND METHODS Fifty-four patients with an atrophic nonunion in the isthmic region of the femoral shaft were included in the study. The patients were divided into two groups. Group A consisted of 24 patients who underwent collagen/nano-hydroxyapatite composite scaffold in addition to exchange intramedullary nailing and iliac autograft, while group B consisted of 30 patients without scaffold. Short Form-36 (SF-36) questionnaire scores, union rates, time to union, return to work were complications were compared. RESULTS Mean age of patients was 47.5 ± 14.1. The mean follow-up period was 3.56 ± 1.88 years. There was no statistically significant difference between Group A and B in terms of age, gender, smoking and alcohol use, and trauma mechanism. Time to union and return to work were statistically significantly shorter in Group A than in Group B (p = 0.004, p = 0.001). All of the SF-36 survey scores at month six were better in Group A. In the first year, mental health and general health perception were still statistically better in group A (p = 0.009, p = 0.008). CONCLUSION In the treatment of atrophic nonunions of the femoral shaft isthmic region, the use of collagen/nano-hydroxyapatite composite scaffolds together with exchange intramedullary nailing affects the union positively. This positive effect also brings about earlier return to work and better quality of life.
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Affiliation(s)
- Nevzat Gönder
- Department of Orthopaedics and Traumatology, T.C. Ministry of Health Islahiye State Hospital, 27800 Gaziantep, Turkey
| | - İbrahim Halil Demir
- Department of Orthopaedics and Traumatology, Gaziantep University Faculty of Medicine, 27310 Gaziantep, Turkey
| | - Erman Öğümsöğütlü
- Department of Orthopaedics and Traumatology, Gaziantep University Faculty of Medicine, 27310 Gaziantep, Turkey
| | - Volkan Kılınçoğlu
- Department of Orthopaedics and Traumatology, Gaziantep University Faculty of Medicine, 27310 Gaziantep, Turkey
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19
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Braun BJ, Orth M, Diebels S, Wickert K, Andres A, Gawlitza J, Bücker A, Pohlemann T, Roland M. Individualized Determination of the Mechanical Fracture Environment After Tibial Exchange Nailing-A Simulation-Based Feasibility Study. Front Surg 2021; 8:749209. [PMID: 34660686 PMCID: PMC8511819 DOI: 10.3389/fsurg.2021.749209] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 09/01/2021] [Indexed: 01/08/2023] Open
Abstract
Non-union rate after tibial fractures remains high. Apart from largely uncontrollable biologic, injury, and patient-specific factors, the mechanical fracture environment is a key determinant of healing. Our aim was to establish a patient-specific simulation workflow to determine the mechanical fracture environment and allow for an estimation of its healing potential. In a referred patient with failed nail-osteosynthesis after tibial-shaft fracture exchange nailing was performed. Post-operative CT-scans were used to construct a three-dimensional model of the treatment situation in an image processing and computer-aided design system. Resulting forces, computed in a simulation-driven workflow based on patient monitoring and motion capturing were used to simulate the mechanical fracture environment before and after exchange nailing. Implant stresses for the initial and revision situation, as well as interfragmentary movement, resulting hydrostatic, and octahedral shear strain were calculated and compared to the clinical course. The simulation model was able to adequately predict hardware stresses in the initial situation where mechanical implant failure occurred. Furthermore, hydrostatic and octahedral shear strain of the revision situation were calculated to be within published healing boundaries—accordingly the fracture healed uneventfully. Our workflow is able to determine the mechanical environment of a fracture fixation, calculate implant stresses, interfragmentary movement, and the resulting strain. Critical mechanical boundary conditions for fracture healing can be determined in relation to individual loading parameters. Based on this individualized treatment recommendations during the early post-operative phase in lower leg fractures are possible in order to prevent implant failure and non-union development.
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Affiliation(s)
- Benedikt J Braun
- University Hospital Tuebingen on Behalf of the Eberhard-Karls-University Tuebingen, Faculty of Medicine, BG Hospital Tuebingen, Tuebingen, Germany
| | - Marcel Orth
- Department of Trauma, Hand and Reconstructive Surgery, Saarland University Hospital, Homburg, Germany
| | - Stefan Diebels
- Department of Applied Mechanics, Saarland University, Saarbruecken, Germany
| | - Kerstin Wickert
- Department of Applied Mechanics, Saarland University, Saarbruecken, Germany
| | - Annchristin Andres
- Department of Applied Mechanics, Saarland University, Saarbruecken, Germany
| | - Joshua Gawlitza
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, Munich, Germany
| | - Arno Bücker
- Clinic of Diagnostic and Interventional Radiology, Saarland University Hospital, Homburg, Germany
| | - Tim Pohlemann
- Department of Trauma, Hand and Reconstructive Surgery, Saarland University Hospital, Homburg, Germany
| | - Michael Roland
- Department of Applied Mechanics, Saarland University, Saarbruecken, Germany
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Santoshi JA, Reddy L, Agrawal U. Femoral Neck Nonunion Associated With Delayed Union of Ipsilateral Femoral Shaft Fracture. Cureus 2021; 13:e15612. [PMID: 34277230 PMCID: PMC8274465 DOI: 10.7759/cureus.15612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2021] [Indexed: 11/29/2022] Open
Abstract
We report the case of a 36-year-old man, who presented to us five months after the initial trauma. He had been treated elsewhere with a cephalomedullary femoral nail. He described severe pain in his right thigh and groin that confined him to a wheelchair. He had shortening of the right lower limb and painful restriction of movements of the right hip. Radiographs demonstrated hypertrophic callus with a gap at the femoral shaft while the neck fracture was in varus malalignment with bone resorption; the neck fracture been fixed using two hip screws that were missing the nail. The patient was managed with removal of the previous hardware, reamed retrograde nailing and Pauwels’ intertrochanteric valgus osteotomy fixed using a 120o double-angled condylar blade plate. Both the fracture sites were not opened. Postoperatively, the femoral shaft showed radiographic evidence of union at three months, while the femoral neck and the intertrochanteric osteotomy site had united at five months. As per the Friedman and Wyman criteria, our patient has a “good” outcome at the four-year follow-up.
