Nonunion Of Femoral Shaft Fracture Research Articles

"Fragment Width Ratio" as a Predictor of Nonunion for Femoral Shaft Fracture With Third Fragments.

Previous studies have reported that large fracture fragment with displacement might cause nonunion of femoral shaft fractures. We therefore intended to delineate significant risk factors for developing a nonunion predisposed by a major fracture fragment. We analyzed 61 patients who were operated on using interlocking nails for femoral shaft fractures from 2009 to 2018. We classified patients with modified Radiographic Union Scale for Tibia fractures scores of less than 11 or needing reoperations by 1 year postoperatively as nonunion. We thereafter measured parameters of the displaced fracture fragment and fracture site to identify the significant difference between the union and non-union groups. We also applied the receiver operating characteristic curve to demonstrate a threshold value for the fragment width (FW) ratio. Among 61 patients with complete follow-up, no significant difference was found regarding length, displacement, and angulation of fragments between patients with and without union. Except for higher mean FW (P=.03) and the FW ratio (P=.01) in patients with nonunion, the logistic regression analysis demonstrated that FW ratio significantly affected union (P=.018; odds ratio, 0.21; 95% CI, 0.001-0.522). Although a fracture fragment greater than 4 cm with displacement greater than 2 cm was reported to significantly cause nonunions, our study showed that an FW ratio greater than 0.55 instead of fragment size or displacement was predictive for the occurrence of nonunion adjoining to the fracture site. Fixation of the third fracture fragment should not be ignored for preventing a nonunion. More attention should be paid to achieve a better fixation for a major fracture fragment with an FW ratio greater than 0.55 to avoid the development of non-union following the use of interlocking nail for femoral shaft fracture. [Orthopedics. 2023;46(3):169-174.].

The Effect of Augmentative Plating for the Treatment of Nonunion of Femoral Shaft Fractures after Intramedullary Nailing: A Case Series

Background: Several treatment approaches are now considered to manage femoral nonunion following intramedullary (IM) nailing. Augmentation plating over a maintained IM nail was a successful treatment for femur fracture nonunion in recent years. We aimed to describe our experiences in evaluating the union of bone for these patients after plate augmentation with serial examinations and radiologic studies.
 Methods: This was a case study on 21 patients who had a nonunion or delayed union of the femoral shaft fracture (FSF) after IM nailing. After initial intervention, they were monitored for 20.4 months (range: 12-72 months).
 Results: A closed IM nail was used in 18 patients, while the other three patients were shown as non-IM nail cases with a dynamic hip screw (DHS) in one patient, an external fixator in one other patient, and plate fixation in another one that was planned for augmentation plating. After plating, appropriate union appeared in all patients. Fracture union took an average of 7 months ranging from 3 to 12 months.
 Conclusion: Augmentation plating for treating FSF nonunion with leaving the nail in place results in excellent and favorable clinical outcomes with the radiographic recovery of the nonunion site in all of the cases with no complication.

Patterns of Non-union of Femoral Shaft Fracture in Basra Teaching Hospital. A Retrospective review.

Background and objectives: Long bone fractures are witnessed almost every day in the orthopedic practice. Femoral shaft fractures (FSF) generally are due to high energy trauma in working age group. non-union of FSF is not infrequently encountered challenge. This study reviews cases of FSF that ends up with non-union in Basra Teaching Hospital to explore some factors related to non-union. Patients and methods: A retrospective case series were conducted in Basra Teaching Hospital from January 2012 - June 2014 including 124 patient with FSF. Thirty three patients were identified during the study period (18 months), demographic criteria and injury patterns, initial treatment, early complications, subsequent interventions and fate of the patients are described. Results: Among 33 patients with nonunion FSF, 23 were males and 10 females, aged from 15 to 60 years (mean = 35). High energy trauma is the chief source of FSF in this analysis . After 9 - 12 months from initial trauma, patients ends up with non-union, 9 atrophic, 13hypertrophic and 11 infected non-union. Thirty patients underwent revision surgery, with addition of bone graft , three patients no revision surgery, within the study period ( 18 months ), 25achieved successful union or showing signs of progressive union , 3 had united fractures with chronic osteomyelitis , 5 non-united fractures . Conclusion: nonunion of FSF a great challenge to the orthopedic surgeon and the patient life and development, to overcome this problem both the surgeon and the patient should cooperate to avoid this tragedy story.

