Treatment Of Femoral Shaft Nonunion Research Articles

Effect of bone grafting on bone union in exchange nailing for the treatment of femoral shaft nonunions.

This study aims to investigate the effect of bone grafting on the bone union in exchange nailing (EN) for the treatment of femoral shaft nonunions. A total of 26 patients (16 male) were included in this study. The mean age of the patients was 36.1±9.3. Bone grafts were used in 8 patients (bone graft group), and EN was performed without bone grafting (no bone graft group) in 18 patients. Etiology, fracture type, location, and classification of the fractures at the time of initial injury were evaluated. The reduction type (open or closed) and locking status of the nails were also noted. Nonunion types were recorded. In the bone grafting group, iliac bone autografts were used in seven patients and a synthetic bone graft was used in one patient. Following EN, the presence and duration of bone union, and the increase in the nails' diameter were analyzed for each group and compared. Union rates were 100% and 94.4% in bone grafting and no bone grafting groups, respectively. The mean union period was not significant between the groups (22.5 and 16.5 months, respectively). The mean increase in the nail diameter was 1.88 mm in the bone graft group and 2.00 mm in the no bone graft group (p>0.05). This study demonstrated that high union rates can be achieved with EN by means of using larger diameter nails with or without bone grafting in the management of femoral shaft nonunions, and bone grafting had no significant effect on union rates and periods.

Plate augmentation and bone grafting in treatment of femoral shaft nonunion initially fixed by intramedullary nail.

Introduction: This study aims to evaluate the results of plate augmentation and bone grafting without removing the nail in the treatment of nonunited, nailed femoral shaft fractures. Methods: Twenty patients with atrophic nonunion femoral shaft fractures initially fixed by intramedullary nail were treated by augmentation plating and iliac bone graft with retention of the nail. Patients were evaluated at regular intervals using an X-ray and Wu scoring system, which assesses clinical and radiological signs of healing. Results: All 20 patients achieved bony union at a mean time of 4.9 months (3–8 months). According to Wu’s score, 12 cases showed excellent results, and 8 cases obtained good results with no complications recorded. Conclusion: augmentation plating and iliac bone graft provide a good and safe method of treatment of previously nailed and non-united femoral shaft fractures.Level of evidence: Level 4; Case Series.

Efficacy and Safety of Long-Term Intravenous Tranexamic Acid Administration for Blood Management in Revision Surgery for Femoral Shaft Nonunion: A Retrospective Case-Control Study.

Femoral shaft nonunion is a complication that seriously affects physiological functions. We aimed to assess the effectiveness and safety of short- and long-term intravenous tranexamic acid (TXA) administration in the perioperative period of revision surgery for femoral shaft nonunion. In this retrospective study, 53 patients undergoing double-locking plates with channel bone grafting technology for the treatment of femoral shaft nonunion were divided into 3 groups: the patients in group A without use TXA during hospitalization, the patients in group B received intravenous (IV) 1-g TXA at 30 min before the surgery and deep soaked 1-g TXA for 5 min before closing the incision, and then 1-g TXA IV again 6 h after surgery, and the patients in group C received 1-g TXA IV before the operation, 1-g TXA topically during the operation, and subsequent long-term 1-g TXA IV until discharged. The primary outcomes were total blood loss (TBL) and hidden blood loss (HBL). The secondary outcomes included actual hemoglobin (Hb) loss values, transfusion requirement, number of units transfused, postoperative laboratory values (Hb, hematocrit, fibrinogen, and D-dimer), visual analogue scale (VAS) scores, and hospitalization time. The mean TBL was lower in group C than in group A (1168 mL vs. 2714 mL, P < 0.001) and group B (1168 mL vs. 1557 mL, P = 0.008). The differences in HBL volumes were also significant between groups A and C (P < 0.001) and between groups A and B (P < 0.01). The actual Hb loss in the 3 groups showed a consistent trend with TBL, but no significant differences between groups B and C (P = 0.23). On postoperative day (POD) 3, the Hb level was higher in group C than in group A (111.1 g/L vs. 94.6 g/L, P = 0.02). No significant differences were found in VAS, hospital stay, thromboembolic complications, incision-related complications, and TXA adverse reactions among groups. Long-term intravenous TXA during hospitalization can effectively reduce perioperative blood loss, Hb drop, and postoperative hyperfibrinolysis, but is associated with an increased incidence of adverse reactions.