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Affiliation(s)
- John A Santoshi
- Orthopaedics, All India Institute of Medical Sciences, Bhopal, IND
| | - Lingaraj Reddy
- Orthopaedics, Pondicherry Institute of Medical Sciences, Puducherry, IND
| | - Udit Agrawal
- Orthopaedics, All India Institute of Medical Sciences, Bhopal, IND
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21
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Fracture nonunion in long bones: A literature review of risk factors and surgical management. Injury 2021; 52 Suppl 2:S3-S11. [PMID: 33221036 DOI: 10.1016/j.injury.2020.11.029] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 11/06/2020] [Accepted: 11/10/2020] [Indexed: 02/02/2023]
Abstract
Nonunion following a long bone fracture causes considerable morbidity when it occurs. Risk factors depend on specific fractures but there is a complex interplay of injury severity, comorbidities, patient medication and infection. The majority of nonunions occur after long bone fractures with the tibia, femur, forearm, humerus and clavicle predominating. Despite interest in the biological augmentation of fracture healing, the majority of nonunions can be effectively managed with conventional surgical techniques. In this review we present a review of risk factors for nonunion and the outcome following surgical management.
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22
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Weil S, Fontalis A, Guessoum M, Trompeter A. Augmented compression in exchange nailing for femoral and tibial non-unions accelerates time to radiographic union. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:931-936. [PMID: 33709267 DOI: 10.1007/s00590-021-02900-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 02/08/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Exchange nailing is widely used for the management of aseptic femoral and tibial non-union. Compressive forces markedly reduce strain, increasing rate and incidence of union. Additional compressive forces can be applied to the non-union site by using the design features of some modern nailing systems. This study hypothesises that the use of additional compression in exchange nailing results in faster time to union. METHODS All femoral and tibial shaft non-unions were identified over a 4-year period between 2014-2018. Intraoperative compression during exchange nailing was either applied or not applied with a dedicated active compression device through the intramedullary nail. An initial 'radiographic union score for tibia' (RUST) score was calculated from preoperative lateral and AP radiographs and compared with the postoperative radiographs at 6-8 weeks. Healing was defined as bridging callus on at least three cortices (RUST > 10). RESULTS A total of 119 patients were identified. Following application of exclusion criteria, we analysed data for 19 patients, 10 undergoing exchange nailing with intraoperative compression and 9 without. The pre-exchange RUST score was comparable between the compressed group and standard exchange group with mean of 7.11 versus 7.5 (p = 0.636). At 6-8 weeks post-op, there was a significant difference between the median RUST score in the compressed group vs standard exchange group, 11 compared to 8.39 (p = 0.001). CONCLUSIONS Our study shows that time to union was accelerated when additional compression was applied to exchange nailing, resulting in reduced follow-up visits and number of radiographs required.
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Affiliation(s)
- Simon Weil
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, Blackshaw road, London, SW17 0QT, UK.
| | - Andreas Fontalis
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, Blackshaw road, London, SW17 0QT, UK
| | - Myriam Guessoum
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, Blackshaw road, London, SW17 0QT, UK
| | - Alex Trompeter
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, Blackshaw road, London, SW17 0QT, UK
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Predicting Functional Outcomes Following Fracture Nonunion Repair-Development and Validation of a Risk Profiling Tool. J Orthop Trauma 2020; 34:e214-e220. [PMID: 32433198 DOI: 10.1097/bot.0000000000001718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To develop a tool that can be used preoperatively to identify patients at risk of poor functional outcome following operative repair of fracture nonunion. DESIGN Retrospective analysis of prospectively collected data. SETTING Academic medical center. PATIENTS/PARTICIPANTS Three hundred twenty-eight patients who underwent operative repair of a fracture nonunion were prospectively followed for a minimum of 12 months post-operatively. INTERVENTION After randomization, 223 (68%) patients comprised an experimental cohort and 105 (32%) patients comprised a separate validation cohort. Within the experimental cohort, forward stepwise multivariate logistic regression was applied to 17 independent variables to generate a predictive model identifying patients at risk of having a poor functional outcome [Predicting Risk of Function in Trauma-Nonunion (PRoFiT-NU) Score]. MAIN OUTCOME MEASUREMENTS Functional outcomes were assessed using the Short Musculoskeletal Function Assessment (SMFA). Poor outcome was defined as an SMFA function index greater than 10 points above the mean at 12 months post-operatively. RESULTS Significant predictors of poor outcome were lower extremity nonunion [odds ratio (OR) = 3.082; P = 0.021], tobacco use (OR = 2.994; P = 0.009), worker's compensation insurance (OR = 3.986; P = 0.005), radiographic bone loss (OR = 2.397; P = 0.040), and preoperative SMFA function index (OR = 1.027; P = 0.001). The PRoFiT-NU model was significant and a good predictor of poor functional outcome (χ(5) = 51.98, P < 0.0005; area under the receiver operating curve = 0.79). Within the separate validation cohort, 16% of patients had a poor outcome at a PRoFiT-NU score below 25% (low risk), 39% of patients had a poor outcome at a PRoFiT-NU score between 25% and 50% (intermediate risk), and 63% of patients had a poor outcome at a PRoFiT-NU score above 50% (high risk). CONCLUSIONS The PRoFiT-NU score is an accurate predictor of poor functional outcome following fracture nonunion repair. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence description of levels of evidence.