The efficacy of augmentative anti-rotational plating plus decortication and autogenic bone grafting for aseptic nonunion after intramedullary nailing of femoral shaft fracture

Abstract Background: Femoral interlocking intramedullary (IM) nailing fixation is an effective method for the treatment of femoral shaft fractures. Aseptic nonunion of femoral shaft fracture after IM nailing is uncommon. Currently, the treatment for aseptic femoral shaft nonunion is controversial. The aim of this study was to investigate the clinical effect of augmentative antirotational plating plus decortication and autogenic bone grafting for aseptic femoral shaft nonunion after IM nailing failure. Methods: A retrospective study was conducted on 25 cases of aseptic femoral shaft fracture nonunion treated with IM nailing from January 2015 to August 2019. All patients were treated by leaving the nail in situ, debridement of nonunion sites, decortication, autogenous iliac bone grafting, and augmentative antirotational plating fixation. The time to fracture union and complications were recorded. Results: All patients were followed up for 12–18 months. The union rate after revision surgery was 100%. The average union time was 5.5 months (range, 4-10). Subjective pain symptoms had disappeared in all patients. There were no incision infections or internal fixator fatigue fractures. Average scores of the physical function and bodily pain components of the SF-36 were 95.5 (range, 91-98) and 94.1 (range, 90-97), respectively. No other obvious complications occurred postoperatively. Conclusion: Augmentative antirotational plating plus decortication and autogenic bone grafting is an excellent choice for treating femoral shaft fracture nonunion after IM nailing; this approach has an overall high union rate and few complications.

Advantages and limitations of intramedullary nailing for the surgical treatment of ipsilateral intertrochanteric and femoral shaft fractures: a retrospective comparative study based on propensity score matching.

The aim of the present study was to introduce surgical technique using long PFNA for the treatment of ipsilateral intertrochanteric and femoral shaft fractures, and evaluate the characteristics of this fracture by comparing its surgical outcomes with those of isolated intertrochanteric and femoral shaft fractures. Between March 2013 and December 2018, 38 patients with ipsilateral intertrochanteric and femoral shaft fracture were identified at two institutions. Twenty-eight patients with ipsilateral intertrochanteric and femoral shaft fractures were enrolled in the present study. After propensity score matching, fifty-six patients with isolated intertrochanteric (group B) and femoral shaft (group C) fractures were finally enrolled in the present study for 1:2 matching to compare surgical outcomes to that of ipsilateral intertrochanteric and femoral shaft fractures (Group A). All 28 patients achieved union of intertrochanteric fractures, while two experienced non-union of femoral shaft fractures. The union time of intertrochanteric fractures in group A was significantly shorter than that in group B. The union time of femoral shaft fractures in group A was significantly longer than that in group C. The surgical treatment of ipsilateral intertrochanteric and femoral shaft fractures using long PFNA was advantageous as it allowed both fractures on the same femur to be fixed in one go and showed good surgical outcomes. However, fixation of femoral shaft fractures might be insufficient depending on the fracture level and configuration, and can be a cause of hypertrophic non-union.

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

BackgroundAtrophic 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.MethodsWe 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.ResultsOverall, 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.ConclusionAAP 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.

The treatment of nonunion of femoral shaft fractures after intramedullarynaildynamizationwith temporary compression using external fixator followed by relocking of the internal intramedullary nail

Objective To introduce the technique we invented to treat hypertrophic and oligotrophic nonunion of femoral shaft fracture after dynamization of intramedullary nail (IMN) and to report its preliminary results. Methods The data of 2 cases with hypertrophic nonunions of femoral shaft fracture and 1 case with oligotrophic nonunion following IMN dynamization who had been treated by the technique from March 2006 to July 2017 in Beijing Jishuitan hospital were retrospectively studied. There were 2 females and 1 male, aged 50, 66 and 24 years old. 2 parallel half pins were inserted from anterior to posterior at the trochanteric and condylar zones of the femur for antegrade intramedullary nailing patients, and from lateral to medial sides for retrograde intramedullary nailing patient respectively, then the pins were connected with monolateral limb reconstruction fixator. The fracture nonunion site was compressed by the fixator up to 10-15 mm. The holes at the end of intramedullary nail where their screws were removed for dynamization were locked again with 2 locking screws, and then the frame was removed. The patients are allowed to start their rehabilitation and fully bear their body weight 1 day after the operation. Results The three patients were followed up for 25, 22, and 7 months after the surgery, respectively. The X-ray films showed the fracture healed at 7 months in two case, and at 12 months in one. One patient got her nail removed 25 months after the operation, feeling good 37 months after the removal. Conclusion This technique is an option to manage the hypertrophic and oligotrophic fracture nonunion of the femur after dynamization of IMN. It is mini-invasive to the nonunion site, easy to practice and allows early rehabilitation. Key words: Femoral fractures; Fractures, ununited; Fracture fixation, intramedullary; External fixators

