Retrograde Nailing Research Articles

Comparison of Two Surgical Techniques for Periprosthetic Supracondylar Femoral Fractures: Minimally Invasive Locking Plate Versus Retrograde Femoral Nails.

Objectives:This study aimed to compare minimal invasive locking plate and retrograde intramedullary nailing in the treatment of supracondylar femur fracture following total knee arthroplasty (TKA) in respect of fracture healing, complications, and functional results.Methods:A retrospective analysis was made of 32 supracondylar femur fractures comprising 20 cases treated with minimal invasive locking plate fixation and 12 with retrograde femoral nailing. The two techniques were compared in respect of range of motion (ROM), functional scores, intraoperative blood loss, surgery time, and radiological examination findings.Results:The mean functional scores did not differ between the nailing and plate fixation groups. In the minimal invasive locking plate group, 2 (10%) patients had delayed union, so revision surgery was applied. The mean post-operative ROM was comparable between two groups (86.2° vs. 86°). Reduction quality in the sagittal plane and maintenance of the initial reduction were better in the minimal invasive locking plate group. Greater shortening of the lower extremity was seen in the retrograde femoral nailing group than in the minimal invasive locking plate group (20.3 vs. 9.3 mm). Perioperative blood loss was greater (2 units vs. 1.2 units) and mean operating time was longer in the minimal invasive locking plate group (126.5 min vs. 102.2 min).Conclusion:In patients with good bone stock, supracondylar femur fracture following TKA can be treated successfully with retrograde nailing or minimal invasive locking plate. Retrograde femoral nailing has the advantage of less blood loss and a shorter operating time. Reduction quality may be improved with the minimal invasive locking plate fixation technique. Both surgery techniques can be successfully used by orthopedic surgeons taking a case-by-case approach.

A Single Retrograde Intramedullary Nail Technique for Treatment of Displaced Proximal Humeral Fractures in Children: Case Series and Review of the Literature.

Background:Displaced proximal humeral fractures in older children with low remodeling potential need to be reduced and fixed. There are many options for stabilization, including external fixation, rigid internal fixation with screws and plates, percutaneous pinning, and flexible intramedullary nailing. The use of 2 flexible retrograde nails, originated at the University of Nancy, France, became the most popular technique in Europe. The aim of this study was to describe and assess a modified, single retrograde nail technique to treat fractures of the proximal part of the humerus.Methods:We performed a retrospective monocentric study. From June 2016 to May 2019, a modified retrograde nail technique with 1 prebent nail was used for the management of 21 consecutive children with a closed displaced proximal humeral fracture. Demographic and surgical data were collected. The surgical technique is similar to the classic elastic stable intramedullary nailing, but only 1 nail is used. The average surgical time and perioperative complications were used as criteria for the feasibility of this technique. Radiographs were obtained preoperatively; at 1, 4, and 6 weeks postoperatively; and after implant removal at an average of 4.2 months postoperatively. The clinical outcomes were assessed on the basis of the shoulder range of motion documented in the medical records and by using the French edition of the QuickDASH (shortened version of the Disabilities of the Arm, Shoulder and Hand [DASH] questionnaire) evaluation scale at the time of implant removal.Results:Nineteen patients with a mean age of 12.6 years and a mean follow-up of 6 months were included in the study. The mean surgical time was 49 minutes. The single intramedullary nail technique provided a satisfactory reduction of all fractures. No perioperative complication occurred. In 1 case, partial loss of reduction was observed on the first-week control radiograph. All patients had a healed fracture, no deficits, excellent results according to the QuickDASH score, a normal range of motion, and excellent strength of the shoulder joint at the time of implant removal (at a mean of 4.2 months).Conclusions:The current study confirms the feasibility and efficacy of the single retrograde intramedullary nail technique to treat displaced proximal humeral fractures in children.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Evaluation of outcomes of distal femoral fractures treated by retrograde nailing technique