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``Sandwich technique" with dual strut allograft in surgical treatment of femoral nonunion. Injury 2020; 51:1057-1061. [PMID: 32107008 DOI: 10.1016/j.injury.2020.02.090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 02/12/2020] [Accepted: 02/17/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The treatment of femoral nonunion is challenging for both the surgeon and the patient. Strut allografts increase the bone stock, enhance fracture healing and increase stability by acting as a biological plate. In this study, we aimed to report the results of the sandwich technique with two-strut allograft in the treatment of oligotrophic or atrophic femoral nonunions. METHODS Medical records of the patients who were treated due to femoral nonunion in a single center were retrospectively reviewed. Twenty-one patients (10 males, 11 females) with a mean age of 49 (range: 21 to 79) years were included in the study. The left side was affected in 11 patients, whereas the right side was affected in ten. The patients had 11 femoral shaft fractures, seven proximal femoral fractures and three distal femoral fractures. The mean time from the previous operation to the nonunion surgery was 9.6 (range: 6 to 22) months. RESULTS Union was achieved in all patients after a mean period of 6.2 (range: 4 to 10) months. The mean follow-up time was 46.8 (range: 12 to 86) months. One patient had superficial surgical site infection in the autologous graft donor site. CONCLUSION The sandwich technique with two-strut allograft provides good results in the treatment of femoral nonunion. The technique can be used on any type of nonunion, at any segment of the femur and can be combined with different fixation techniques.
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Hierholzer C, Friederichs J, Augat P, Woltmann A, Trapp O, Bühren V, von Rüden C. [Evolution and principles of intramedullary locked nailing]. Unfallchirurg 2019; 121:239-255. [PMID: 29464295 DOI: 10.1007/s00113-018-0461-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Key factors for successful osteosynthetic fracture stabilization are anatomical fracture reduction, restoration of axis and torsion alignment as well as tissue-preserving operative techniques. In long bone fractures, the use of intramedullary long bridging nailing offers ideal conditions for bone healing, as axial and rotational stability is provided by canal-filling nails and locking screws. In addition, the tissue in the fracture region is protected as the intramedullary nail insertion is distant from the fracture. The indication spectrum for modern intramedullary locked nailing includes diaphyseal fractures of long bones, metaphyseal fractures and reconstructions, as well as treatment of nonunion, osteotomy and arthrodesis of the lower extremities. Continuous improvements in nail design and instrumentation as well as the introduction of anatomical reconstruction nails will optimize the spectrum and effectiveness of intramedullary osteosynthesis even further.
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Affiliation(s)
- C Hierholzer
- Abteilung Unfallchirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland
- Klinik für Traumatologie, Universitätsspital Zürich, Zürich, Schweiz
| | - J Friederichs
- Abteilung Unfallchirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland
| | - P Augat
- Universitätsinstitut für Biomechanik, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich
- Institut für Biomechanik, BG Unfallklinik Murnau, Murnau, Deutschland
| | - A Woltmann
- Abteilung Unfallchirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland
| | - O Trapp
- Abteilung Unfallchirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland
| | - V Bühren
- Abteilung Unfallchirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland
| | - C von Rüden
- Abteilung Unfallchirurgie, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland.
- Universitätsinstitut für Biomechanik, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich.
- Institut für Biomechanik, BG Unfallklinik Murnau, Murnau, Deutschland.
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Mardani-Kivi M, Karimi Mobarakeh M, Keyhani S, Azari Z. Double-plate fixation together with bridging bone grafting in nonunion of femoral supracondylar, subtrochanteric, and shaft fractures is an effective technique. Musculoskelet Surg 2019; 104:215-226. [PMID: 31243698 DOI: 10.1007/s12306-019-00615-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 06/20/2019] [Indexed: 01/17/2023]
Abstract
PURPOSE The aims of the present study were to evaluate and report the therapeutic outcomes of double-plate fixation in combination with autogenous bridging bone grafting in treatment of nonunion fractures of femur. METHODS In this retrospective case series study, 41 patients with nonunion fracture of femur who underwent surgery by double-plate fixation and autogenous bridging bone grafting in academic referral center from July 2010 to July 2015 were enrolled. Totally, 32 males and 9 females with mean age of 35 years were evaluated. They were evaluated for related risk factors, previous therapeutic methods, time interval between injury to nonunion surgery and surgery to full clinical and radiological union, duration of follow-up, levels of postoperative limb shortening, and movement limitations. RESULTS Ten patients had open fractures and eight patients had infected nonunion in the femoral supracondylar, subtrochanteric, and shaft fractures. Nailing was the most common used method as the primary treatment of femoral shaft fractures. In addition, the mean follow-up time was 37 months. Full union was obtained even in infected cases. Deep vein thrombosis was found in one patient and pulmonary thromboembolism in another patient, and both patients were treated successfully. Moreover, limitations of articular movements were seen in seven patients. CONCLUSION Double-plate fixation in combination with bridging bone grafting is an effective method in the treatment of nonunion of femoral supracondylar, subtrochanteric, and shaft fractures even in the infected cases.
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Affiliation(s)
- Mohsen Mardani-Kivi
- Ghaem Clinical Research Development Unit, Guilan University of Medical Sciences, Rasht, Iran
| | | | - Sohrab Keyhani
- Orthopedic Department, Akhtar Hospital, Shahid-Beheshti University of Medical Sciences, Tehran, Iran
| | - Zoleikha Azari
- Orthopedic Research Center, Guilan University of Medical Sciences, Rasht, Iran.
- Orthopedic Department, Poursina Hospital, Guilan University of Medical Sciences, Parastar Ave., Rasht, 4137816375, Iran.