Comparison of a multidimensional cross locking plate versus a locking compression plate for the treatment of femoral shaft nonunion: Finite element analysis

The purpose of this study was to explore the advantages and disadvantages of a multi-dimensional cross locking plate (MDC-LP) compared with a locking compression plate (LCP) as the augmentation plate (AP) over an intramedullary nail (IMN) for the treatment of femoral shaft nonunion by using finite element analysis.A finite element model of the femur was developed to analyze the maximum stress, stress distribution, displacement of fixation and nonunion site under increasing axial and torsional loads.Some differences in the stress distribution and stress values on the fixations were observed in the five fixation models. The MDC-LP with eight screw fixation showed the lowest variety of nonunion site displacement under the increasing axial and torsional loads. Models of the MDC-LP were more stable with regard to the bending and torsional forces.The short MDC-LP with eight screw insertion as an augmentation plate over intramedullary nail shows biomechanical advantages compared to the LCP. The MDC-LP may be an appropriate and effective treatment option for femoral shaft nonunion.

Research progress of augmentation plate for femoral shaft nonunion after intramedullary nail fixation

To review the history, current situation, and progress of augmentation plate (AP) for femoral shaft nonunion after intramedullary nail fixation. The results of the clinical studies about the AP in treatment of femoral shaft nonunion after intramedullary nail fixation in recent years were widely reviewed and analyzed. The AP has been successfully applied to femoral shaft nonunion after intramedullary nail fixation since 1997. According to breakage of the previous nailing, AP is divided into two categories: AP with retaining the previous intramedullary nail and AP with exchanging intramedullary nail. AP is not only suitable for simple nonunion, but also for complex nonunion with severe deformity. Compared with exchanging intramedullary nail, lateral plate, and dual plate, AP has less surgical trauma, shorter healing time, higher healing rate, and faster returning to society. However, there are still some problems with the revision method, including difficulty in bicortical screw fixation, lack of anatomic plate suitable for femoral shaft nonunion, and lack of postoperative function and quality of life assessment. Compared with other revision methods, AP could achieve higher fracture healing rate and better clinical prognosis for patients with femoral shaft nonunion. However, whether patients benefit from AP in terms of function and quality of life remain uncertain. Furthermore, high-quality randomized controlled clinical studies are needed to further confirm that AP are superior to the other revision fixations.

Exchange nailing versus augmentative plating in the treatment of femoral shaft nonunion after intramedullary nailing: a meta-analysis.

With advances in the treatment of femoral shaft nonunion after intramedullary nailing, the optimal option remains controversial. This study aimed to quantitatively investigate outcomes in a comparison of exchange nailing and augmentative plating for femoral shaft nonunion after intramedullary nailing.The EMBASE, PubMed, Cochrane library and Clinical databases were systematically searched dating from their inception to March 2018. All retrospective controlled and prospective trials evaluating exchange nailing and augmentative plating for the treatment of femoral shaft nonunion after intramedullary nailing were identified. Two investigators extracted all related data independently and we used the review manager software to perform the meta-analysis.Three studies with a total of 232 patients were eligible for data extraction in our study. The meta-analysis indicated that the augmentative plating group had a lower nonunion rate, shorter time to union, less intra-operative blood loss, and shorter operative time than the exchange nailing group. While for the infection rate, there was no significant difference between augmentative plating and exchange nailing group.The available evidence has shown that augmentative plating is superior to exchange nailing for femoral shaft nonunion after intramedullary nailing.Cite this article: EFORT Open Rev 2019;4:513-518. DOI: 10.1302/2058-5241.4.180054

Sliding bone graft combined with double locking plate fixation for the treatment of femoral shaft nonunion.

ObjectivesThe aim of this study was to describe and evaluate a novel method of sliding bone graft combined with double locking plate fixation in treating femoral shaft nonunion.MethodsClinical data from patients with femoral shaft nonunion that was treated with sliding bone grafts combined with double locking plate fixation were retrospectively collected. Data included duration of surgery, blood loss, union rate, time to union and possible complications.ResultsTwenty-five patients included in the study were followed for a mean duration of 16.6 ± 2.6 months (range, 12–22 months). All of the fractures (100%) achieved bony union. Mean time to union was 6.0 ± 1.0 months (range, 4–8 months). No infections or medullary cavity occlusions were observed.ConclusionsSliding bone graft combined with double locking plate fixation was shown to be a safe, effective, and convenient surgical option for the treatment of nonunion, due to its high union rates with no complications. Further studies with larger sample sizes and longer-term follow-up are warranted.

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.

