Results of a simple treatment protocol for aseptic femoral shaft nonunion in 330 patients

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.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Augmentation plate without bone graft in the management of distal tibial diaphyseal non-union

PURPOSE

The objective of this study was to assess the efficacy of augmentation plating with retaining of previous implant in situ in cases of non-united oligotrophic or atrophic aseptic distal tibial diaphyseal and metaphyseal fractures without bone grafting depending on the unified bone healing and non-union theory.

METHODS

Through the period between December 2019 and December 2022, twelve patients with distal third tibial non-unions who were fixed at time of fracture either by intramedullary interlocking nails (seven cases) or by minimally invasive plate osteosynthesis (five cases) were included. Non-union was diagnosed on basis of absence of any healing progression in three months period or absence of fracture healing after six months from index surgery. All patients had oligotrophic or atrophic non-union. Augmentation plating through an anterolateral approach was done on average of 7.25 months after initial surgery (6-9 months). Circumferential exposure of the fracture site and debridement of fibrous tissue were not necessary. No bone grafting was done as no cases had major bone defect.

RESULTS

All patients achieved complete radiological union with a mean time of 21.8 weeks (range 18-30 weeks) that mean full callus formation in all cortices. All patients were walking independently after three months (13weeks) from surgery and returned to work even in cases of absent complete radiological union. No cases had been complicated with wound healing problems (infection or dehiscence). One patient had incomplete ankle dorsiflexion (10°) due to tight calf muscles and one patient had paresthesia on the dorsum of the foot that was not improved at last follow up (one year after surgery).

CONCLUSION

Augmentation plating is a safe and effective option for management of distal tibial diaphyseal nonunion even in cases of oligotrophic or atrophic non-union.

Augmentative lag screws as a treatment for aseptic hypertrophic nonunion after internal fracture fixation

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.

Medial augmentation plating of aseptic distal femoral nonunions

BACKGROUND

Distal femur nonunions are well-recognized contributors to persistent functional disability, with limited data regarding their treatment options. In the current study, we asked whether additional medial augmentation plating is a feasible treatment option for patients with aseptic distal femoral nonunion and intact lateral implants.

METHODS

We conducted a single-center, retrospective study including 20 patients treated for aseptic distal femoral nonunion between 2002 and 2017. The treatment procedure included a medial approach to the distal femur, debridement of the nonunion site, bone grafting and medial augmentation plating utilizing a large-fragment titanium plate. Outcome measures were bone-related and functional results, measured by the Hospital for Special Surgery Knee Rating Scale (HSS) and the German Short Musculoskeletal Function Assessment questionnaire (SMFA-D).

RESULTS

Eighteen of 20 nonunions showed osseous healing at 8.16 ± 5.23 (range: 3-21) months after augmentation plating. Regarding functional results, the mean HSS score was 74.17 ± 11.12 (range: 57-87). The mean SMFA-D functional index was 47.38 ± 16.78 (range 25.74-71.32) at the last follow-up. Index procedure-associated complications included two cases of persistent nonunion and one case of infection.

CONCLUSIONS

According to the assessed outcome measures, augmentation plating is a feasible treatment option, with a high proportion of patients achieving bony union and good functional outcomes and a few patients experiencing complications.

Reunion of post nail aseptic non-union of diaphyseal femoral fractures by augmentation plating, decortication and bone grafting - Replacement for exchange nailing

INTRODUCTION

The aim is to re-unite post nail aseptic non-union of diaphyseal femoral fractures in an economical and safe way with almost certainty, reducing dependence on others with early rehabilitation. The cascade of fracture healing is dependent on mechanical stability and uninterrupted cellular and bio-chemical responses (biology). Intra-medullary nailing in fresh diaphyseal femoral fractures is gold standard treatment with high success rate, still non-union of these fractures is reported, though the incidence has declined considerably.

METHOD

This prospective study conducted at level one trauma centre on twenty-one patients in four years starting from July 2015 to June 2019. Eighteen patients had non-union with intact implant and three had broken nail. Non-union site approached through lateral approach. Non-union site fixed by 4.5 broad combi-hole LCP or distal femoral locking compression plate (DF-LCP) depending on fracture site. Decortication, Bone grafting done retaining the previous nail in situ in eighteen patients and in three patients, broken nail was exchanged with same size of unreamed nail and then, similar procedure carried out.