Background: Distal femur fractures are less common injuries accounting for approximately 1% of fractures in the elderly. They occur due to high-velocity injury in adults and simple fall in the elderly. Management of these type injuries in the elderly is more challenging because of osteoporosis. Retrograde nailing represents an established fixation method for fractures of the distal femur and offers an alternative to the existing technique of antegrade nailing. Materials and Methods: Prospective study of 70 patients, aged between 16 and 85 years, whose distal femoral fractures were treated with a retrograde femoral nail from December 2016 to November 2018 in the department of orthopedics of a tertiary care centre in North India were followed to assess the outcome of treatment. The fracture was caused by a motor-vehicle accident in 58 patients (82.85 percent) and a fall on the ground in 12 (17.14%). 26 (37.14%) of the fractures were open. All the patients were followed up at about 3 weeks, 6 weeks, 3 months, 6 months, and 1 year. On each visit pain, functional range of movements was noted and the union was assessed clinically and radiologically at regular intervals. Results: Out of 70 patients, 60 patients were males and the remaining patients were female. Twenty-six patients had open fractures and 44 patients had closed fractures. All the patients in our study united without any case of nonunion and knee infection. The mean time required to achieve union was 5.42 ± 2.48 months in closed fractures, while in open fractures, it was 5.7 ± 1.65 months. The mean range of knee movement in open fractures was from 15.0° ± 12.57° to 113.75° ± 14.69 °, while in closed fractures, it was from 5.38° ± 6.43° to 122.18° ± 15.0°. Five patients had loosening of the distal interlocking screws impinging on the skin. Based on the criteria recommended by Schatzker the outcome was assessed as excellent in 33 (47.14%) cases, good in 27 (38.57%) cases, and fair in 7 (10%) cases. The outcome in 3 (04.29%) cases was graded as poor. Conclusions: Retrograde intramedullary nailing makes possible a biological osteosynthesis of distal femoral fractures. It also produces good functional results even in elderly patients.

The surgical management of metastatic lesions of the femur

ABSTRACT BACKGROUND: Malignant tumours commonly metastasise to bone. When this occurs in the femur, surgical intervention is required to reduce pain and restore mobility post fracture, or as a prophylactic measure when fracture is anticipated. This is typically in the form of replacement with hemi- or total arthroplasty or stabilisation with an intramedullary device. The indications for one modality over the other are debatable and the reported outcomes and complications are varied. The purpose of this study is to assess the management algorithm for bony metastasis of the femur at a tertiary bone tumour unit, and the outcomes of the surgical strategies employed METHODS: A retrospective cohort study was performed of all patients presenting to our institution with femoral metastasis, both with and without pathological fracture, who were managed surgically from April 2016 to February 2020. Fractures of the femoral neck were managed with cemented arthroplasty. All other fractures were managed with intramedullary nailing, as were all lesions requiring prophylactic stabilisation. Data was recorded regarding demographics, primary pathology, location of lesion, type of surgery, and implant used. The incidence of complications including radiological failure of fixation, infection, thromboembolic phenomena, re-operation and mortality were recorded RESULTS: Eighty-five femurs in 77 patients were included (mean age 61 years, range 20-90). Lesions were located in the femoral neck (19/85, 22%), intertrochanteric (20/85, 24%), subtrochanteric (40/85, 47%), diaphyseal (2/85, 2%) and metaphyseal/per-condylar (4/85, 5%) regions of the femur. A total of 64/85 (753%) procedures were performed for fractures and 21/85 (25%) prophylactically. Eighteen of the 85 (21%) underwent long-stemmed cemented bipolar hemiarthroplasty, 1/85 (1%) long-stemmed cemented total hip replacement (THR), 62/85 (73%) cephalomedullary nailing, and 4/85 (5%) retrograde femoral intramedullary nailing. Mean follow-up was eight months (range 1-36). There were no dislocations or periprosthetic fractures in the arthroplasty group. One failure (1/66, 2%) of fixation occurred in the intramedullary nailing group. Six deaths occurred in the arthroplasty group (6/64, 9%) and 24 in the nailing group (24/66, 36%) during the study period. Four patients suffered from thromboembolic phenomena (4/77, 5%). Of the 13 patients who sustained a pathological fracture and were managed with intramedullary nailing and followed up for at least one year, all had achieved clinical and radiological union CONCLUSION: Femoral metastasis can be appropriately managed with intramedullary nailing, both prophylac-tically and in the event of fracture, with a low rate of implant failure and an expectation that healing will occur once stabilised. Intracapsular fractures can be managed with long-stemmed cemented arthroplasty with a low risk of subsequent fracture or dislocation Level of evidence: Level 4 Keywords: bone metastasis, femur, pathological fracture

Study on effectiveness of retrograde nailing with long intramedullary supracondylar nail for shaft and supracondylar fractures of femur

