Nonunion Repair Research Articles

Treatment of Femoral Diaphyseal Nonunions

There have been conflicting reports regarding treatment of femoral diaphyseal nonunions using reamed intramedullary nailing. Although high union rates have been reported using this technique, not all orthopaedic surgeons have experienced the same success. A retrospective review of charts and radiographs of 39 adult patients with nonunions of the femoral diaphysis treated at the authors' institution with reamed intramedullary nailing, compression, and with and without interlocking was done. The time from the index procedure to nonunion repair was 4 to 75 months (average, 19 months). Fifteen patients had 18 procedures between the index operation and nonunion repair. The average followup from nonunion repair to the most recent examination was 22.5 months (range, 3-108 months) with a median of 15 months. At the last followup, the overall union rate was 74% after one procedure and 97% after two or more procedures. There were seven complications including two infections, one pulmonary embolus, one occurrence of a deep venous thrombosis, a hematoma, and one case of malrotation. The data support the use of antegrade reamed nailing as a successful technique for treatment of most femoral diaphyseal nonunions.

Humeral shaft nonunion: evaluation of uniform surgical repair in fifty-one patients.

To determine whether a standardized treatment of aseptic humeral shaft nonunions results in union after one operation without substantial complications. Retrospective study. University hospital. Between 1975 and 1998, fifty-eight patients sustained a humeral shaft fracture that resulted in an aseptic nonunion. Fifty-one patients between the ages of twenty-three and eighty-six years (mean 50.8 years) were included and evaluated. Surgical treatment consisted of an anterolateral approach with radial nerve identification and subsequent neurolysis, decortication, compression plating, and frequent application of autogenous bone grafts. No immobilization with brace or cast after treatment was functional. Success rate of nonunion repair, reinterventions, complications, range of motion, patient satisfaction. After one year, consolidation was apparent in all cases. All but two patients had an essentially normal range of motion of the shoulder and elbow, and 96 percent rated their result as excellent or good. After nonunion repair, two patients had a transient sensory neuropathy of the radial nerve. In one patient, a second intervention was needed after a fall from bed one week after the index operation. The results of this study indicate that our standard surgical procedure for treatment of nonunion of the humeral shaft is reliable and achieves consolidation in one procedure without significant complications.

Failure of exchange reamed intramedullary nails for ununited femoral shaft fractures.

To determine the effectiveness of exchange reamed nails for treatment of aseptic femoral delayed unions and nonunions. Retrospective chart review. Nineteen patients admitted to the Carolinas Medical Center Level I trauma center from 1990 to 1996 for repair of femoral shaft fracture nonunion following contemporary locked nailing performed at least six months previously. These patients showed no radiographic evidence of progression of fracture healing for three months and had clinical symptoms of nonunion. Exchange reamed nails to treat ununited femoral shaft fracture. Radiographic and clinical evidence of union of the fracture or of the necessity for additional procedures. In 53 percent of the patients the secondary procedure resulted in fracture union, whereas in 47 percent, one or more additional procedures were required. Eight of the nine fractures that did not unite with exchange nailing united after a subsequent procedure (bone grafting, compression plating, or nail dynamization). Neither the type of nonunion, the location of the shaft fracture, the use of static versus dynamic cross-locking, nor the use of tobacco products was statistically predictive of the need for additional procedures. Reevaluation of routine exchange nailing as the recommended treatment for aseptic femoral delayed union or nonunion may be required. A significant number of patients who undergo reamed exchange nailing will require additional procedures to achieve fracture healing.

The significance of hardware failure in anterior cervical plate fixation. Patients with 2- to 7-year follow-up.

