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

Somford, Matthijs P.; Van Den Bekerom, Michel P. J.; Kloen, Peter

doi:10.1007/s11751-013-0168-5

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

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Author(s): Matthijs P. Somford , Michel P. J. van den Bekerom , Peter Kloen

Publication date (Electronic): 27 July 2013

Journal: Strategies in Trauma and Limb Reconstruction

Publisher: Springer Milan

Keywords: Nonunion, Pseudarthrosis, Review, Femur

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Abstract

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.

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Most cited references 61

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The use of endosteal substitution in the treatment of recalcitrant nonunions of the femur: report of seven cases.

T Matelic, J Mast, Dougald M. Monroe (1995)

Seven patients, with an average age of 53 years, were treated for bone loss or recalcitrant nonunions of the femur. The average duration from initial injury to presentation was 37 months (range 4-92 months). The patients had undergone one to eight (mean, 3.9) previous surgical attempts at achieving union. The nonunion involved the diaphysis in three patients, the diaphyseal-supracondylar junction in three patients, and the pertrochanteric region in one patient. All patients were treated using a standard lateral plate in combination with an endosteal plate and primary iliac crest bone grafting. The mean surgical time was 6.3 h, and the average blood loss was 1.7 L. There were three complications, including one superficial wound infection, one nonfatal pulmonary embolism, and one wound hematoma. At a mean follow-up of 12.6 months (range 4-24 months), all fractures had healed with an average time to union of 19.2 weeks (range 15-36 weeks). Knee flexion averaged 118 degrees (range 100-135 degrees), and all patients were satisfied with the operative procedure. Endosteal plating, in combination with a standard lateral plate and iliac crest bone-grafting, can successfully treat difficult nonunions of the femur.

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Nonunion following intramedullary nailing of the femur with and without reaming. Results of a multicenter randomized clinical trial.

(2003)

Intramedullary nailing of the femur without reaming of the medullary canal has been advocated as a method to reduce marrow embolization to the lungs and the rate of infection after open fractures. The use of nailing without reaming, however, has been associated with lower rates of fracture-healing. The purpose of this prospective study was to compare the rate of union of femoral shaft fractures following intramedullary nailing with and without reaming. Two hundred and twenty-four patients were enrolled in a multicenter, prospective, randomized clinical trial to compare nailing without reaming and nailing with reaming. One hundred and six patients with 107 femoral shaft fractures were treated with a smaller diameter nail without reaming of the canal, and 118 patients with 121 fractures had reaming of the canal and insertion of a relatively larger diameter nail. Patients were followed at six-week intervals until union occurred or a nonunion was diagnosed. The two groups were comparable with regard to the measured patient and injury characteristics. Eight (7.5%) of the 107 fractures in the group without reaming had a nonunion compared with two (1.7%) of 121 fractures in the group with reaming (p = 0.049). The relative risk of nonunion was 4.5 times greater (95% confidence interval = 1 to 20) without reaming and with use of a relatively small-diameter nail. Intramedullary nailing of femoral shaft fractures without reaming results in a significantly higher rate of nonunion compared with intramedullary nailing with reaming.

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The outcome of closed, intramedullary exchange nailing with reamed insertion in the treatment of femoral shaft nonunions.

Rami Mosheiff, David A. Weil, E Shroeder … (2009)

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.

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Author and article information

Contributors

Matthijs P. Somford: +31-20-5669111 , mp_somford@hotmail.com

Michel P. J. van den Bekerom: Bekerom@gmail.com

Peter Kloen: P.kloen@amc.uva.nl

Journal

Journal ID (nlm-ta): Strategies Trauma Limb Reconstr

Journal ID (iso-abbrev): Strategies Trauma Limb Reconstr

Title: Strategies in Trauma and Limb Reconstruction

Publisher: Springer Milan (Milan )

ISSN (Print): 1828-8936

ISSN (Electronic): 1828-8928

Publication date (Electronic): 27 July 2013

Publication date PMC-release: 27 July 2013

Publication date (Print): August 2013

Volume: 8

Issue: 2

Pages: 77-88

Affiliations

[ ]Department of Orthopaedic Surgery, Academic Medical Centre, Meibergdreef 15, P.O. Box 22660, 1105 AZ Amsterdam, The Netherlands

[ ]OLVG, Amsterdam, The Netherlands

Article

Publisher ID: 168

DOI: 10.1007/s11751-013-0168-5

PMC ID: 3732674

PubMed ID: 23892497

SO-VID: 44f87aff-0b36-4d24-9a1a-29338381b0c9

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.