• Orthopaedics Clinical Trials
• Hip & Knee Conditions
• Orthopaedic Procedures

• Orthopaedics Clinical Trials
• Hip & Knee Conditions
• Orthopaedic Procedures
• Orthopaedics

The optimal treatment for femoral shaft nonunion after intramedullary nail fixation is controversial and is a challenge for orthopaedic surgeons. Bosong Zhang, MD, Jishuitan Hospital, Beijing, China, described a retrospective study comparing nail exchange with augmentation plating to treat femoral shaft nonunion after nail fixation.

The nonunion rate for femur shaft fracture after nailing is as high as 12.5% [Pihlajamäki HK et al. J Orthop Trauma. 2002]. Strategies for the treatment of femur shaft nonunion are bone grafting, exchange nailing, nail removal plus plating and bone grafting, leaving the nail in situ plus external fixation, and nail retention plus augmentation plating and bone grafting. In the literature, the union rate for exchange nailing ranges from 72% to 100% [Brinker MR, O'Connor DP. J Bone Joint Surg Am. 2007], compared with almost 100% for augmentation plating and bone grafting [Park J et al. J Orthop Trauma. 2010; Choi YS et al. Int Orthop. 2005].

The results of augmentation plating were compared with exchange nailing for femoral shaft nonunion after nailing in 104 cases. From March 2003 to June 2011, exchange nailing without autogenous bone grafting was performed in 21 patients, and augmentation plating with nail retention and autogenous bone grafting was performed in 83.

Exchange nailing was performed by nail removal, followed by use of a reamer to enlarge the femoral canal and insertion of a larger-diameter nail to enhance fixation stability. Prof Zhang noted that rotational instability is one reason for nonunion of femoral shaft fracture after interlocking nailing [Park J et al. J Orthop Trauma. 2010; Zhao G et al. Chinese J Surg. 2009; Ueng SW et al. J Trauma. 1997]. Augmentation plating combined with leaving the nail in situ in this instance can resolve the rotational instability and allow fracture healing [Choi YS et al. Int Orthop. 2005; Wu CC et al. Int Orthop. 2002]. The augmentation plate procedure in this study used a nonrotating plate and insertion of 3 screws on each side of the fracture. Screws were placed bicortically; the locking screw was placed monocortically. Simultaneous bone grafting was performed in patients who received an augmentation plate.

There were no significant differences between the 2 groups in age, sex, volume of postoperative drainage, and length of hospital stay. For patients who underwent augmentation plating and bone grafting, operation time was significantly shorter, and volume of both intraoperative blood loss and autogenous blood reinfused was significantly less. In addition, this group had a significantly lower cost of hospitalization and a significantly shorter time to radiographic union than patients who underwent exchange nailing. The union rate with augmentation plating was 100%.

Prof Zhang enumerated key differences between exchange nailing and augmentation plating via an antirotating plate. Augmentation plating is indicated for treatment of fracture nonunion anywhere along the length of the femur, whereas exchange nailing is indicated for the proximal two-thirds of the femur. Exchange nailing is contraindicated with bone loss and when no larger nail is available, and it requires use of a C-arm for intraoperative imaging. Use of augmentation plating requires bone grafting, but as shown in this study, augmentation plating has a shorter fracture union time and is associated with less operative blood loss. In addition, the cost tends to be lower with augmentation plating.

Prof Zhang concluded that for femoral shaft nonunion, use of an antirotating plate, leaving the nail in situ, with autogenous bone grafting may be a better option than exchange nailing.

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