Skip to main content

Advertisement

SpringerLink
Log in

Comparing outcomes of plate augmentation, nail exchange, and nail exchange with plate augmentation in the treatment of atrophic femoral shaft nonunion after intramedullary nailing: a multicenter retrospective study

  • Trauma Surgery
  • Published:
Archives of Orthopaedic and Trauma Surgery Aims and scope Submit manuscript

Abstract

Introduction

Intramedullary (IM) nailing is the treatment of choice for femoral shaft fractures, but nonunion rates have been reported to be as high as 12%. Surgical interventions for nonunion involve exchange nailing or plate augmentation. Recently, a combined treatment of exchange nailing and plate augmentation has demonstrated good results, but its comparative effectiveness remains unclear. This study aimed to compare the clinical and radiographic outcomes of three different surgical interventions for atrophic femoral shaft nonunion, and investigate the factors that affect bone healing after reoperation.

Materials and methods

A retrospective study was conducted at five university hospitals involving 149 patients with aseptic atrophic nonunion after IM nailing. These patients underwent reoperation with plate augmentation, exchange nailing, or combined treatment. Clinical and radiographic outcomes were assessed and compared according to reoperation procedure. Logistic regression analysis was performed to identify factors affecting persistent nonunion after reoperation.

Results

Of the cohort, 57 patients underwent plate augmentation, 64 underwent exchange nailing, and 28 received combined treatment. There were no significant differences in patient demographics among the groups. Exchange nailing produced a significantly lower union rate than did the combined treatment (82.8% vs. 100%, p = 0.016), whereas no significant difference was observed in the union rate and time to the union between plate augmentation and the combined treatment. Combined treatment showed the longest operative time and the greatest transfusion requirements. The risk factors for persistent nonunion included age, absence of autogenous bone grafts, and use of an exchange nailing technique.

Conclusions

Exchange nailing as a treatment for atrophic femoral shaft nonunion after IM nailing resulted in a lower union rate. The efficacy of the combined treatment requires further study, and persistent nonunion may be influenced by age, bone grafting, and surgical techniques. A comprehensive approach targeting both biological environment and mechanical stability is crucial in the treatment of atrophic femoral shaft nonunion.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

Data availability

Data on this research are available from the corresponding author, K-CP, upon reasonable request.

References

  1. Ricci WM, Gallagher B, Haidukewych GJ (2009) Intramedullary nailing of femoral shaft fractures: current concepts. J Am Acad Orthop Surg 17(5):296–305. https://doi.org/10.5435/00124635-200905000-00004

    Article  PubMed  Google Scholar 

  2. Ricci WM, Bellabarba C, Evanoff B, Herscovici D, DiPasquale T, Sanders R (2001) Retrograde versus antegrade nailing of femoral shaft fractures. J Orthop Trauma 15(3):161–169. https://doi.org/10.1097/00005131-200103000-00003

    Article  PubMed  CAS  Google Scholar 

  3. Wolinsky PR, McCarty E, Shyr Y, Johnson K (1999) Reamed intramedullary nailing of the femur: 551 cases. J Trauma 46(3):392–399. https://doi.org/10.1097/00005373-199903000-00007

    Article  PubMed  CAS  Google Scholar 

  4. Winquist RA, Hansen ST Jr, Clawson DK (1984) Closed intramedullary nailing of femoral fractures. A report of five hundred and twenty cases. J Bone Jt Surg Am 66(4):529–539

    Article  CAS  Google Scholar 

  5. Garnavos C (2017) Treatment of aseptic non-union after intramedullary nailing without removal of the nail. Injury 48(Suppl 1):S76-81. https://doi.org/10.1016/j.injury.2017.04.022

    Article  PubMed  Google Scholar 

  6. Park K, Kim K, Choi YS (2011) Comparison of mechanical rigidity between plate augmentation leaving the nail in situ and interlocking nail using cadaveric fracture model of the femur. Int Orthop 35(4):581–585. https://doi.org/10.1007/s00264-010-0983-y

    Article  PubMed  Google Scholar 

  7. Vaishya R, Agarwal AK, Gupta N, Vijay V (2016) Plate augmentation with retention of intramedullary nail is effective for resistant femoral shaft non-union. J Orthop 13(4):242–245. https://doi.org/10.1016/j.jor.2016.06.003

