We evaluated the effect of revision with dynamic compression plate and cancellous bone graft for aseptic nonunion after intramedullary nailing of femoral shaft fracture.
Fifty patients with aseptic nonunion of femoral shaft fracture after intramedullary nailing were reviewed and analyzed retrospectively between 1996 and 2007. There were 40 men and 10 women with an average age of 44 years (range, 19-76 years). Thirty-five were diaphyseal fractures, 8 were distal fractures, and 7 were proximal fractures. Twenty-eight fractures were defined as atrophic nonunion, 13 fractures were hypertrophic nonunion, and 9 fractures could not be defined clearly. All fractures were managed by retaining previous implants, open reduction and internal fixation with dynamic compression plate, and supplementation by cancellous bone graft. The average follow-up period was 76 months (range, 24-128 months). Functional evaluations were done by Harris Hip score and Hospital for Special Surgery knee score.
All nonunions united on average at 24 weeks (range, 18-32 weeks). One superficial wound infection occurred. At follow-up, each patient was evaluated to have satisfactory function results, with near normal hip/knee functions without noticeable pain, and full return to preinjury activities/work without pain.
Augmentative dynamic compression plate with cancellous bone graft is a reliable and effective treatment for revision of aseptic nonunion of femoral shaft fracture after intramedullary nailing.
Acute fractures of the femoral shaft are usually managed with intramedullary nailing. The union rate is high. The nonunion rate ranges from 1% to 10%.1-4 Various risk factors of femoral shaft fracture nonunion have been identified: open fracture, impaired vascularity, lack of mechanical stability, fracture site distraction, bone loss, excessive soft tissue stripping, soft tissue interposition, and/or smoking.1-6
Some operative treatment options of femoral shaft fracture nonunion after intramedullary nailing have been reported, including nail dynamization, exchange nailing, external fixator, or dynamic compression plate, with or without bone graft or bone graft substitutes.1,2,5-15 Different success rates and complications have been reported. There are some reports of managing nonunion of femoral shaft fracture with dynamic compression plate and bone graft with good results.7-10,15 Nevertheless, these reports were all small in case numbers. This article focuses on the results of a larger series of patients undergoing open reduction and internal fixation with dynamic compression plate, supplemented with cancellous bone graft, for aseptic nonunion of femoral shaft fracture after intramedullary nailing.
Materials and Methods
From 1996 to 2007, 55 cases of aseptic nonunion of femoral shaft fractures after intramedullary nailing were treated in the same way without exception by the authors (C.M.C., Y.P.S., C.L.L., F.Y.C.). Five patients were lost during follow-up due to various causes and were excluded from this series. The remaining 50 patients with aseptic nonunion of femoral shaft fracture after intramedullary nailing were enrolled, reviewed, and analyzed. All 50 nonunions were proven to be aseptic by normal preoperative erythrocyte sediment rate, normal preoperative C-reactive protein, and negative results of at least 2 intraoperative cultures.
No bilateral fractures were met. Nonunion was defined as failure to unite the fracture within 9 months of the initial injury.16 Among the 50 patients, there were 40 men and 10 women with an average age of 44 years (range, 19-76 years). The causes of initial injury were traffic accident (40), falling (17), and direct contusion by miscellaneous materials (3). Thirty-five were diaphyseal fractures, 8 were distal, and 7 were proximal. In the acute stage, 36 fractures were fixed with interlocking nail (22 first-generation nails and 14 second generation nails with 5 broken nails), 7 fractures were fixed with Kuntscher nail (1 broken nail), 5 fractures were fixed with long gamma nail, and 2 fractures were fixed with proximal femoral nail (first generation). Nineteen of these primary treatments were performed at our hospital and 31 at other institutions.
On radiographic evaluation (Anteroposterior, lateral, and 2 oblique views [45° internal and external] that include the hip and knee joints in each view) and classification of the nonunions, 28 fractures were defined as atrophic nonunion, 13 fractures were hypertrophic nonunion (with apparent hypertrophic callus over the proximal or distal end of the ununited fracture gap), and 9 fractures could not be defined clearly.17 All the radiographic evaluations were done by 3 authors (C.M.C., Y.P.S., F.Y.C.). The timing of treatment of the nonunion averaged 14 months after the initial trauma (range, 9-24 months).