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Lai PJ, Hsu YH, Chou YC, Yeh WL, Ueng SWN, Yu YH. Augmentative antirotational plating provided a significantly higher union rate than exchanging reamed nailing in treatment for femoral shaft aseptic atrophic nonunion - retrospective cohort study. BMC Musculoskelet Disord 2019; 20:127. [PMID: 30909909 PMCID: PMC6434807 DOI: 10.1186/s12891-019-2514-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 03/17/2019] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Po-Ju Lai
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital and Chang Gung University, 5, Fu-Hsing St. Kwei Shan, Tao-Yuan, 33302, Taiwan
| | - Yung-Heng Hsu
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital and Chang Gung University, 5, Fu-Hsing St. Kwei Shan, Tao-Yuan, 33302, Taiwan
| | - Ying-Chao Chou
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital and Chang Gung University, 5, Fu-Hsing St. Kwei Shan, Tao-Yuan, 33302, Taiwan
| | - Wen-Ling Yeh
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital and Chang Gung University, 5, Fu-Hsing St. Kwei Shan, Tao-Yuan, 33302, Taiwan
| | - Steve W N Ueng
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital and Chang Gung University, 5, Fu-Hsing St. Kwei Shan, Tao-Yuan, 33302, Taiwan.
| | - Yi-Hsun Yu
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital and Chang Gung University, 5, Fu-Hsing St. Kwei Shan, Tao-Yuan, 33302, Taiwan.
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Zhang HJ, Wang S, Dong YH, Zheng WD, Sun Z, Zheng J. Successful management of lower limb nonunion using locking plates and bone graft with retention of intramedullary nail. Medicine (Baltimore) 2019; 98:e14949. [PMID: 30921194 PMCID: PMC6455660 DOI: 10.1097/md.0000000000014949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 01/23/2019] [Accepted: 02/26/2019] [Indexed: 11/26/2022] Open
Abstract
This study aims to investigate the clinical effect of the combined an additional locking plate with bone graft based on retaining the original intramedullary nail for the treatment of lower limb nonunion.From June 2008 to December 2012, 39 patients were admitted and treated, who developed non-infectious bone nonunion after intramedullary nail fixation for long bone fracture in the lower limb. Additional locking plate and autogenous iliac bone grafting were performed for these patients, in which the original intramedullary nail was retained. Follow-ups were performed once at postoperative months 1, 2, 3, 6, and 12, and every year onwards. During these follow-ups, imaging and clinical function examinations were performed, in order to observe callus growth and the fractured limb functions.All patients have been followed-up, in which the duration of these follow-ups ranged between 8 and 24 months. All patients gained bony union within 6 to 11 months, and the healing rate was 100%. Radiographic healing time ranged between 8 and 15 months. Full weight-bearing time ranged between 2 and 10 months. According to Harris hip scores and Hospital for Special Surgery (HSS) Knee joint scores, 17 cases were excellent, 2 cases were good, and 1 case was acceptable; with an excellent and good rate of 95.00%. According to HHS score for the knee, 15 cases were excellent, 3 cases were good, and 1 case was acceptable; with an excellent and good rate of 94.74%.The combined treatment of the additional blocking plate with bone grafting based on retaining the original intramedullary nail for bone nonunion could effectively eliminate lateral and rotatory instability of the fractured ends. This surgical method had a short operation time, high healing rate and other advantages.
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Affiliation(s)
- Hong-Jun Zhang
- Department of Orthopedics, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou
| | - Shuai Wang
- Department of Hip Injury, Luoyang Orthopedic Hospital of Henan Province, Luoyang, China
| | - Yong-Hui Dong
- Department of Orthopedics, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou
| | - Wen-Di Zheng
- Department of Orthopedics, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou
| | - Zhe Sun
- Department of Hip Injury, Luoyang Orthopedic Hospital of Henan Province, Luoyang, China
| | - Jia Zheng
- Department of Orthopedics, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou
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Davis E, Vemulapalli KC, Hansen D, Kellam JF, Achor TS. Secondary Union of a Critical Segmental Femoral Defect: A Case Report. JBJS Case Connect 2018; 8:e87. [PMID: 30431476 DOI: 10.2106/jbjs.cc.17.00302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We report the case of a 41-year-old man who sustained an open femoral shaft fracture with 10 cm of segmental bone loss in a motorcycle collision. He underwent serial irrigation and debridement procedures and intramedullary nailing of the fracture. He was lost to follow-up, but presented 9 months after the injury with abundant callus formation; at 11 months, the simple hypertrophic nonunion was treated with exchange nailing. CONCLUSION Although unusual, secondary union of segmental femoral defects may occur. The mechanism by which this occurs is poorly understood, but is likely related to the biology of the fracture site, the effects of reaming, and the mechanics of the fixation.
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Affiliation(s)
- Elizabeth Davis
- Department of Orthopedic Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
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30
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DiSilvio F, Foyil S, Schiffman B, Bernstein M, Summers H, Lack WD. Long Bone Union Accurately Predicted by Cortical Bridging within 4 Months. JB JS Open Access 2018; 3:e0012. [PMID: 30882051 PMCID: PMC6400511 DOI: 10.2106/jbjs.oa.18.00012] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background: Previous retrospective research found that the presence or absence of bridging callus within 4 months postoperatively discriminated accurately between eventual union and nonunion of fractures of the tibial shaft. However, there remains no consensus regarding early prognostication of long bone nonunion. We prospectively assessed the accuracy and reliability of the presence of any bridging callus within 4 months in a cohort that was expanded to include both tibial and femoral shaft fractures. Methods: We identified 194 consecutive fractures of the shaft of the tibia (OTA/AO type 42-A, B, or C) and femur (OTA/AO type 32-A, B, or C) that were treated with intramedullary nailing. Exclusions for inadequate follow-up (55), extended delay prior to nailing (10), and skeletal immaturity (3) resulted in a study population of 126 fractures (56 tibiae and 70 femora) in 115 patients. Digital radiographs made between 3 and 4 months postoperatively were independently assessed by 3 orthopaedic traumatologists. The accuracy of assessment of the presence of any bridging callus, bicortical bridging, and tricortical bridging to predict union or nonunion was assessed with chi-square analysis and by interobserver reliability (kappa statistic). Results: The nonunion rate was 4% (5 of 126 fractures). The presence of any bridging callus by 4 months accurately predicted union (121 of 122 fractures) and its absence predicted nonunion (4 of 4 fractures). There was 1 incorrect prediction of union for a fracture that failed to unite (p < 0.001). Bicortical or greater bridging predicted union when present (116 of 116 fractures) and nonunion when absent (5 of 10 fractures), incorrectly predicting that 5 healing fractures would go on to nonunion (p < 0.001). Tricortical or greater bridging predicted union when present (103 of 103 fractures) and nonunion when absent (5 of 23 fractures), incorrectly predicting that 18 healing fractures would go on to nonunion (p < 0.001). Interobserver reliability was calculated for any bridging (kappa value, 0.91), bicortical bridging (kappa value, 0.79), tricortical bridging (kappa value, 0.71), and the exact number of cortices bridged (kappa value, 0.67). Conclusions: The presence of any bridging callus within 4 months accurately predicts the final healing outcome for tibial and femoral shaft fractures treated with intramedullary nailing. This criterion is simple and reliable, and only standard radiographs are needed to make the determination. Basing the prognosis on the bridging of additional cortices risks overestimation of the nonunion rate and is associated with relatively poor reliability.