Introduction: Due to modern lifestyle changes, the incidence of distal femur fractures has risen and more so in association with shaft fractures of femur because of fast world and high velocity trauma occurring in road traffic accidents. Dilemma arises when we face distal third shaft and associated supracondylar or inter-condylar fracture of femur. The aim of this study is to remove the hesitancy of performing retrograde nailing by long IMSC nail without any complications. Materials and Methods: A prospective study of 150 patients with fracture of femur shaft and supracondylar fractures was done. They were treated by using this technique, from January 2003-2017. These patients were followed up till fracture union & evaluated further postoperatively for finding its benefits. Results: In our study, the mean age of patients was 35 years. 65.3% were males and 34.7%% were females. The mode of injury in case of majority of the patients had RTA (road traffic accident) 93 patients (62%). In the present, surgical and technical related complications were encountered in 10 patients (6.7%). Our patients had a mean value of 80 points according to Neer score. Conclusions: We conclude that retrograde long IMSC nail is reliable as an alternative for conventional procedures like ante-grade nailing and plate fixation in femoral fracture shaft and supracondylar region. It is especially beneficial in conditions like osteoporosis, pregnancy & previous implant or prosthesis on ipsi-lateral side and ankylosed hip. Retrograde nailing can be done on simple radio-luscent top operating tables which are commonly available everywhere. Keywords: Femur shaft fractures, Supracondylar femur fractures, Retrograde long IMSC nailing, Fracture union.

Peri-implant fractures proximal to a long retrograde femoral nail – A case series

Low energy peri-trochanteric fractures may happen in the presence of a retrograde nail in the femur. The management of these peri-implant fractures are very rarely reported. This is a series of seven cases from a level one trauma centre in Hong Kong. All fractures arose from low energy falls and were either inter-trochanteric or subtrochanteric. Removal of previous implants to allow cephalo-medullary fixation of the new fracture could be considered, but this is often difficult, time-consuming, and may inflict damage to the articular cartilage. Furthermore, this is not an option if the distal fracture is not yet well healed. Six of the seven fractures presented here were treated operatively with an extra-medullary device fixed to the proximal shaft with cerclage cables. The choice of fixation implants were based on the fracture type and available space above the proximal end of the retrograde nail. All seven fractures healed with no implant failure and major complications. There were no thirty-day and one-year mortality. A treatment algorithm is proposed for the management of these uncommon but difficult cases.

Comparison of Functional Outcome of Intra-Articular Distal Femur Fracture Management with Retrograde Nail with That of Locking Compression Plate - A Clinical Interventional Study

Comparison of Functional Outcome of Intra-Articular Distal Femur Fracture Management with Retrograde Nail with That of Locking Compression Plate - A Clinical Interventional Study

Functional outcome of retrograde nailing versus locked plating of extra-articular distal femoral fractures in adults: A randomized controlled trial

Background: Distal femoral fracture constitutes the supracondylar and intercondylar fractures of femur. These are treated by locking plates as well as with nails. Despite the widespread use of both techniques, there are only few comparative studies. The two clinical techniques used to stabilize distal femur fractures are compared in this study.
 Objectives: The aim of this study was to compare plating and nailing in terms of functional outcome using the Hospital for Special Surgery (HSS) Knee Score of operative fixation of extra-articular femur fracture.
 Methodology: A randomized controlled trial was conducted with a total of 30 patients presenting to BP Koirala Institute of Health Sciences in a period of twelve months. All skeletally mature (>16 years) adult patients with isolated traumatic closed extra-articular fracture of distal femur without distal neurovascular deficit and giving written and informed consent were included. Patients with re-fractures, poly-trauma, fracture dislocations, pathological fracture and compartment syndrome were excluded. They were operated and followed up at 2, 6, 12 and 24 weeks. 
 Results: The demographic profiles of the two groups were comparable. There was no significant difference in functional outcome (Hospital for Special Surgery score), union or complications between them.
 Conclusion: This study showed that there was no significant difference in terms of functional outcome (Hospital for Special Surgery score), union, fracture alignment, range of motion (knee, hip joint), infection, other outcome measures between plating and nailing in the treatment of distal femoral fracture in adults. Hence, further study is required to come to firm conclusions.

Tibiotalocalcaneal Fusion With Antibiotic Cement-Coated Nails for Refractory Deep Infection After Ankle ORIF.