Results of Exchange Nailing in Hypertrophic Nonunion of Femoral Shaft Fracture Treated with Nailing

Results of Exchange Nailing in Hypertrophic Nonunion of Femoral Shaft Fracture Treated with Nailing

Study of outcome of treatment for nonunion of femoral shaft fractures: A case series

Introduction: Nonunion of femoral shaft fractures continues to hinder the successful outcome femur fracture treatment in spite of increased understanding of biomechanics and improvements of implant design. Nonunion of femur fracture presents a difficult treatment challenge for the surgeon and a disastrous personal and economic hardship for the patient. Method and Material: 20 consecutive cases of fractures shaft of femur non-union were admitted to the Orthopaedics Department, Dhiraj Hospital, Waghodia were included in this study. All patients underwent revision surgery in form of exchange nailing with autologous cancellous bone graft with plate augmentation in required cases. Results: Out of 20 patients maximum belonged to the age group of 31-40(8). 13 (65%) patient had hypertrophic non-union and 7 (35%) had atrophic non-union. Average follow up of patients was upto 14 months post operatively. Out of 20 patients, 14 (70%) patient achieved union at their last follow up. Radiological signs of bone union was observed at a average of 7.5 months (5.5 to 11 months). Discussion and Conclusion: The use of plate augmentation and bone grafting for the treatment of femoral shaft nonunion, along with exchange interlocking intramedullary nail, to remove the rotational instability of the nonunion site increased the chances of union. Bone grafting performed simultaneously filled the bony defect and stimulated healing.

Platelet-rich plasma combined with conventional surgery in the treatment of atrophic nonunion of femoral shaft fractures: study protocol for a prospective, randomized, controlled clinical trial

Platelet-rich plasma combined with conventional surgery in the treatment of atrophic nonunion of femoral shaft fractures: study protocol for a prospective, randomized, controlled clinical trial

Platelet-rich plasma combined with conventional surgery in the treatment of atrophic nonunion of femoral shaft fractures: study protocol for a prospective, randomized, controlled clinical trial

Background: Internal and external fixation combined with autologous bone graft for the treatment of atrophic nonunion has a long treatment cycle, and there remain cases where the nonunion cannot be cured. Platelet-rich plasma contains a variety of growth factors and a large number of white blood cells, and contributes to tissue healing. However, there have been no clinical studies on the effectiveness of platelet-rich plasma combined with conventional surgery in the treatment of atrophic nonunion. Methods/Design: We conducted a prospective, open-label, randomized, controlled clinical trial at the Affiliated Hospital of Qinghai University, China. Ninety-two patients with atrophic nonunion of femoral shaft fractures were equally and randomly divided into a control group and an experimental group. The patients in the control group received conventional surgery, while the patients in the experimental group were injected with autologous platelet-rich plasma in addition to receiving conventional surgery. The primary outcome was fracture healing rate at 9 months postoperatively. The secondary outcomes were visual analogue scale scores for resting state and passive motion, healing time, treatment costs, and adverse reactions. Our partial results revealed that the visual analogue scale scores and complications were similar between the two groups on postoperative days 1–3. The healing rate was significantly higher in the experimental group compared with the control group. The healing time was significantly shorter in the experimental group compared with the control group. Discussion: The present trial was designed in August 2014, and case recruitment was completed in September 2016. Data for the last case will be collected in June 2018, and the data analysis will be completed in December 2018. The trial will provide objective data on the clinical use of platelet-rich plasma combined with conventional surgery for the treatment of atrophic nonunion. Trial registration: ClinicalTrials.gov identifier: NCT03129971. Ethics: The study protocol has been approved by the Ethics Committee of Affiliated Hospital of Qinghai University of China (approval number: QHG0223A). Informed consent: Written informed consent was obtained from all participants.

Plate augmentation with retention of intramedullary nail is effective for resistant femoral shaft non-union

ObjectiveNon-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. MethodsIn 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. ResultsBone 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 71min. No major complication or implant failure was encountered. An average residual shortening of the limb was 0.9cm and average range of motion of the knee was 115°. ConclusionPlate augmentation seems an effective, reliable, safe and an easy procedure for the treatment of femoral shaft non-union after an intramedullary nailing.