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Affiliation(s)
- Frank DiSilvio
- Loyola University Stritch School of Medicine, Maywood, Illinois
| | - Sarah Foyil
- Departments of Surgery (S.F.) and Orthopaedic Surgery and Rehabilitation (H.S. and W.D.L.), Loyola University Medical Center, Maywood, Illinois
| | - Brett Schiffman
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
| | - Mitchell Bernstein
- Departments of Surgery and Pediatric Surgery, McGill University, Montreal, Quebec, Canada
| | - Hobie Summers
- Departments of Surgery (S.F.) and Orthopaedic Surgery and Rehabilitation (H.S. and W.D.L.), Loyola University Medical Center, Maywood, Illinois
| | - William D Lack
- Departments of Surgery (S.F.) and Orthopaedic Surgery and Rehabilitation (H.S. and W.D.L.), Loyola University Medical Center, Maywood, Illinois
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Vaughn JE, Shah RV, Samman T, Stirton J, Liu J, Ebraheim NA. Systematic review of dynamization vs exchange nailing for delayed/non-union femoral fractures. World J Orthop 2018; 9:92-99. [PMID: 30079298 PMCID: PMC6068728 DOI: 10.5312/wjo.v9.i7.92] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 04/24/2018] [Accepted: 05/30/2018] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Jacob E Vaughn
- College of Medicine and Life Sciences, University of Toledo, Toledo, OH 43614, United States
| | - Ronit V Shah
- College of Medicine and Life Sciences, University of Toledo, Toledo, OH 43614, United States
| | - Tarek Samman
- College of Medicine and Life Sciences, University of Toledo, Toledo, OH 43614, United States
| | - Jacob Stirton
- Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH 43614, United States
| | - Jiayong Liu
- Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH 43614, United States
| | - Nabil A Ebraheim
- Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH 43614, United States
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Rocha LR, Sartore RC, Leal AC, Dias RB, Duarte MEL, Guimarães JAM, Bonfim DC. Bone intramedullary reaming grafts the fracture site with CD146 + skeletal progenitors and downmodulates the inflammatory environment. Injury 2017; 48 Suppl 4:S41-S49. [PMID: 29145967 DOI: 10.1016/s0020-1383(17)30774-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Femoral shaft fractures generally occur in young adults following a high-energy trauma and are prone to delayed union/non-union. Novel therapies to stimulate bone regeneration will have to mimic some of the aspects of the biology of fracture healing; however, which are these aspects is unclear. Locked intramedullary nailing is the current treatment of choice for the stabilisation of femur shaft fractures, and it is associated with accelerated healing and increased union rates. These benefits were partially attributed to the reaming procedure, which, regardless of significantly destroying the haematoma, stimulates the healing response. To better understand how reaming influences healing, we evaluated the viability of the nucleated cell fraction and the frequency of CD146+ skeletal progenitors, which contain multipotent cells, in the post-reaming haematoma. We also screened the concentrations of inflammatory mediators and growth factors in the fracture site after reaming compared with those in the original haematoma. METHODS Pre- and post-reaming haematomas were percutaneously aspirated from the fracture site of 15 patients with closed femoral shaft fractures. Cellular viability and the percentage of CD146+ progenitors were analysed by flow cytometry. The concentrations of cytokines and growth factors were determined by ELISA. RESULTS AnnexinV/Pi analysis showed that the viability of the total nucleated cell fraction was decreased in the post-reaming haematoma. However, the procedure increased the percentage of CD146+ skeletal progenitors in the fracture site. Analysis of cytokines and growth factors in supernatants showed a decreased concentration of the inflammatory mediators IL-6, CCL-4, and MCP-1, along with an increase of anti-inflammatory IL-10, and the growth factors bFGF and PDGF-AB. CONCLUSION These findings support the view that the positive effects of reaming on fracture healing might result from mechanically grafting the fracture site with a population of skeletal progenitors that contain multipotent cells; transitioning the signalling environment to a less inflammatory state, and enhancing the availability of specific osteogenic and angiogenic factors. A better understanding of the requisite stimuli for optimal bone repair, considering the disturbances made by orthopaedic treatments, will be determinant for the development of innovative treatments for bone repair.
