Aseptic femoral nonunion treated with exchange locked nailing with intramedullary augmentation cancellous bone graft

Abstract

Background Closed reamed locked intramedullary nailing has been the treatment of choice for most of femoral shaft fractures. A high union rate with a low complication rate is generally predictable. For an aseptic femoral shaft nonunion with a prior inserted intramedullary nail, exchange nailing is one of favored surgical techniques for treatment. However, a greatly varied success rate of 72–100% has been reported. To improve the success rate of exchange femur nailing, a modified bone grafting technique was developed. The purpose of this retrospective study intended to evaluate outcomes of such a revised technique. Methods From July 2011 to March 2019, 48 consecutive adult patients (average, 38 years; range, 19–67 years) with aseptic femoral shaft nonunions after intramedullary nailing treatment were studied. All femoral shaft fractures were initially caused by traffic accidents, which were treated by a closed or open intramedullary nailing technique at various hospitals. The current revision treatment was performed after an average of 2.2 years (range 1.1–6.2 years) from initial injuries. In the surgery, the prior nail was removed and the marrow cavity was reamed widely (at least 2 mm as possible). Sufficient cancellous bone grafts harvested on the trochanteric marrow wall from the inside were placed in the marrow cavity of the junction of nonunion fragments. A new 1-mm smaller size locked intramedullary nail was inserted. Whether the dynamic or static mode of nails were used mainly depended on the nonunion level. Postoperatively, protected weight bearing with crutches was allowed for all patients. Results Forty-one patients were followed for an average of 2.8 years (85.4%; range, 1.9–4.5 years) and all fractures healed. The union rate was 100% (41/41, p < 0.001) with a union time of an average of 3.4 months (range, 2.5–5.0 months). There were no complications of deep infection, nonunions, malunions, implant failures or an avulsed trochanter tip fracture. The satisfactory knee function improved from 73.2% (30/41) preoperatively to 92.7% (38/41) at the latest follow-up (p = 0.019). Conclusions The described modified bone grafting technique may effectively improve a union rate of exchange femur nailing while the surgical procedure is not complicated. It may therefore be used concomitantly in all aseptic femoral shaft nonunions when exchange nailing is performed.

Long-Term Outcomes Following Single-Stage Reamed Intramedullary Exchange Nailing in Apparently Aseptic Femoral Shaft Nonunion with Unsuspected Proof of Bacteria

“…Due to the insufficient addressing of the biomechanics that may underlie nonunion, implant retention is not expedient [ 17 ]. These principles are basically integrated into the single-stage reamed intramedullary exchange nailing, emphasizing the need to remove the previous osteosynthesis material [ 53 , 54 ] and aim for infection eradication to achieve nonunion healing, in combination with the avoidance of infection recurrence in the sense of chronic osteomyelitis after osseous healing, and, finally, the recovery of a sufficient regaining of function [ 55 ]. Nevertheless, the higher number of additional surgical revisions in case of positive bacterial culture necessary until osseous healing demonstrated in this study—44% of the femoral shaft nonunion with and 18% without proof of bacteria—is in accordance with the current multidisciplinary surgical treatment principles for septic diaphyseal femoral nonunion and could be also demonstrated by other studies analyzing nonunion at different locations, observing a revision rate in case of infected nonunion between 6 to 22% [ 56 ].…”

Delayed Union and Nonunion: Current Concepts, Prevention, and Correction: A Review

“…On the other hand, intramedullary reaming during exchange nailing has been refined and augmented over time, serving as a valuable debridement tool for septic nonunion and a delivery method for intramedullary lavage and antibiotic therapy [ 98 ]. Clinical research utilizing exchange nailing in conjunction with biologic and regenerative therapies is ongoing and offers promising future paths for the treatment of both aseptic and septic nonunion [ 93 , 98 , 99 ].…”

What Is the Best Treatment of the Femoral Shaft Nonunion after Intramedullary Nailing? A Systematic Review

“…Of the 16 studies selected, 14 were retrospective [13][14][15][16][17][18][19][20][21][22][23][24][25][26] and 2 were prospective [27,28]. Overall, data from 632 patients were analyzed in our systematic review (summarized data are reported on Table 1).…”