Augmentative plating for treatment of nonunion of femoral shaft fracture after intramedullary nailing: a biomechanical study

Objective To compare biomechanical effects of augmentative plating assisted by different types and numbers of intramedullary nails in the treatment of nonunion of femoral shaft fracture after intramedullary nailing. Methods Twenty-five specimens of synthetic femur were randomly divided into an experimental group (20 bones) and a control group (5 bones) . All the bones were made into models of nonunion of femoral shaft fracture after intramedullary nailing. The control group was subjected to no augmentative plating. The experimental group was further divided into 4 subgroups (n=5) which were subjected to fixation respectively by: a 7-hole plate with 3 bicortical screws on each side, a 7-hole plate with 3 unicortical screws on each side, a 5-hole plate with 2 bicortical screws on each side, and a 5-hole plate with 2 unicortical screws on each side. The torque values of all the subgroups were measured and compared when the models were subjected to torsional angles of 5°, 10°, 15°, 20° and 25°. Results The anti-torsional strengths at torsional angles of 5°, 10°, 15°, 20° and 25° in the 4 experimental groups were all significantly greater than in the control group (P<0.05) . At a torsion angle of 25°, the mean torque value in the 3-bicortical-screw group (46.51±6.66 nm) was significantly greater than in the 2-bicortical-screw group (39.03±8.52 nm) (P<0.05) . At torsion angles of 5°, 10° and 25°, the mean torque values in the 3-unicortical-screw group (13.48±1.68 nm, 23.29±3.72 nm and 48.19±5.34 nm, respectively) were significantly greater than in the 3-unicortical-screw group (9.56±3.62 nm, 16.99±5.49 nm and 38.69±6.56 nm, respectively) (P<0.05) . At torsion angles of 20° and 25°, the mean torque values in the 3-unicortical-screw group (39.15±5.07 nm and 48.19±5.34 nm) were significantly greater than in the 2-bicortical-screw group (32.50±5.65 nm and 39.03±8.52 nm) (P<0.05). Conclusions The anti-torsional strength of fixation by 3 screws on each side is significantly greater than by 2 screws on each side. When the number of screws is the same, there is no significant difference between fixation by unicortical locking screws and that by bicortical conventional screws. Augmentative plating with 3 unicortical screws or 3 bicortical conventional screws on each side is recommended for treatment of nonunion of femoral shaft fracture after intramedullary nailing. Key words: Femoral fractures; Fractures, ununited; Bone plates; Fracture fixation, internal; Biomechanics

Effects of third fragment size and displacement on non-union of femoral shaft fractures after locking for intramedullary nailing

BackgroundThe femoral shaft fractures with large fragments makes anatomical reduction challenging and often results in non-union. In some studies, the degree of fragment displacement was reported to have affected non-union, but the association between the one fragment size and degree of displacement has not been fully clarified. Therefore we performed a retrospective study to assess: (1) the more influential factor of non-union: the degree of fragment displacement, or the fragment size? (2) the non-union rates according to different sizes and degrees of displacement. HypothesisThe degree of displacement is the more potent factor of non-union than the third fragment size in femoral shaft fractures. Patients and methodsWe assessed retrospectively 64 cases, which could be followed up for longer than one year. Fragments were divided according to the length of their long axis into three groups: group A (0–3.9cm), (n=21); group B (4–7.9cm), (n=22); group C (8cm or more), (n=21). Fragment displacement was also assessed in the proximal (P) or distal (D) end to the nearest cortex of the femoral shaft, and divided into the following groups: group P1 (n=44) or D1 (n=47), (0–9mm); group P2 (n=10) or D2 (n=11), (10–19mm); group P3 (n=7) or D3 (n=3), (20–29mm); and group P4 (n=3) or D4 (n=3), (30mm or more). ResultsThe bone union rate was 86% in the small (less than 8cm) fragment groups and 71% in the large (8cm or more) fragment group (P=0.046). With respect to the degree of displacement, the union rate was lower (P=0.001) and the average union time was longer (P=0.012) in the 20mm or more group for both the proximal fragment part and the distal fragment part (P=0.002, P=0.014). A logistic regression analysis underlined the displacement in the proximal site (OR: 0.298, 95% CI: 0.118–0.750) as in the distal site (OR: 0.359, 95% CI: 0.162–0.793) as a larger effect on union rate than the fragment size that as no effect in logistic regression (OR 3.8, 95% CI: 0.669–21.6). ConclusionNon-union develops significantly more frequently in femoral shaft fractures with fragments 8cm or longer or when the displacement in the proximal area is 20mm or greater and 10mm or greater in the distal area during the intramedullary nailing procedure. Regarding union rate, the degree of displacement has more influence than the third fragment size in femoral shaft fractures. Level of evidenceIV, retrospective cohort study.