Deep infection after open reduction internal fixation (ORIF) of ankle fractures represents a challenge to the orthopaedic surgeon, particularly in patients in whom conventional surgical treatments have failed. The aim of this study was to assess the results of a modified technique of tibiotalocalcaneal fusion using a retrograde locked intramedullary nail covered in cement with antibiotics. Six patients treated using the authors' technique were analyzed retrospectively. All patients had deep infection after ankle osteosynthesis and several surgical procedures (debridement, external fixation, etc) had failed. Radiographs were analyzed to confirm the healing of the bone. Outcome was measured by maintained construct stability and eradication of infection (no clinical signs of infection and normal values of laboratory markers). The average age of the series was 64.2 (range, 50-75) years, and the average follow-up period was 19.5 (range, 8-41) months. Tibiotalocalcaneal stability and eradication of the infection were achieved in all patients, along with the normalization of clinical and radiologic parameters. In the patient who underwent a talectomy, one of the calcaneal locking screws broke, with no clinical repercussions. Tibiotalocalcaneal fusion with antibiotic cement-coated retrograde nails was useful in providing clinically acceptable results in the control of chronic infection in complex patients after the failure of previous surgeries. Level IV, therapeutic study.

Clinical outcomes of revision with retrograde intermedullary nailing for failed plating of distal femoral fractures: a retrospective study.

To assess the feasibility and effectiveness of retrograde intramedullary nail (RIN) revision surgeries for locking compression plate (LCP) failure in distal femoral fractures. This retrospective study included 13 patients who suffered from metalwork failures after they initially underwent open reduction and LCP fixation. In patients who eventually underwent RIN revision from January 2014 to December 2016, range of motion (ROM) and Hospital for Special Surgery (HSS) scores obtained before surgery and at the final follow-up time were analysed. The average operative time was 155 minutes (range, 120-210 minutes), and the average blood loss volume was 650ml (range, 200-1350ml). There were two cases of complications (15.38%): one was calf muscle vein thrombosis, and the other was a superficial infection. No deep tissue infection or deep vein thrombosis was observed post-operatively. The average follow-up time was 16months (range, 12-24months). All fractures healed in a mean of 6.5months (range, 4-12months), and one patient underwent an additional bone graft surgery that did not involve a bone graft during the RIN revision operation (this eventually healed at 12months post-operatively). The mean ROM before the operation was 86.92 ± 12.34°. At the final follow-up, the mean ROM was 112.69 ± 9.27°. There was a significant difference between pre-operative and post-operative ROM (P < 0.01). The mean HSS score improved significantly from 38.85 ± 9.62 points pre-operatively to 79.62 ± 5.42 points post-operatively. There was a significant difference between pre-operative and post-operative HSS scores (P < 0.01). RIN revision surgery achieved excellent clinical results in patients with LCP failure.

Can titanium elastic nail be safely used for paediatric subtrochanteric femur fractures?

In this study, we aimed to show that subtrochanteric femur fractures, an uncommon type of fracture in the paediatric age group, can be treated with titanium elastic nailing (TEN). We reviewed the patients treated with TEN in the paediatric age group with subtrochanteric femur fractures who had been treated at the Orthopaedics and Traumatology Clinic of Izmir Tepecik Research and Training Hospital between January 2011 and December 2016 retrospectively. All fractures were fixed by retrograde nailing with supracondylar entry following reduction. Patients' demographics as well as data such as fracture type, fracture level, time of operation, reduction type, time to union, shortness, additional fixation, duration of additional fixation, Flynn scores and reduction loss were evaluated. The 20 patients included in our study were followed up for at least 1 year, had an age range of 54-173 months (mean, 104 ± 31.82 months) and were operated within 2-11 days after fracture. All patients had fracture union and only three patients had union with an angulation of less than 5°. None of the patients had limb length inequality. Fourteen patients underwent reoperation, all of these were routine operations for implant removal and no patients required reoperation for complications. We think that paediatric subtrochanteric femur fractures can be treated by TEN fixation using the proper technique, with a limited invasive intervention.

