Abstract
The majority of femoral fractures are surgically treated with intramedullary nails. Non-union rate is low but challenging and costly if it occurs. There have been encouraging results from the use of augmentative plating as a treatment for non-union of femoral fractures. We performed a systematic review of the literature to compare union rates, time to union and complications between exchange nailing and augmentative plating as a primary procedure following a diagnosis of femoral non-union following initial nailing. We found a total of 21 papers, which found the mean union rate of augmentative plating to be 99.8% compared to 74% (P = 2.05−12) found for exchange nailing. Times to union were comparable at 5.9 months for augmentative plating and 6.3 months for exchange nailing (P = 0.68916), and complication rate was 4% for augmentative plating compared to 20% for exchange nailing. From the evidence available, plate augmentation provides a more reliable union rate if used as the first operative intervention on a non-union of a femoral fracture compared to exchange nailing.Level of Evidence IV Systematic review of therapeutic studies.
Highlights
In the western world, the majority of displaced femoral diaphyseal fractures are treated operatively using intramedullary nails (IMNs) with early return to function and a low incidence of complications [1]
Inclusion criteria were papers written in English and limited to surgical procedures undertaken for aseptic femoral diaphyseal nonunions that had been treated with an IMN initially and with only one surgical revision procedure; infected non-unions were excluded
The papers included: one cohort study comparing the two methods [3]; one randomised control trial comparing closed versus open bone-grafting techniques along with exchange nailing [4]; one cohort series comparing the effect of reaming size when exchanging the nail [5]; seven exchange-nailing case series [6–13]; one cohort series comparing augmented plating versus exchange plating [14]; and ten plate augmentation case series [15–23]
Summary
The majority of displaced femoral diaphyseal fractures are treated operatively using intramedullary nails (IMNs) with early return to function and a low incidence of complications [1]. When femoral non-unions do occur, the treatment options can be time consuming, challenging and expensive. Based upon a health economics study from the UK, the cost of treating a femoral non-union is at least £17,000 (US $22,000) per patient [2]. The most common method of treating femoral diaphyseal non-unions is to perform an exchange-nailing procedure, whereby the original IM nail is removed, and the femoral canal is reamed to stimulate the natural healing response. Reaming permits a larger diameter IMN to be inserted improving the mechanical stability. Despite this exchange, IM nailing is not as uniformly successful and persistent non-unions do occur
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