Is augmentation plating an effective treatment for non-union of femoral shaft fractures with nail in situ?

There are few reports of non-union femur shaft fractures treated with plate fixation with the nail in situ. This study reports our results in 40 cases. Retrospective series of non-union and delayed union of femoral shaft after intramedullary nailing treated with plate fixation. Patients were serially followed-up till 12months. Fracture union, time to union, knee range of motion, deformity, shortening and complications were recorded. Descriptive statistics were performed as applicable. There were 40 patients with mean age of 35years (18-65). There were 14 cases of hypertrophic non-union, 24 cases of atrophic non-union and 2 cases of delayed union. The average time of surgery was 1 ½h and average blood loss was 300ml. Exchange nailing was done in 9 cases. Union was achieved in 39 patients. The mean time to fracture union was 4months. Post-operative knee range of motion was >120° in 35 patients. One patient developed deep infection which was treated with removal of implants and exchange nailing with a vancomycin coated nail and union was achieved. Plating is an effective treatment for non-union of diaphyseal femur fractures after intramedullary fixation with the nail in situ.

Augmentation plating in hypertrophic non-union after nail fixation of femoral shaft fracture compared with exchange plating

Background Augmentation plating has been used successfully to treat hypertrophic non-union after nail fixation. This study compared the efficacy of augmentation plating and exchange plating for treating hypertrophic non-union of femoral shaft fracture after intramedullary nail fixation. Methods A total of 12 patients received augmentation plating and 15 patients received exchange plating as treatment for femoral shaft hypertrophic non-union. The procedures were conducted at our medical centre between January 2005 and January 2012. Clinical follow-up was conducted at 2 weeks, 1 month and then monthly until union was achieved to compare union time, operation time, bleeding and complications between the two groups. Results All patients underwent follow-up examinations until fracture union was achieved. The average length of followup time after the second treatment was (18.37±3.28) months. The time needed for union was (4.17±0.94) months in the augmentation plating group and (5.33±1.72) months in the exchange plating group. The operation time was (90.00±17.58) minutes in the augmentation plating group and (160.00±25.35) minutes in the exchange plating group. The amount of blood loss during the operation was (270.00±43.32) ml in the augmentation plating group and (530.00±103.65) ml in the exchange plating group. Both groups showed significant difference (P &lt;0.05) in their results. No complications were reported after the second operation. Conclusions Augmentation plating after nail fixation could remove local rotation instability, facilitate simple operation, create minimal damage and enable exercise for early functional recovery. Therefore, augmentation plating is excellent for treating hypertrophic non-union after nail fixation in femoral shaft fracture.

Management of nonunion of femoral shaft fracture and deformity of femur with fixator-assisted nailing

Objective To evaluate the effect of fixator-assisted nailing (FAN) technique for the treatment of femoral deformity,nonunion of femoral shaft fracture with deformity and malunion.Methods The data of 8 patients with nonunion of femoral shaft fracture with deformity,3 patients with femoral deformity caused by Rickets disease and 2 patients with femoral fracture malunion who received treatment FAN technique was retrospectively analyzed.There were 11 males and 2 females,with an average age of 33 years (range,16-50 years).One-stage operation was used in 10 patients:after the fracture was distracted and reduced with external fixator,an intramedullary nail was used for final fixation.Two-stage strategy was used in 3 patients.Unilateral external fixator was used in 12 patients,ring fixator was used in 1 patient.Femoral intramedullary nailing was used in 8 patients,retro-femoral intramedullary nailing was used in 5 patients; autograft from callus of fracture site was used in 1 patient.Results The 12 patients were followed up for 12-48months with an average of 21 months.The fractures of 7 patients united 3-6 months (average,3.9 months)later after the operation.The osteotomy site of 5 patients united 3-5 months (average,3.5 months) later after the operation.The results were evaluated according to the Paley classification of functional results.There were 9 cases rated as excellent,2 as good and 1 as fair.The lower leg discrepancy (LLD) before and after operation was (48.2±23.0) mm and (27.3±24.6) mm,individually; the length of limb increased 4.6-41.0 mm (average,23.3 mm).The pre-and post-operative MAD was (27.5±24.4) mm and (6.3±8.3) mm.There was no neurovascular injury or infection occurred in any of the patients.All the patients were satisfied with the result of treatment.Conclusion FAN technique combines the accuracy,minimal invasiveness and safety of external fixation together with patient compliance of IM nail.It is an effective method to manage nonunion of femoral shaft fracture with deformity,malunion of femur,and femoral deformity cause by rickets. Key words: Femur; Fractures, ununited; Abnormalities; External fixators; Fracture fixation, intramedullary