Comparative study of outcome of retrograde intramedullary nailing and locking compression plating of distal femoral fractures in adults

Fractures in the elderly are often challenging due to osteoporotic bone and co-morbidities and long term disability can occur. Surgery is the standard mode of treatment and hence a quick surgical treatment for early weight bearing and mobilization is required in order to prevent long term complications due to prolonged bed rest. All patients were documented prospectively, complete demographic details and clinical history was obtained. Clinical and radiographic evaluation was done in all the patients. Informed consent was taken and all patients were treated with DFLCP and retrograde nailing randomly. Duration of hospitalization was documented and follow up was done for 2 years. In this study, fracture union time was12-24 weeks with among the patients of the DLFP group with 75 percent have union and was 12-24weeks among the patients of the retrograde nailing group with union occurring in 80 percent of patients respectively. Significant results were obtained while comparing the mean fracture union time among the patients of the two study groups. In our study, follow up was done up to 2 years with 60% of patients followed up to 15 months in both the groups.

Clinical evaluation of tibiocalcaneal arthrodesis with retrograde intramedullary nail fixation in diabetic patients.

The aim of this study was to evaluate clinical and functional outcomes in diabetic patients undergoing tibiocalcaneal arthrodesis using a retrograde nail. A total of 12 diabetic patients [8 men and 4 women; mean age at intervention: 56.8 years (range: 27-76 years)] who underwent tibiocalcaneal arthrodesis by a retrograde nail were enrolled in this study. The indication for surgery was massive talar osteonecrosis in four patients, Charcot arthropathy in another four patients, and various severe ankle/hindfoot derangements in four patients. All surgeries were performed by the same surgeon. All patients were evaluated by their American Orthopedic Foot and Ankle Score (AOFAS) score, and radiographic follow-up was performed. The mean follow-up time was 59.5 months (range: 27-121 months). Ten patients (83.3%) healed and were able to walk with full weight bearing without crutches. Among them, nine patients (75%) achieved union with solid bone healing. The mean overall improvement in the AOFAS score was 72.5% (preoperatively: 40 points vs postoperatively: 69 points; p<0.001). We observe a complication in 50% of our patients. Minor complications included two cases of dehiscence of the surgical wound, one case of soft tissue irritation owing to hardware protrusion, and one cause of lymphedema. Two patients had deep infection and underwent surgical removal of hardware, debridement, and antibiotic treatment: one healed after the treatment but never recovered full weight bearing and the other one died from other complications. These two deep infections occurred after 23 months of follow-up. Tibiocalcaneal arthrodesis using retrograde nails is a salvage technique extremely effective in ankle and hindfoot disorders in a diabetic patient. This procedure allows good functional outcomes and pain relief. When correctly indicated, it is a safe procedure with good clinical outcomes and low risk of below-knee amputation. Level IV, Therapeutic study.

Technical Trick: Dual Plate Fixation of Periprosthetic Distal Femur Fractures.

Treatment of periprosthetic distal femur fractures remains challenging due to assuring adequate distal fixation. Traditional treatment options include lateral locked plating and retrograde nailing, although recently dual implant constructs have been explored with promising results. Allowing immediate weight-bearing in this patient population has benefits with regards to rehabilitation and outcome. Recent literature has focused on nail-plate constructs, however plate-plate constructs are preferred at our institution as they do not require arthroplasty component compatibility, facilitate the coronal plane reduction, and allow for immediate weight-bearing.

Antegrade Elastic Intramedullary Nailing Insertion Technique Results in Higher Incidence of Symptomatic Implants in Pediatric Ulnar Fractures.

Introduction:Retrograde and antegrade nailing techniques are the two options available to a surgeon when using elastic stable intramedullary nailing; however, the literature comparing these two nailing techniques is scarce. Thus, we conducted a retrospective review of all pediatric and adolescent ulnar fractures treated with elastic stable intramedullary nailing at our facility. We hypothesize that the clinical outcomes (implant and wound complications) and the time between surgery and radiographic union will be similar for both techniques.Methods:A retrospective chart review of pediatric ulnar fracture patients treated at our facility was performed. Demographic and health information associated with the injury were collected, and the clinical outcomes of the two techniques were compared.Results:A total of 53 patients with 54 fractures were included in this study. Antegrade nail insertion was used to treat 59.2% fractures. Radiographic union was achieved in all patients. Nail insertion technique was not associated with postoperative wound complications, time to radiographic union or implant removal, or significant deficits in upper extremity rotation (P > 0.05). Antegrade nailing resulted in a symptomatic implantation 3.97 times more frequently than compared with retrograde nailing (P = 0.036).Discussion:Antegrade nailing demonstrates a similar healing profile but higher implant complications compared with the retrograde nailing technique in pediatric ulnar fractures.