In this retrospective study, the incidence of anterior cervical hardware failure was reviewed in 109 patients with degenerative disorders treated by one surgeon. To evaluate the risk of injury caused by hardware failure in anterior cervical spine reconstruction. Anterior plating is used for stabilization after cervical spine trauma and other conditions of instability. There has been a concern among surgeons about the risks involved when anterior cervical plating fails (fracturing or loosening of the construct). The series included placement of 70 nonconstrained plates and 39 constrained plates. The average length of follow-up was 43 months. Hardware failure was defined as any broken or loosened screw or plate, regardless of clinical significance. There were 32 Orozco (Synthes, Inc., Paoli, PA) failures, 5 cervical spine locking plate failures, and 2 Orion (Sofamor Danek USA, Inc., Memphis, TN) failures. There were no injuries to tracheoesophageal or neurovascular structures as a result of hardware implantation or failure. The incidence of prominent hardware that endangers tracheoesophageal structures is minimal. In most cases, careful and long-term follow-up can ensure that failed hardware has not progressed and can confirm that late failure has not occurred. Hardware failure should increase the surgeon's suspicion of a nonunion, but immediate removal of the failed hardware is rarely necessary. If reoperation is necessary for nonunion repair, kyphosis correction, or other secondary procedures, the hardware can be removed at that time. Constrained systems (cervical spine locking plate, Orion) had significantly (P2 = 7.65, P < 0.01) fewer failures than the nonconstrained Orozco system.

THE TRICEPS-SPLITTING APPROACH FOR REPAIR OF DISTAL HUMERAL MALUNION IN CHILDREN. A REPORT OF A TECHNIQUE

Abstract Repair of cubitus varus in a child requires a distal humeral osteotomy. The triceps-splitting surgical approach was used for repair of distal humeral malunion in 10 children. Six patients had repair of cubitus varus, 3 had fixation of a fresh fracture, and 1 had repair of a nonunion. No problems with healing were noted. Triceps weakness and elbow stiffness did not occur. The triceps-splitting approach is particularly well suited for repair of cubitus varus in children because, compared with the lateral approach, it is cosmetically favorable, avoids ulnar and cutaneous nerves, does not damage extensor function, provides excellent visualization of the osteotomy site, and does not result in joint stiffness.

STRESS FRACTURE OF THE TIBIA AFTER HARVEST OF A VASCULARIZED FIBULAR GRAFT FOR REPAIR OF NONUNION OF THE HUMERUS

STRESS FRACTURE OF THE TIBIA AFTER HARVEST OF A VASCULARIZED FIBULAR GRAFT FOR REPAIR OF NONUNION OF THE HUMERUS

Repair of Nonunion of Tibial Osteotomy

Nonunion after high tibial osteotomy is an uncommon complication. Ten cases have been treated with a single plate; failure occurred twice in five. Double plates, bolted together, healed in all five attempts. Although the healed osteotomies had only "fair" functional results, none have as yet required total knee arthroplasty (TKA).

Treatment of nonunions of the scaphoid with the Ender compression blade plate system

A relatively high failure rate is associated with bone grafting with or without screw fixation in scaphoid nonunions. Complicating factors include avascular necrosis, cystic degeneration, and osseous size discrepancy or compromise. The Ender blade plate is suitable for adding stability in these cases, in spite of the necessity for late removal and the possibility of articular impingement. Twenty patients were treated with this technique. Nine of these patients had had previous unsuccessful attempts at nonunion repair. Nineteen had satisfactory results, but one had a persistent nonunion. The use of the Ender blade plate system is applicable for treatment of these difficult cases that are not ideally suited to compression screw fixation.

Metatarsal osteotomy using a double-threaded compression screw: an adjunct to revision forefoot surgery.

A double-threaded compression screw (Herbert) was used as internal fixation of metatarsal neck osteotomy and nonunion repair in 16 patients (18 feet). Fifteen patients had associated symptomatic conditions of the foot. Twelve patients had one or more previous surgical procedures on the involved foot. Fourteen patients (15 feet) underwent 20 primary or revision lesser metatarsal osteotomies. Four of these patients had undergone previous lesser metatarsal osteotomies and had developed recurrent pain beneath six metatarsals and transfer metatarsalgia in one case. The remaining two patients (three feet), with six nonunions from previous metatarsal osteotomies, had repair with screw fixation and bone grafting. Follow-up for the series averaged 14 months.

Mechanisms and results of non-union repair with pulsing electromagnetic fields

Mechanisms and results of non-union repair with pulsing electromagnetic fields

Prevention and repair of nonunion of fractures in the adult forearm.

*From the Department of Orthopedic Surgery, College of Physicians and Surgeons, Columbia University, and the Fracture Service, Presbyterian-New York Orthopaedic Hospitals, New York, N.Y.