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Affiliation(s)
- Leonardo R Rocha
- Master Program in Musculoskeletal Sciences, National Institute of Traumatology and Orthopedics, Rio de Janeiro, RJ, Brazil; Trauma Center, National Institute of Traumatology and Orthopedics, Rio de Janeiro, RJ, Brazil
| | - Rafaela C Sartore
- Research Division, National Institute of Traumatology and Orthopedics, Rio de Janeiro, RJ, Brazil
| | - Ana C Leal
- Research Division, National Institute of Traumatology and Orthopedics, Rio de Janeiro, RJ, Brazil
| | - Rhayra B Dias
- Master Program in Musculoskeletal Sciences, National Institute of Traumatology and Orthopedics, Rio de Janeiro, RJ, Brazil; Research Division, National Institute of Traumatology and Orthopedics, Rio de Janeiro, RJ, Brazil
| | - Maria Eugenia L Duarte
- Research Division, National Institute of Traumatology and Orthopedics, Rio de Janeiro, RJ, Brazil
| | - João Antônio M Guimarães
- Trauma Center, National Institute of Traumatology and Orthopedics, Rio de Janeiro, RJ, Brazil; Research Division, National Institute of Traumatology and Orthopedics, Rio de Janeiro, RJ, Brazil
| | - Danielle C Bonfim
- Research Division, National Institute of Traumatology and Orthopedics, Rio de Janeiro, RJ, Brazil.
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Hackl S, Hierholzer C, Friederichs J, Woltmann A, Bühren V, von Rüden C. Long-term outcome following additional rhBMP-7 application in revision surgery of aseptic humeral, femoral, and tibial shaft nonunion. BMC Musculoskelet Disord 2017; 18:342. [PMID: 28784168 PMCID: PMC5547494 DOI: 10.1186/s12891-017-1704-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 07/31/2017] [Indexed: 12/12/2022] Open
Abstract
Background Surgical revision concepts for the treatment of aseptic humeral, femoral, and tibial diaphyseal nonunion were evaluated. It was analyzed if the range of time to bone healing was shorter, and if clinical and radiological long-term outcome was better following application of additional recombinant human Bone Morphogenetic Protein-7 (rhBMP-7) compared to no additional rhBMP-7 use. Methods In a retrospective comparative study between 06/2006 and 05/2013, 112 patients diagnosed with aseptic diaphyseal humerus (22 patients), femur (41 patients), and tibia (49 patients) nonunion were treated using internal fixation and bone graft augmentation. For additional stimulation of bone healing, growth factor rhBMP-7 was locally administered in 62 out of 112 patients. Follow-up studies including clinical and radiological assessment were performed at regular intervals as well as after at least one year following nonunion surgery. Results One hundred and two out of 112 (humerus: 19, femur: 37, tibia: 47) nonunion healed within 12 months after revision surgery without any significant differences between the cohort groups. According to the DASH outcome measure for the humerus (p = 0.679), LEFS for the femur (p = 0.251) and the tibia (p = 0.946) as well as to the SF-12 for all entities, no significant differences between the treatment groups were found. Conclusions Aseptic diaphyseal nonunion in humerus, femur, and tibia healed irrespectively of additional rhBMP-7 application. Moreover, the results of this study suggest that successful nonunion healing can be linked to precise surgical concepts using radical removal of nonunion tissue, stable fixation and restoration of axis, length and torsion, rather than to the additional use of signaling proteins. Trial registration This clinical trial was conducted according to ICMJE guidelines as well as to the approval of the National Medical Board (Ethics Committee of the Bavarian State Chamber of Physicians; TRN: 2016-104) and has been retrospectively registered with the German Clinical Trails Register (TRN: DRKS00012652).
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Affiliation(s)
- Simon Hackl
- Department of Trauma Surgery, BG Trauma Center Murnau, Professor Küntscher Str. 8, 82418, Murnau, Germany
| | | | - Jan Friederichs
- Department of Trauma Surgery, BG Trauma Center Murnau, Professor Küntscher Str. 8, 82418, Murnau, Germany
| | - Alexander Woltmann
- Department of Trauma Surgery, BG Trauma Center Murnau, Professor Küntscher Str. 8, 82418, Murnau, Germany
| | - Volker Bühren
- Department of Trauma Surgery, BG Trauma Center Murnau, Professor Küntscher Str. 8, 82418, Murnau, Germany
| | - Christian von Rüden
- Department of Trauma Surgery, BG Trauma Center Murnau, Professor Küntscher Str. 8, 82418, Murnau, Germany. .,Institute of Biomechanics, Paracelsus Medical University, Salzburg, Austria. .,Institute of Biomechanics, BG Trauma Center Murnau, Murnau, Germany.
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Abstract
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.
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Abstract
Exchange nailing has proven to be a reliable surgical technique for the management of aseptic femoral shaft nonunions. Similar to primary intramedullary nail fixation for femur fractures, exchange nailing for aseptic hypertrophic nonunions of the femur relies on successful navigation of the starting point and proper nail trajectory to minimize coronal and sagittal plane deformities. Compared with the supine position, the lateral decubitus position has the advantage of allowing gravity to displace the soft tissue around the piriformis start site to facilitate nail entry. In addition, the C-arm position and access to the affected limb from both sides by the surgeon and surgical assistant facilitate visualization of existing deformities and the ability to perform correction maneuvers. The purpose of this review is to highlight technical pearls associated with exchange nailing in a lateral decubitus position. Although other techniques are available, and should be used when indicated, exchange nailing provides patients with the opportunity to an early return to activity, improvement in pain and disability, and ultimate bony union.