Each patient received the same surgical protocol for treatment of the nonunion. The protocol consisted of lateral approach of the fracture site, retaining the previous implant, decortication, refreshing the fracture site (removal of interposed tissues), reduction of the fracture with appropriate cortical contact (in cases with broken nails or loose nails), internal fixation with 1 broad 4.5-mm dynamic compression plate, and application of cancellous bone graft (harvested from ipsilateral anterior iliac crest) around the medial, posterior, and anterior aspects of the nonunion site. In all 50 cases, at least 2 sets of intraoperative cultures were taken with negative results. All the procedures were done by the authors, under general anesthesia (C.M.C., Y.P.S., F.Y.C.). All the fractures were reduced as anatomically as possible and fixed without compression of the fracture by the plates. Both proximal and distal to the nonunion site, at least 6 cortexes were purchased rigidly by cortical screws through the dynamic compression plate (bypassing the retained nail). All the screws had bicortical fixation. The fixation stability in each patient was rigid enough; therefore, full weight bearing of the operated limb as tolerated and range of motion (ROM) exercise of the hip and knee started immediately postoperatively. No other supplemental fixation, such as cast or brace, was used postoperatively. The functional result was supervised throughout the follow-up period.
Postoperatively, each patient was followed once every 2 weeks in the first month and once a month thereafter. Additional visits were prescribed if needed. Functional evaluation was done at every visit and once every 2 months after fracture union. Each patient had 1 special chart with detailed records of personal data, mechanism, and associated condition of the injury; type and classification of the fracture and nonunion; course of the management (including timing of treatment, the implant chosen, size or number of implant, status of fixation, course of operation, blood loss, operation time, type and duration of antibiotics used, hospital day, early complication, late complication, and management of complication); condition and course of the fracture healing; functional recovery; and total number and average number of operations until final follow-up. Radiographs were taken at every follow-up visit, and all the evaluations and records were done by senior staff (C.M.C., Y.P.S., F.Y.C). Normal union was clinically defined as the absence of tenderness and movement on palpation, and radiologically, as both bridging callus and partial obliteration of the fracture site on at least 3 cortices on radiographs in 2 planes within 6 months. Delayed union was defined as union evidenced in 6 to 9 months, and nonunion as no evidence of union after 9 months. Malunion was defined as varus or valgus deformity >10°, anterior or posterior angulation >10°, rotational deformity >10°, or shortening >15 mm, compared to the contralateral side. Average follow-up was 76 months (range, 24-128 months). Functional evaluations were done by Harris Hip score and Hospital for Special Surgery knee score.
All the fractures united solidly as in Figures 1 and 2. Average operation time (from incision to complete closure of the wound) was 81 minutes (range, 60-130 minutes). Average introperative blood loss was 380 mL (range, 250-850 mL). Average hospital stay was 7.5 days (range, 5-14 days). Average radiographic union time was 24 weeks (range, 18-32 weeks). Combining the preoperative and intraoperative findings, the putative causes of nonunion in these 50 fractures were noted to be soft tissue interposition (7 fractures), poor reduction (5), inadequate fixation (16), secondary traumatic insult (4), combined causes (11), and no significant cause (7).
No donor site complication occurred. One superficial infection was noted (2%), and the infection healed after debridement and antibiotic treatment. No deep infection developed in this series. No delayed union or malunion was noted in this series.
All the cases were found to have satisfactory function results, with near normal hip/knee functions with no noticeable pain and full return to preinjury activities/work without pain at final follow-up. The functional evaluations by Harris Hip Score and Hospital for Special Surgery knee score showed good to excellent results in each patient (Table).
In combined use of dynamic compression plate and cancellous bone graft for femoral shaft nonunion, both rigid fixation (by dynamic compression plate) and improved osteogenesis (by refreshing the fracture and use of cancellous bone graft) were successful. Thus, the problems of nonunion (either poor fixation in hypertrophic nonunion or poor osteogenesis in atrophic nonunion) could be overcome and union was successful as expected. The aforementioned rigid fixation and improved osteogenesis were the most important factors to achieve a 100% union rate in this series, and our results were comparable or even better than those in other series.1,2,5-15 Theoretically, hypertrophic nonunions already have good biology, that would be compromised by exploration and stripping from application of dynamic compression plate; therefore, cancellous autograft is required to reinforce the biology for union in the revision surgery with dynamic compression plate.
The functional results of the ipsilateral hip and knee in this study were shown to be good or excellent in all patients, which supports the other advantages of revision with dynamic compression plate and bone graft. In comparison to exchange nailing or external fixator for treatment of the femoral shaft nonunion, the apparent advantages of using augmentative dynamic compression plate with cancellous bone graft include avoiding removal of the previous nail, more mechanical stability, additional biological effect to the union, and preservation of hip and knee functions.