Tibiotalocalcaneal arthrodesis through retrograde nailing for the treatment of juxtaarticular distal tibia aseptic non-unions: A retrospective study at a minimum follow-up of 4 years

IntroductionThe purpose of this study is to determine the efficacy of tibiotalocalcaneal arthrodesis by reamed intramedullary nail in the management of the distal tibia non-unions, associated with end-stage osteoarthritis of ankle and subtalar joints. Materials and methods8 patients with radiographical and clinical diagnosis of non-union of the distal tibia have been treated with tibiotalocalcaneal arthrodesis by intramedullary retrograde nail and were retrospectively evaluated. Patients were radiographically and clinically evaluated preoperatively and at final follow-up regarding: satisfaction, AOFAS, VAS. Surgical technique is described. ResultsMean follow-up was 69.2 ± 23.2 months (range 48–108). In terms of subjective outcome, patients reported a highly satisfying result. All patients returned to daily activities, with an average time of 24.7 ± 8.7 weeks. 6 patients could return to their previous work activity, with an average time of 23.6 ± 6.3 weeks. ConclusionsThe procedure showed good results at final follow up. Consolidation was achieved in all the treated cases. Considering AOFAS and VAS scores at final follow-up, there was an evident improvement of the conditions of the patients.

Mid-term results of hindfoot arthrodesis with a retrograde intra­medullary nail in 24 patients with diabetic Charcot neuroarthropathy

Background and purpose — Hindfoot arthrodesis using retrograde intramedullary nailing assumes a critical role in limb salvage for patients with diabetic Charcot neuro­arthropathy (CN). However, this procedure is compelling and fraught with complications in diabetic patients. We report the mid-term clinical and radiological outcomes of retrograde intramedullary nailing for severe foot and ankle deformity in patients with diabetic CN.Patients and methods — Hindfoot arthrodesis was performed using a retrograde intramedullary nail in 24 patients (15 females) with diabetic Charcot foot. The mean age of the patients was 62 years (33–82); the mean follow-up was 45 months (24–70). The primary outcomes were rates of fusion, limb salvage, and complications.Results — The overall fusion rate was 23/24, and none of the patients needed amputation. The rate of superficial wound infection was 4/24, and no deep infection or osteomyelitis was observed postoperatively.Interpretation — For selected cases of diabetic CN with severe foot and ankle deformity, hindfoot arthrodesis using a retrograde intramedullary nail seems to be a good technique in achieving fusion, limb salvage, and avoidance of complications.

Retrograde nailing, trabecular metal implant and use of bone marrow aspirate concentrate after failed ankle joint replacement

BackgroundAnkle fusion after removal of alloplasty is known to be a procedure with a high potential for non-unions and poor function, especially tibio-talo-calcaneal fusion. We wanted to review our results after using a novel method for the procedure, combining retrograde nailing with a trabecular metal implant and bone marrow aspirate concentration applied in an ostoconductive pad in addition to autologous bone grafting. Materials and methodsRetrospective review of a patient series, with some prospectively registered data. 31 ankles in 30 patients were operated from January 2016 to February 2019. ResultsThere were two non-unions (6.5%), and one delayed union, none of these were reoperated. The mean postoperative Manchester-Oxford Foot and Ankle Questionnaire score (MOxFQ) was 33.6 points. 9 patients scored an average MOxFQ at 72.9 immediately before surgery, while at follow-up this had decreased to 36.2, an improvement of 36.7 points (95% CI 18.3–54.9). There were 1 minor infection and 5 possible nerve injuries. One patient had the leg amputated 1 year after the surgery due to a non-related necrotizing fasciitis. ConclusionWe present reasonably good short to medium term patient satisfaction and fusion rates with this novel combination of techniques.

Distal femural fractures. Surgical options

Distal femur fractures are complex and relatively rare. Conservative treatment has now been abandoned. The purpose of surgical treatment is to obtain an anatomical reduction of the articular surface, restoring the coronal and sagittal axis of the skeletal segment with a stable osteosynthesis, thus avoiding post-operative immobilization and allowing for early physical therapy. The literature reports similar results with different kinds of osteosynthesis: anterograde or retrograde nailing, dynamic compression screw plate, locking compression plates, and blade plates. Not only the type of fracture, but also the experience of the single surgeon should be taken into account when choosing the type of osteosynthesis.

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

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. 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 1.0cm, 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. 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 1.0cm 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 23.5months (12-51months). Excellent and good clinical results were observed in all patients. There was no plate or screw breakage, and no patient developed infection. 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.