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Sancheti KH, Pradhan C, Patil A, Puram C, Bharti P, Sancheti P, Shyam A. Effectiveness of exchange K-nail and augmented plating in aseptic femoral diaphyseal non-union. Injury 2017; 48 Suppl 2:S61-S65. [PMID: 28802423 DOI: 10.1016/s0020-1383(17)30496-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Femoral diaphyseal non-unions present difficult scenario to manage. There are multiple options but most of them still report varying incidences of failure. We combined the principles of augmented plating and exchange nailing and aim to study the effectiveness of this technique. METHOD A retrospective study at a tertiary trauma centre was conducted. Seventy patients (60 men, 10 women), average age 40.7±15.27 years (range 18-81 years) with diaphyseal femoral fracture non-unions treated between July 2010 and January 2015 were reviewed. The average interval between first and the last surgery was 18.07±17.65 months (range 4-96 months). Forty six patients had hypertrophic non-union and 24 patients had atrophic non-union. Twenty one patients had undergone a prior surgery for non-union, 13 dynamisation, 4 bone grafting, 1 augmented plating and 3 exchange nailing. Non-unions were treated with implant removal, freshening of bone edges and exchange K-nailing and augmented plating. Autologous bone grafting and raising of osteoperiosteal flaps was done in all cases. Outcome measures were radiographic evidence of fracture union at minimum three out of four cortices, knee range of motion as compared to opposite knee, and study of complications. RESULTS All patients demonstrated radiographic evidence of fracture union with an average time of 16.77±2.38 weeks (range 12-26 weeks). Mean knee range of motion of unaffected limb was 126±9.76° (range 90-140°) while in operated limb it was 121.1±11.36° (range 80-140°), p>0.01. Patients with hypertrophic non-unions, prior surgery for non-union and supra- or infra-isthmal non-unions had shorter union time. Two patients had superficial infection which was managed by superficial debridement and two patients had pain at proximal nail tip site which was managed by anti-inflammatory medication. None of the patients required additional surgery for implant removal. CONCLUSION Exchange K nailing with Bone graft and additional plating technique for non-union diaphyseal femur fracture achieved good union rates with minimal complication. In our series none of the patient required revision and the technique probably will further minimise the revision rates compared to current options for non-union femur.
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Affiliation(s)
- K H Sancheti
- Sancheti Institute for Orthopaedic and Rehabilitation, Shivajinagar, Pune India
| | - Chetan Pradhan
- Sancheti Institute for Orthopaedic and Rehabilitation, Shivajinagar, Pune India
| | - Atul Patil
- Sancheti Institute for Orthopaedic and Rehabilitation, Shivajinagar, Pune India
| | - Chetan Puram
- Sancheti Institute for Orthopaedic and Rehabilitation, Shivajinagar, Pune India
| | - Parkalp Bharti
- Sancheti Institute for Orthopaedic and Rehabilitation, Shivajinagar, Pune India
| | - Parag Sancheti
- Sancheti Institute for Orthopaedic and Rehabilitation, Shivajinagar, Pune India
| | - Ashok Shyam
- Sancheti Institute for Orthopaedic and Rehabilitation, Shivajinagar, Pune India; Indian Orthopaedic Research Group, Thane, India.
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Sasaki G, Watanabe Y, Takaki M, Yasui Y, Miyamoto W, Kawano H, Matsushita T. Chipping and lengthening over nailing technique for femoral shaft nonunion with shortening. INTERNATIONAL ORTHOPAEDICS 2017. [PMID: 28639009 DOI: 10.1007/s00264-017-3535-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE Chipping and lengthening over nailing (CLON) technique was developed to treat femoral shaft nonunion with shortening more than 10 mm. The purpose of the current retrospective case series was to clarify the effectiveness of the CLON technique on the femoral shaft nonunion following intramedullary nailing. METHODS Clinical and radiological outcomes in the patients receiving operative treatment for femoral shaft nonunion between August 2012 and December 2016 were retrospectively reviewed using the Refractory Fracture Data Registry at the authors' institution. The CLON technique was indicated for patients with the femoral shaft nonunion with shortening more than 10 mm. RESULTS Five patients with median follow-up of 32 months (range, 14 to 50 months) were included in this study. All patients achieved bone union at the median of 8 months after the CLON technique. The median limb length discrepancy was 2.0 mm at the most recent follow-up. CONCLUSIONS The present study demonstrated that the CLON technique for femoral shaft nonunion may be the first choice as operative treatment for femoral shaft nonunion with shortening more than 10 mm.
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Affiliation(s)
- Gen Sasaki
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, 2-11-1, Kaga, Itabashi, Tokyo, 173-8605, Japan.
| | - Yoshinobu Watanabe
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, 2-11-1, Kaga, Itabashi, Tokyo, 173-8605, Japan
| | - Motoyuki Takaki
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, 2-11-1, Kaga, Itabashi, Tokyo, 173-8605, Japan
- Fukushima Medical University, Fukushima, Japan
- Southern TOHOKU General Hospital, Koriyama, Japan
| | - Youichi Yasui
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, 2-11-1, Kaga, Itabashi, Tokyo, 173-8605, Japan
| | - Wataru Miyamoto
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, 2-11-1, Kaga, Itabashi, Tokyo, 173-8605, Japan
| | - Hirotaka Kawano
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, 2-11-1, Kaga, Itabashi, Tokyo, 173-8605, Japan
| | - Takashi Matsushita
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, 2-11-1, Kaga, Itabashi, Tokyo, 173-8605, Japan
- Fukushima Medical University, Fukushima, Japan
- Southern TOHOKU General Hospital, Koriyama, Japan
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Moghaddam A, Thaler B, Bruckner T, Tanner M, Schmidmaier G. Treatment of atrophic femoral non-unions according to the diamond concept: Results of one- and two-step surgical procedure. J Orthop 2016; 14:123-133. [PMID: 27843223 DOI: 10.1016/j.jor.2016.10.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 10/13/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The treatment of non-unions in long bones poses a great challenge, particularly in cases of infection or large osseous defects. This article evaluates the use of the diamond concept in the treatment of femoral non-unions in a one-step or two-step procedure according to the Masquelet technique. PATIENTS AND METHODS Between February 2010 and March 2014, 88 patients with atrophic femoral non-unions were included in our study. The treatment was performed in one step (Group G1) on 41 patients and in two-step Masquelet technique (Group G2) on 47 patients, according to the diamond concept. In 72 cases it was decided to apply the growth factor BMP-7. The mean age of patients was 49.9 ± 15.3. The data were analysed after following up all patients for at least 12 months after surgery. RESULTS 74% of patients achieved consolidation in an average of 9.3 months. Positive bacterial cultures were found in 16 cases (18%). The consolidation rate in G2 was dependent on the non-union localisation and the osteosynthesis method applied. 83% of patients treated by intramedullary reaming achieved consolidation, while this was the case for only 60% of patients with osteosynthesis plates. Smokers in G2 had a larger average osseous defect and a lower consolidation rate. The quality of life as assessed with the SF-12 questionnaire had improved in both groups, with no significant differences between G1 and G2 one year after surgery. CONCLUSIONS One-step therapy is a suitable method of treatment for aseptic femoral non-unions with small osseous defects, using BMP-7 and RIA in the case of primarily failed atrophic non-union treatment. The Masquelet technique is an efficient means of eradicating infections in non-unions. In combination with intramedullary nailing, this technique is the method of choice for the treatment of femoral shaft non-unions with large defects.