The disadvantages of using dynamic compression plate and cancellous autograft are more soft tissue stripping, more blood loss, and possible donor site complication. In this series, no donor site complication occurred, the incidence of superficial infection was 2%, which is comparable to other reports, and the average blood loss was 380 mL, which is also comparable to other reports.2-15 However, to avoid soft tissue complications, it is important to manage the soft tissue meticulously during surgical procedures.
Limitations of this study include the retrospective nature of the reviews, mixed types of nonunion (atrophic, hypertrophic, and undefined), single method of treatment without comparison to other treatments, and relatively small sample size.
Revision by retaining the previous nail, refreshing the nonunion site, and fixation by augmentative dynamic compression plate with supplemental cancellous bone graft is an effective and reliable treatment for aseptic nonunion of femoral shaft fracture after intramedullary nailing.
- Canadian Orthopaedic Trauma Society. Nonunion following intramedullary nailing of the femur with and without reaming. Results of a multicenter randomized clinical trial. J Bone Joint Surg Am. 2003; 85(11):2093-2096.
- Lynch JR, Taitsman LA, Barei DP, Nork SE. Femoral nonunion: risk factors and treatment options. J Am Acad Orthop Surg. 2008; 16(2):88-97.
- Winquist RA, Hansen ST Jr, Clawson DK. Closed intramedullary nailing of femoral fractures: A report of 520 cases. J Bone Joint Surg Am. 1984; 66(4):529-539.
- Wolinsky PR, McCarty E, Shyr Y, Johnson K. Reamed intramedullary nailing of the femur: 551 cases. J Trauma. 1999; 46(3):392-399.
- Malik MH, Harwood P, Diggle P, Khan SA. Factors affecting rates of infection and nonunion in intramedullary nailing. Nonunion of the humeral shaft. J Bone Joint Surg Br. 2004; 86(4):556-560.
- Noumi T, Yokoyama K, Ohtsuka H, Nakamura K, Itoman M. Intramedullary nailing for open fractures of the femoral shaft: evaluation of contributing factors on deep infection and nonunion using multivariate analysis. Injury. 2005; 36(9):1085-1093.
- Abdel-Aa AM, Farouk OA, Elsayed A, Said HG. The use of a locked plate in the treatment of ununited femoral shaft fractures. J Trauma. 2004; 57(4):832-836.
- Bellabarba C, Ricci WM, Bolhafner BR. Result of indirect reduction and plating of femoral shaft nonunions after intramedullary nailing. J Orthop Trauma. 2001; 15(4):254-263.
- Bungaro P, Pascarella R, Colozza A, Zinghi GF. Rigid fixation with plate and bone graft in failures of intramedullary osteosynthesis for the treatment of diaphyseal nonunion of the femur. Chir Organi Mov. 1999; 84(3):263-267.
- Choi YS, Kim KS. Plate augmentation leaving the nail in situ and bone grafting for nonunion of femoral shaft fractures. Int Orthop. 2005; 29(5):287-290.
- Finkemeier CG, Chapman MW. Treatment of femoral diaphyseal nonunions. Clin Orthop Relat Res. 2002; (398):223-234.
- Hak DJ, Lee SS, Goulet JA. Success of exchange reamed intramedullary nailing for femoral shaft nonunion or delayed union. J Orthop Trauma. 2000; 14(3):178-182.
- Menon DK, Dougall TW, Pool RD, Simonis RB. Augmentative ilizarov external fixation after failure of diaphyseal union with intramedullary nailing. J Orthop Trauma. 2002;16(7):491-497.
- Ring D, Barrick WT, Jupiter JB. Recalcitrant nonunion. Clin Orthop Relat Res. 1997; (340):181-189.
- Ueng SWN, Chao EK, Lee SS, Shih CH. Augmentative plate fixation for the management of femoral nonunion with broken interlocking nail. J Trauma. 1997; 43(4):640-644.
- Brinker MR. Nonunions: evaluation and treatment. In: Browner BD, ed. Skeletal Trauma: Basic Science, Management, and Reconstruction. 3rd ed. Philadelphia, PA: Saunders; 2003:507-604.
- Weber BG, Cech O. Pseudoarthrosis: Pathology, Biomechanics, Therapy, Results. Berne, Switzerland: Hans Huber Medical Publisher; 1976.
Drs Chen, Su, Lin, and Chiu are from the Department of Orthopedics and Traumatology, and Ms Hung is from the Department of Nursing, Taipei Veterans General Hospital, and Dr Chiu is also from National Yang-Ming University, Taipei, Taiwan.
Drs Chen, Su, Lin, and Chiu and Ms Hung have no relevant financial relationships to disclose.
Correspondence should be addressed to: Fang-Yao Chiu, MD, Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, 201, Sec 2, Shih-Pai Rd, Taipei 112, Taiwan (email@example.com).