RESULT

All non-unions in 21 patients reunited without any complications. All patients regained painless unsupported walk.

DISCUSSION

The most preferred treatment for this complex non-union is reamed exchanged nailing. Larger nail increases mechanical stability by better frictional contact with surrounding bone in isthumic fracture but fails in cases of fractures with comminution, spacious distal fragment and fracture with small distal fragment. Various studies reported success rate in reamed exchange nailing from 53-96% with an average 74%. The main cause of instability is rotational stress which is completely obliterated by augmentation plating and various studies report 100% success. Augmentation plate with retained nail increases stiffness and strength of construct. Concomitant decortication and cancellous bone graft stimulates osteogenesis.

CONCLUSION

It is a simple, safe and economical procedure, correcting and providing both mechanical and biological environments to convert non-union into osseous union. It will be a treatment of choice in times to come.

Treatment of aseptic nonunion after medial opening-wedge high tibial osteotomy

BACKGROUND

Nonunion after medial opening-wedge high tibial osteotomy (OWHTO) is a rare but serious complication with very limited data regarding its treatment. The aim of this study was to analyze the healing rate after operative treatment of nonunion after OWHTO.

METHODS

We performed a single-center, retrospective study that included 14 patients with nonunion after OWHTO between 2010 and 2018. The treatment for all patients consisted of local debridement and cancellous bone grafting at the osteotomy gap. Revision osteosynthesis due to a loss of correction/loosening of the locking screws or plates was performed in 5 patients. In 7 patients, lateral hinge fractures were treated with additional lateral plating. Union was confirmed using the modified "Radiographic Union Score for Tibial fractures". Outcome measure was the Lysholm Knee Score at final follow-up.

RESULTS

The mean age of the patients included in our study was 48.4 ± 6.7 years. Three patients were female (21.4%). The mean follow-up period was 20.8 ± 12.8 months. Union was achieved in 12/14 patients (85.7%) after a mean of 6 months (range, 3-13). The mean Lysholm Knee Score at the final follow-up was 83.2 ± 11.6. Two patients did not reach definitive union during the follow-up. In one patient, an infection of the nonunion following bone grafting was successfully treated with a two-stage procedure. Two patients needed additional cancellous bone grafting 6 and 8 months after the first revision surgery. All patients showed pain-free full weight bearing after union was achieved.

CONCLUSIONS

Nonunions after OWHTO can generally be treated successfully with cancellous bone grafting. For patients who have loss of correction, loosening of the osteosynthetic material or fracture of the lateral hinge, an additional revision or additive osteosynthesis may be required.

LEVEL OF EVIDENCE

Grade III.

Augmentation plating leaving the nail in situ is an excellent option for treating femoral shaft nonunion after IM nailing: a multicentre study

PURPOSE

In recent years, plate augmentation over a retained intramedullary (IM) nail has been shown to be an effective option for managing femur fracture nonunions because it improves the biomechanical environment of the fracture site without causing additional biological damage. In the current study, we present outcome data from 22 consecutive patients treated with plate augmentation for femoral shaft nonunion leaving the nail in situ.

PATIENTS AND METHODS

Between 2015 and 2018, 22 consecutive patients with femoral shaft aseptic nonunion after IM nailing were treated with plate augmentation over a retained nail at four different institutions. Nonunion was categorized based on its anatomical location and was classified according to the Weber and Cech classification. Cortical defects greater than 1.0 cm, the type of nailing procedure, and the number of previous interventions were recorded. Patients were assessed clinically and radiographically to measure the healing of nonunion sites. The time to fracture union and complications were recorded. Descriptive statistics were used when applicable.