    Article  PubMed  PubMed Central  Google Scholar 

  8. Hak DJ, Lee SS, Goulet JA (2000) Success of exchange reamed intramedullary nailing for femoral shaft nonunion or delayed union. J Orthop Trauma 14(3):178–182. https://doi.org/10.1097/00005131-200003000-00005

    Article  PubMed  CAS  Google Scholar 

  9. Bellabarba C, Ricci WM, Bolhofner BR (2001) Results of indirect reduction and plating of femoral shaft nonunions after intramedullary nailing. J Orthop Trauma 15(4):254–263. https://doi.org/10.1097/00005131-200105000-00004

    Article  PubMed  CAS  Google Scholar 

  10. Lai PJ, Hsu YH, Chou YC, Yeh WL, Ueng SWN, Yu YH (2019) Augmentative antirotational plating provided a significantly higher union rate than exchanging reamed nailing in treatment for femoral shaft aseptic atrophic nonunion - retrospective cohort study. BMC Musculoskelet Disord 20(1):127. https://doi.org/10.1186/s12891-019-2514-3

    Article  PubMed  PubMed Central  Google Scholar 

  11. Çimen O, Öner A, Köksal A, Dırvar F, Mert M, Kargın D (2023) A comparison of exchange nailing and plate augmentation over a retained intramedullary nail in aseptic oligotrophic and atrophic femoral shaft pseudoarthrosis. Jt Dis Relat Surg 34(1):121–129. https://doi.org/10.52312/jdrs.2023.788

    Article  PubMed  PubMed Central  Google Scholar 

  12. Khalifa AA, Fadle AA, Elsherif ME et al (2022) Concomitant intramedullary nailing and plate augmentation as a single-stage procedure in treating complicated nonunited femoral shaft fractures. Trauma 24(4):286–293. https://doi.org/10.1177/14604086211007037

    Article  Google Scholar 

  13. Meinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF (2018) Fracture and dislocation classification compendium-2018. J Orthop Trauma 32(1 Suppl):1s–170s. https://doi.org/10.1097/bot.0000000000001063

    Article  Google Scholar 

  14. Weber BG, Brunner C (1981) The treatment of nonunions without electrical stimulation. Clin Orthop Relat Res 161:24–32

    Article  Google Scholar 

  15. Wittauer M, Burch MA, McNally M et al (2021) Definition of long-bone nonunion: a scoping review of prospective clinical trials to evaluate current practice. Injury 52(11):3200–3205. https://doi.org/10.1016/j.injury.2021.09.008

    Article  PubMed  Google Scholar 

  16. Govaert GAM, Kuehl R, Atkins BL et al (2020) Diagnosing fracture-related infection: current concepts and recommendations. J Orthop Trauma 34(1):8–17. https://doi.org/10.1097/bot.0000000000001614

    Article  PubMed  Google Scholar 

  17. Gustilo RB, Mendoza RM, Williams DN (1984) Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma 24(8):742–746. https://doi.org/10.1097/00005373-198408000-00009

    Article  PubMed  CAS  Google Scholar 

  18. Ru J-y, Chen L-x, Hu F-y et al (2018) Factors associated with development of re-nonunion after primary revision in femoral shaft nonunion subsequent to failed intramedullary nailing. J Orthop Surg Res 13(1):180. https://doi.org/10.1186/s13018-018-0886-y

    Article  PubMed  PubMed Central  Google Scholar 

  19. Cone R, Roszman A, Conway Y, Cichos K, McGwin G, Spitler CA (2023) Risk factors for nonunion of distal femur fractures. J Orthop Trauma 37(4):175–180. https://doi.org/10.1097/bot.0000000000002553

    Article  PubMed  Google Scholar 

  20. Reichert IL, McCarthy ID, Hughes SP (1995) The acute vascular response to intramedullary reaming. Microsphere estimation of blood flow in the intact ovine tibia. J Bone Jt Surg Br 77(3):490–493

    Article  CAS  Google Scholar 

  21. Greksa F, Tóth K, Boros M, Szabó A (2012) Periosteal microvascular reorganization after tibial reaming and intramedullary nailing in rats. J Orthop Sci 17(4):477–483. https://doi.org/10.1007/s00776-012-0222-z

    Article  PubMed  Google Scholar 

  22. Clark D, Nakamura M, Miclau T, Marcucio R (2017) Effects of aging on fracture healing. Curr Osteoporos Rep 15(6):601–608. https://doi.org/10.1007/s11914-017-0413-9