Pedicled Vascularized Medial Femoral Epicondyle Bone Grafts for the Treatment of Femoral Shaft Nonunion

Pedicled Vascularized Medial Femoral Epicondyle Bone Grafts for the Treatment of Femoral Shaft Nonunion

Treatment of atrophic femoral non-unions according to the diamond concept: Results of one- and two-step surgical procedure

BackgroundThe treatment of non-unions in long bones poses a great challenge, particularly in cases of infection or large osseous defects. This article evaluates the use of the diamond concept in the treatment of femoral non-unions in a one-step or two-step procedure according to the Masquelet technique. Patients and methodsBetween February 2010 and March 2014, 88 patients with atrophic femoral non-unions were included in our study. The treatment was performed in one step (Group G1) on 41 patients and in two-step Masquelet technique (Group G2) on 47 patients, according to the diamond concept. In 72 cases it was decided to apply the growth factor BMP-7. The mean age of patients was 49.9±15.3. The data were analysed after following up all patients for at least 12 months after surgery. Results74% of patients achieved consolidation in an average of 9.3 months. Positive bacterial cultures were found in 16 cases (18%). The consolidation rate in G2 was dependent on the non-union localisation and the osteosynthesis method applied. 83% of patients treated by intramedullary reaming achieved consolidation, while this was the case for only 60% of patients with osteosynthesis plates. Smokers in G2 had a larger average osseous defect and a lower consolidation rate. The quality of life as assessed with the SF-12 questionnaire had improved in both groups, with no significant differences between G1 and G2 one year after surgery. ConclusionsOne-step therapy is a suitable method of treatment for aseptic femoral non-unions with small osseous defects, using BMP-7 and RIA in the case of primarily failed atrophic non-union treatment. The Masquelet technique is an efficient means of eradicating infections in non-unions. In combination with intramedullary nailing, this technique is the method of choice for the treatment of femoral shaft non-unions with large defects.

Exchange reamed intramedullary nailing versus augmentation compression plating plus autogenous bone grafting for femoral shaft nonunion after intramedullary nailing

Objective To retrospectively compare the outcomes between exchange reamed intramedullary nailing (ERN) and augmentation compression plating (ACP) combined with autogenous bone grafting in treatment of femoral shaft nonunion after intramedullary nailing. Methods A multicentre retrospective study was performed for 178 patients (180 sides) with femoral shaft nonunion after intrame-dullary nailing. Eighty-six (87 sides) out of the 178 patients underwent ERN (Group A) consisting of nonisthmal nonunions in 42 sides (48%) and isthmal nonunions in 45 sides (52%). The remaining 92 patients (93 sides) underwent ACP combined with autogenous bone grafting (Group B)consisting of nonisthmal nonunions in 46 sides (49%) and isthmal nonunions in 47 sides (51%). Comparative study was made on operation time, intraoperative blood loss, time to union, union rate, postoperative draining volume and complication rate. Results Mean follow-up was 4.1 years (range, 1-7.1 years). Union rate was 86% for Group A and 100% for Group B (OR=3. 28, 95%CI 0.8-14.0). In Group A re-nonunion was seen in 12 sides including nonisthmal nonunions in 10 sides (83%) and isthmal nonunion with cortical bone defect>3 cm in 2 sides (17%). Group A reported higher values in time to union, intraoperative blood loss as well as complication rate and lower healing rate over Group B(P 0.05). However, for nonisthmal nonunions, operation time was (127.3±21.7)min in Group A versus (89.9±14.1)min in Group B (P<0.05). Conclusions In contrast, ACP combined with autogenous bone grafting results in shorter time to union and higher bone union rate during the treatment of femoral shaft nonunion after failed intramedullary nailing. Especially for nonisthmal or isthmal femoral shaft nonunions with larger bone defect, ACP combined with autogenous bone grafting brings relatively more advantages. Key words: Femoral fractures; Fractures, ununited; Intramedullary nailing

Operative treatment for femoral shaft nonunions, a systematic review of the literature

The objective of this article is to systematically review the currently available literature to formulate evidence-based guidelines for the treatment of femoral shaft nonunions for clinical practice and to establish recommendations for future research. Articles from PubMed/MEDLINE, Cochrane Clinical Trial Register, and EMBASE, that presented data concerning treatment of nonunions of femoral shaft fractures in adult humans, were included for data extraction and analysis. The search was restricted to articles from January 1970 to March 2011 written in the English, German, or Dutch languages. Articles containing data that were thought to have been presented previously were used once. Reports on nonunion after periprosthetic fractures, review articles, expert opinions, abstracts from scientific meetings, and case reports on 5 or fewer patients were excluded. The data that were extracted from the relevant articles included: type of nonunion, type of initial and secondary treatments, follow-up, union rate, and general complications. Most studies had different inclusion criteria and outcome measures, thus prohibiting a proper meta-analysis. Therefore, only the union rate and number of complications were compared between the different treatments. Methodological quality was assessed by assigning levels of evidence as previously defined by the Centre for Evidence-Based Medicine. This systematic review provides evidence in favour of plating if a nail is the first treatment; after failed plate fixation, nailing has a 96 % union rate. After failed nailing, augmentative plating results in a 96 % union rate compared to 73 % in the exchange nailing group.