RESULTS

One site location was supra-isthmic, 12 were isthmic, and 9 were infra-isthmic. There were 10 cases of vascular nonunion and 12 cases of avascular nonunion. A cortical defect greater than 1.0 cm was observed in three patients. Antegrade nailing was performed in 11 patients, and retrograde nailing was performed in 11 patients. Reaming was performed in 12 patients. In eight patients, the fracture was openly reduced during the IM nailing index procedure. The average number of previous interventions before augmentation plating was 1.6 (1-4). Bone union was achieved in 19 patients after augmentation plating with an average follow-up of 23.5 months (12-51 months). Excellent and good clinical results were observed in all patients. There was no plate or screw breakage, and no patient developed infection.

CONCLUSION

Augmentation plating leaving the nail in situ is an excellent option for treating femoral shaft nonunion after IM nailing, with a high union rate and few complications. We believe the technique should gradually replace exchange nailing as the standard of care for the majority of femoral shaft nonunions that occur after IM nailing.

Clinical outcomes of femoral shaft non-union: dual plating versus exchange nailing with augmentation plating

Background

By comparing clinical outcomes between dual plating (DP) and exchange nailing with augmentation plating (EN/AP), we aimed to provide better treatment strategies for femoral shaft non-union.

Methods

We retrospectively reviewed 30 patients with aseptic femoral shaft non-union at our level 1 trauma center between January 2014 and January 2017. All patients underwent a one-stage, definitive revision procedure, including DP for 16 patients and EN/AP for 14 patients. Perioperative surgical trauma, fracture healing, complications, and the time to return to work were evaluated.

Results

Twenty-nine patients achieved fracture healing. In the EN/AP group, the fracture healing rate was 100%, the healing time was 5.7 ± 1.7 months, and the time of return to work was 8.2 ± 2.9 months. In the DP group, the fracture healing rate was 94%, the healing time was 8.4 ± 4.1 months, and the time of return to work was 18.4 ± 10.3 months. In terms of fracture healing and return to work, the patients in the EN/AP group required less time than those in the DP group, and the differences were statistically significant (p = 0.024 and p < 0.01 respectively). Except for the length of the incision, the two groups showed no statistically significant differences in operative time, postoperative deformity, and complications.

Conclusions

Both EN/AP and DP are important surgical options for femoral shaft non-union. Compared to DP, EN/AP resulted in a shorter incision, faster fracture healing, and a shorter time to return to work.

Trial registration

ChiCTR-ORC-17014062

Augmentation plating in management of failed femoral nailing

INTRODUCTION

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Anterior augmentation plating of aseptic humeral shaft nonunions after intramedullary nailing

INTRODUCTION

Humeral shaft nonunion after intramedullary nailing is a rare but serious complication. Treatment options include implant removal, open plating, exchange nailing and external fixation. The objective of this retrospective study was to determine whether augmentation plating without nail removal is feasible for treating a humeral shaft nonunion.

MATERIALS AND METHODS

Between 2002 and 2014, 37 patients (mean age 51, range 20-84 years) with aseptic humeral shaft nonunions prior to intramedullary nailing were treated with augmentation plating. The initial fractures had been fixed with retrograde nails (10 cases) or anterograde nails (27 cases). There were 34 atrophic nonunions and 3 hypertrophic nonunions. Nonunion treatment of all patients consisted of local debridement through an anterior approach to the humerus and anterior placement of the augmentation plates. Supplemental bone grafting was performed in all atrophic nonunion cases. All patients were followed until union was radiologically confirmed.

RESULTS

Union was achieved in 36 patients (97 %) after a mean of 6 months (range 3-24 months). There was one case of iatrogenic median nerve palsy that showed complete spontaneous recovery 6 weeks postoperatively. One patient sustained a peri-implant stress fracture that was treated successfully by exchanging the augmentation plate to bridge the nonunion and the fracture. No infections or wound healing complications developed. At a mean follow-up of 14 months, all patients showed free shoulder and elbow motion and no restrictions in daily or working life.

CONCLUSIONS

The results indicate that augmentation plating using an anterior approach is a safe and reliable option for humeral shaft nonunions after failed nailing, and the treatment has no substantial complications. Because the healing rates are similar to the standard technique of nail removal and fixation by compression or locking plates, we consider this technique to be an alternative choice for treatment.