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Affiliation(s)
- Arash Moghaddam
- HTRG - Heidelberg Trauma Research Group, Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, D-69118 Heidelberg, Germany
| | - Benjamin Thaler
- HTRG - Heidelberg Trauma Research Group, Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, D-69118 Heidelberg, Germany
| | - Thomas Bruckner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Im Neuenheimer Feld 305, D-69120 Heidelberg, Germany
| | - Michael Tanner
- HTRG - Heidelberg Trauma Research Group, Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, D-69118 Heidelberg, Germany
| | - Gerhard Schmidmaier
- HTRG - Heidelberg Trauma Research Group, Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, D-69118 Heidelberg, Germany
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Vaishya R, Agarwal AK, Gupta N, Vijay V. Plate augmentation with retention of intramedullary nail is effective for resistant femoral shaft non-union. J Orthop 2016; 13:242-5. [PMID: 27408496 DOI: 10.1016/j.jor.2016.06.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 06/03/2016] [Accepted: 06/06/2016] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE Non-union after intramedullary nail fixation of femur shaft fractures is although infrequent but a challenging condition to treat. The treatment options available to deal with such a situation include exchange nailing, removal of nail and re-osteosynthesis with plating, or Ilizarov fixation. We believe that rotational instability, in the presence of a nail, is one of the main reasons for most of the non-union. We present our experience of plate augmentation leaving the nail in situ for non-union of femoral shaft fracture. METHODS In this retrospective study, we had operated 16 cases of the femoral shaft non-union, which were treated by plate augmentation and bone grafting (if needed) with retention of the intramedullary interlocking nail in situ. The cases of infected non-union and any fracture less than one-year duration were excluded from the study. RESULTS Bone grafting was done only in 4 cases with atrophic non-union. We could achieve union in all the cases at an average time of 6.25 months. The average time of surgery between the primary surgery of interlocking nail fixation and the plate augmentation was 13 months. Mean surgical time for plate augmentation and bone grafting was 71 min. No major complication or implant failure was encountered. An average residual shortening of the limb was 0.9 cm and average range of motion of the knee was 115°. CONCLUSION Plate augmentation seems an effective, reliable, safe and an easy procedure for the treatment of femoral shaft non-union after an intramedullary nailing.
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Affiliation(s)
- Raju Vaishya
- Department of Orthopaedics and Joint Replacement Surgery, Indraprastha Apollo Hospitals, New Delhi 110076, India
| | - Amit Kumar Agarwal
- Department of Orthopaedics and Joint Replacement Surgery, Indraprastha Apollo Hospitals, New Delhi 110076, India
| | - Nishint Gupta
- Department of Orthopaedics and Joint Replacement Surgery, Indraprastha Apollo Hospitals, New Delhi 110076, India
| | - Vipul Vijay
- Department of Orthopaedics and Joint Replacement Surgery, Indraprastha Apollo Hospitals, New Delhi 110076, India
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Abstract
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.
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Abstract
BACKGROUND Intramedullary nailing is the gold standard for the treatment of femoral shaft fractures; however, rotational malalignment remains a common complication. The patient can be positioned on the fracture table in a supine position or alternatively in the lateral decubitus position without any traction. OBJECTIVE The aim of this article is to describe an effective method to control intraoperative torsion of the femur. METHOD The surgical technique described in this article is the standard procedure for femoral shaft fractures and subtrochanteric fractures in this level 1 trauma center. The patient is positioned in a lateral position on a radiolucent table with free draping of the injured leg. Using the C-arm, reduction can be performed with this technique with precise placing of the nails and torsion can be exactly adjusted and controlled with the aid of the femoral neck axis, the distal locking holes and both parallel femoral condyles. RESULTS The described technique represents an effective method for the intraoperative control of femoral torsion. With an acceptable and most probably clinically irrelevant bias, this technique is able to avoid significant rotational malalignment. It does not prolong the operative procedure and does not require additional navigation settings. It has also been shown to be helpful in the treatment of subtrochanteric fractures. CONCLUSION The surgical technique of anterograde intramedullary nailing using the lateral decubitus position without any traction device and free draping of the injured leg represents a safe and reliable treatment concept and offers logistical advantages compared to the supine position of the patient on a fracture table. Together with other described methods of intraoperative torsional control of femoral fractures, the radiological technique described in this study is an easily applicable and safe method, which needs to be confirmed in clinical studies.
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Treatment of the femoral shaft nonunion with double plate fixation and bone grafting: A case series of 14 patients. Injury 2015; 46:1102-7. [PMID: 25712702 DOI: 10.1016/j.injury.2015.01.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 01/01/2015] [Accepted: 01/12/2015] [Indexed: 02/02/2023]
Abstract
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.
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