Treatment of femoral shaft nonunion

Background: Even with the remarkable ability of fractures to heal by the reconstruction of the injured bone to the original form, some situations occur in which there could be delayed union or nonunion. Attending to the cause of the nonunion would usually yield a positive result. Objective: To determine the incidence of osseous union in cases of nonunion of the femoral shaft fractures managed by open reduction and internal fixation. Patients and Methods: Over a two-year period, 17 patients with nonunion of the femoral shaft were treated by open reduction and internal fixation and followed up. The follow up period in each case was 6 months. Clinical and radiological parameters were used in the assessment of osseous union. Results: Majority of the patients seen were in the 18-29-year category (35%) while the male:female ratio was 1.4:1. The average time from injury to presentation was 20 months. Six of the cases were hypertrophic nonunion while 11 were atrophic nonunion. Conclusion: The treatment of femoral shaft nonunion at the National Orthopaedic Hospital, Enugu by open reduction and internal fixation produced osseous union in 88.2% of cases. Keywords: Enugu, femoral shaft, nonunion

Surgical treatment of the aseptic femoral shaft nonunion

Femoral shaft nonunions is difficult complication and a big challenge for the orthopaedic surgeons. These complications occur after open femoral fractures, comminuted fractures, segmental fractures, the infection, after the inadequate fixed osteosynthesis, the systemic disease, and smokers. The paper presents the results of treatment aseptic femoral shaft nonunion in 18 patients. They were primarily operated by the method of internal compresive plate fixation and external fixation (open fractures). For fixation we used dinamic internal fixator by Mitkovic. All nonunions treated by this method are healed. In patients with atrophic femoral shaft nonunions in addition to fixation was performed and bone grafting. This implant has proved successful in the treatment of femoral shaft nonunion. During the fixation no periostal and intramedullary vascularization damage, which is an important prerequisite for bone healing. Implant enables biological and mechanical conditions for nonunion healing.

The Outcome of Closed, Intramedullary Exchange Nailing With Reamed Insertion in the Treatment of Femoral Shaft Nonunions

To determine the effectiveness of closed, intramedullary exchange nailing with reamed insertion for the treatment of femoral shaft nonunions previously treated with an intramedullary nail. Retrospective cohort study. Academic level I trauma center. Forty-two patients whose femoral shaft fracture was initially managed with an intramedullary nail, were subsequently treated by closed, intramedullary exchange nailing with reamed insertion for their femoral nonunion in our center. Seven patients had an infected nonunion as proved by intraoperative cultures. Closed, intramedullary exchange nailing with reamed insertion of a larger diameter nail. Radiographic and clinical evidence of fracture healing. Thirty-six patients (86%) had their fracture heal without further intervention. The average time to achieve union was 4 months after surgery. Of the 6 cases of exchange nailing failure, 3 were aseptic and 3 were septic. All these 6 patients healed after additional procedures. Lack of immediate weight bearing, open fractures, atrophic/oligotrophic nonunions, and infection were associated with treatment failure. A second nail larger by 2 mm or more than the original nail was associated with a higher success rate. Closed, intramedullary exchange nailing with reamed insertion for femoral shaft nonunions previously treated with intramedullary nails has proved to be a successful sole procedure in most cases. A nail at least 2 mm larger in diameter than the first nail should be used if possible. Risk factors of treatment failure should alert the surgeon to consider an alternative treatment to closed exchange nailing.

Femoral shaft nonunions Risk factors for poor outcome following exchange nailing

Age, gender, fracture type, nail locking technique, and bone grafting did not appear to affect union, mean time to union, or need for additional procedures. Evidence on smoking as a prognostic factor was conflicting. Nonsmokers were more likely to achieve procedure compared with smokers in one union after one study. However, the mean time to union and need for additional procedures were not decreased in nonsmokers in two other studies. Studies may have had insufficient power to detect the effects of various prognostic factors. A methodologically rigorous multi-center prognostic study may provide a larger sample size, and help delineate factors affecting outcome in exchange nailing for the treatment of femoral shaft nonunion.