The effects of extracorporeal shock wave treatment combined with expanding bone marrow autografts in the treatment of nonunion of femoral shaft fractures with interlocking intramedullary nails

Objective To investigate the effect of extracorporeal shock waves (ESWs) combined with expanding bone marrow autografts in treating nonunion of femoral shaft fractures with interlocking intramedullary nails.Methods Thirty patients with femoral shaft fractures which had not united were divided into an ESW group,an expanding bone marrow group,and a combined treatment group using a table of random numbers.Each group had 10 cases.In the ESW group,no expanding bone marrow was employed in fixing the intramedullary nails and ESW therapy was begun at day 14 after the operation.In the expanding bone marrow group,bone marrow was grafted around the broken ends of fractured bones.In the combined treatment group patients underwent both treatments.The conditions of the callus and the fracture lines in the 3 groups were separately evaluated using X-rays at the 4th,8th,12th and 16th week after the operation.Results At week 4,the average callus and fracture line scores in the combined treatment and expanding bone marrow groups were significantly better than those in the ESW group.At the 8th week after the operation,the average callus and fracture line scores in the combined treatment group were significantly higher than in the ESW group and expanding bone marrow groups.Later,the callus and fracture scores in all 3 groups continued to rise significantly.At the 12th and 16th week the scores in the combined treatment group were significantly better than those in the ESW group and the expanding bone marrow group,while the scores in the ESW group were significantly better than those in the expanding bone marrow group.The cure rates in the ESW,bone marrow and combined treatment groups were 60％,50％ and 100％ respectively at week 16.Conclusions The combined treatment was significantly more effective than either treatment alone.There was no significant difference in effectiveness between the ESW and expanding bone marrow treatments.ESW combined with expanding bone marrow autograft is an effective way to promote bone knitting in the treatment of nonunion of femoral shaft fractures with interlocking intramedullary nails. Key words: Extracorporeal shock waves; Bone marrow autografts; Intramedullary nails; Femoral fractures

Study of Patients Requiring Reoperation for Non-union of Femoral Shaft Fractures

Study of Patients Requiring Reoperation for Non-union of Femoral Shaft Fractures

Modified intramedullary nailing after failed plating for femoral shaft fractures

Objective To report a modified surgical technique of intramedullary nailing to treat failed plating for femoral shaft fractures.Methods From January 2006 to December 2009,we treated 8 patients with non-union of femoral shaft fracture after plating failure.They were 7 men and one woman,with an average age of 41.1 years (from 19 to 61 years).Plate breaking occurred in 7 patients and screw pull-out in one.The average interval between the primary surgery and the salvage surgery after non-union was 12.4 months (from 4 to 30 months).The surgical procedures were:1.percutaneous screw removal under X-ray with the plat retained; 2.ipsilateral or contralateral harvest of the iliac graft,which was done simultaneously as step 1 by another team; 3.implantation of intramedullary nails; 4.opening the fracture site,removing the plate,confirming alignment,cleaning the scar tissue and grafting; 5.distal locking of intramedullary nails.Anterograde nails were used in 5 cases,retrograde ones in 2 and the femoral proximal nail in one.Results The secondary surgery was successfully completed in all cases to change the intramedullary nailing.The average surgery time was 2.6 hours (from 2.0 to 3.5 hours),and the average surgical blood loss was 1100 mL (from 600 to 1500 mL).The one-year follow-up showed fracture union in all the 8 cases after an average time of 5.5 months (from 4 to 8 months),with no infection or other complications.Conclusions This modified surgical technique of intramedullary nailing can significantly reduce blood loss during the revision surgery for the non-union of femoral shaft fracture after plating failure.The percutaneous screw removal and the recanalization of hardened marrow cavity may be 2 technical difficulties. Key words: Femoral fractures; Fractures, nonunited; Fracture fixation, internal; Bone nails; Surgical techniques