Femoral shaft nonunions

Age, gender, fracture type, nail locking technique, and bone grafting did not appear to affect union, mean time to union, or need for additional procedures. Evidence on smoking as a prognostic factor was conflicting. Nonsmokers were more likely to achieve union after one procedure compared with smokers in one study. However, the mean time to union and need for additional procedures were not decreased in nonsmokers in two other studies. Studies may have had insufficient power to detect the effects of various prognostic factors. A methodologically rigorous multi-center prognostic study may provide a larger sample size, and help delineate factors affecting outcome in exchange nailing for the treatment of femoral shaft nonunion.

Current Concepts: Aseptic Nonunion of Femoral Shaft Diaphysis.

In spite of increased understanding of biomechanics and improvements of implant design, nonunion of femoral shaft fractures continues to hinder the treatment of these injuries. Femoral nonunion presents a difficult treatment challenge for the surgeon and a formidable personal and economic hardship for the patient. In most series of femoral fractures treated with intramedullary nailing techniques, the incidence of this complication is estimated to be 1%. A higher frequency has recently been reported due to advances in trauma care leading to increased survivorship among severely injured patients and expanded indications of intramedullary nailing. Whereas the treatment of femoral shaft fractures has been extensively described in the orthopedic literature, the data regarding treatment of femoral shaft nonunions are sparse and conflicting, as most of the reported series consisted of a small number of cases. However, careful review of the existing literature does provide some answers regarding either conservative or operative management. The gold standard for femoral shaft nonunions invariably includes surgical intervention in the form of closed reamed intramedullary nailing or exchange nailing, but several alternative methods have been reported including electromagnetic fields, low-intensity ultrasound, extracorporeal shock wave therapy, external fixators and exchange or indirect plate osteosynthesis. In this paper, a comprehensive review of the current treatment modalities for aseptic midshaft femoral nonunion is presented, after a concise overview of the incidence, definition, classification and risk factors of this complication.

Results of Indirect Reduction and Plating of Femoral Shaft Nonunions After Intramedullary Nailing

To observe and report the clinical results of indirect plating techniques in the treatment of femoral shaft nonunions originally treated with intramedullary nailing. Prospective consecutive. Regional trauma center. A consecutive series of twenty-three patients with nonunion of femoral shaft fractures previously treated with intramedullary nailing. Surgical treatment with indirect plating techniques using the AO 95-degree condylar blade plate in nonunions of the distal and proximal one thirds and broad large-fragment dynamic compression plating in nonunions of the middle one third, with selective autologous cancellous bone grafting. Emphasis was placed on preoperative planning, intraoperative attention to soft tissue sparing and selection of the appropriately applied implant to correct deformity and obtain union. Healing rate and time, operative blood loss and time, and incidence of complications, including hardware failure, loss of fixation, infection, and postoperative malalignment. Twenty-one of the twenty-three nonunions healed without further intervention at an average of twelve weeks (range 10 to 16 weeks) postoperatively. The two remaining patients (9 percent) had early breakage of their hardware, requiring repeat plating. Union in both of these cases occurred within sixteen weeks of the revision (12 and 16 weeks). Including the two patients requiring reoperation, all twenty-three nonunions healed at an average of seventeen weeks (range 10 to 24 weeks) from the initial plating procedure. There were no intraoperative complications. Average operative time was 164 minutes (range 120 to 240 minutes), and blood loss was 340 milliliters (range 200 to 700 milliliters). There were no cases of significant postoperative axial or rotational malalignment (more than 5 degrees), limb length discrepancy (more than 1 centimeter), or deep infections. Modern plating techniques are effective in the treatment of femoral shaft nonunions after intramedullary fracture fixation. The authors consider this method particularly valuable in the presence of deformity. Union occurred reliably with few complications.

Femoral Shaft Nonunion Treated by a Fluted Intramedullary Rod

Twenty-five consecutive nonunions or delayed unions of the femoral shaft were treated by a fluted intramedullary rod. Fourteen patients were men; 11 were women. Sixteen fractures represented failures of closed management. Five patients had failures of primary open reduction and internal fixation. Four patients had had one attempt at operative treatment of nonunion. All but one fracture united. The one exception required a second procedure. Excellent bending and rotary fixation were achieved and union occurred promptly in most cases. Iliac crest bone grafting was not routinely required for good results. There were no major complications in this series. Two patients with severe knee extension contractures required quadricepsplasty at a later date to recover knee motion. One fracture healed with a 15 degree valgus malunion. The strength and rigidity make this device extremely reliable for the treatment of femoral shaft nonunion.