    Article  PubMed  PubMed Central  Google Scholar 

  23. Nicholson JA, Makaram N, Simpson A, Keating JF (2021) Fracture nonunion in long bones: a literature review of risk factors and surgical management. Injury 52(2 Suppl):3s–11s. https://doi.org/10.1016/j.injury.2020.11.029

    Article  Google Scholar 

  24. Jhunjhunwala HR, Dhawale AA (2016) Is augmentation plating an effective treatment for non-union of femoral shaft fractures with nail in situ? Eur J Trauma Emerg Surg 42(3):339–343. https://doi.org/10.1007/s00068-015-0534-8

    Article  PubMed  CAS  Google Scholar 

  25. Jones CB, Mayo KA (2005) Nonunion treatment: iliac crest bone graft techniques. J Orthop Trauma 19(10 Suppl):S11-13. https://doi.org/10.1097/00005131-200511101-00004

    Article  PubMed  Google Scholar 

  26. Myeroff C, Archdeacon M (2011) Autogenous bone graft: donor sites and techniques. J Bone Jt Surg Am 93(23):2227–2236. https://doi.org/10.2106/jbjs.J.01513

    Article  Google Scholar 

  27. Grundnes O, Reikerås O (1993) Effects of instability on bone healing. Femoral osteotomies studied in rats. Acta Orthop Scand 64(1):55–58. https://doi.org/10.3109/17453679308994529

    Article  PubMed  CAS  Google Scholar 

  28. Mølster AO (1984) Effects of rotational instability on healing of femoral osteotomies in the rat. Acta Orthop Scand 55(6):632–636. https://doi.org/10.3109/17453678408992411

    Article  PubMed  Google Scholar 

  29. Walcher MG, Day RE, Gesslein M, Bail HJ, Kuster MS (2023) Augmentative plating versus exchange intramedullary nailing for the treatment of aseptic non-unions of the femoral shaf—a biomechanical study in a SawboneTM model. J Pers Med 13(4):650

    Article  PubMed  PubMed Central  Google Scholar 

  30. Rupp M, Biehl C, Budak M, Thormann U, Heiss C, Alt V (2018) Diaphyseal long bone nonunions—types, aetiology, economics, and treatment recommendations. Int Orthop 42(2):247–258. https://doi.org/10.1007/s00264-017-3734-5

    Article  PubMed  Google Scholar 

  31. Quan K, Xu Q, Zhu M, Liu X, Dai M (2021) Analysis of risk factors for non-union after surgery for limb fractures: a case-control study of 669 subjects. Front Surg 8:754150. https://doi.org/10.3389/fsurg.2021.754150

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Funding

No funding or other support was offered or received from any organization.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Hanyang University Hospital, Seoul, South Korea

    Incheol Kook & Kyu Tae Hwang

  2. Department of Orthopaedic Surgery, Kyungpook National University Hospital, Daegu, South Korea

    Chang-Wug Oh & Joon-Woo Kim

  3. Department of Orthopaedic Surgery, Yeungnam University Medical Center, Daegu, South Korea

    Oog-Jin Shon

  4. Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea

    Ji-Wan Kim

  5. Department of Orthopaedic Surgery, Hanyang University Guri Hospital, 153, Gyeongchun-ro, Guri, Gyeonggi-do, 11923, South Korea

    Ki-Chul Park

Authors
  1. Incheol Kook
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Chang-Wug Oh
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Oog-Jin Shon
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Joon-Woo Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Ji-Wan Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Kyu Tae Hwang
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Ki-Chul Park
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

C-WO, O-JS, Joon-Woo Kim, Ji-Wan Kim, and KTH contributed to the study conception and design. IK organized and interpreted the data, wrote the manuscript, and performed the statistical analysis. C-WO, O-JS, Joon-Woo Kim, Ji-Wan Kim, and KTH contributed in the revision process. K-CP conceptualized the study and participated in its design and helped to modify the manuscript. All the authors read and approved the final manuscript.

Corresponding author

Correspondence to Ki-Chul Park.

Ethics declarations

Conflict of interest

The authors have no competing interests to declare that are relevant to the content of this article.

Ethical approval

This study was performed in line with the principles of the Declaration of Helsinki. Approval was obtained from the ethics committee of Hanyang university Guri hospital (Approval no.: 2023-02-030).

Informed consent

Informed consent was waived due to the retrospective study design.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kook, I., Oh, CW., Shon, OJ. et al. Comparing outcomes of plate augmentation, nail exchange, and nail exchange with plate augmentation in the treatment of atrophic femoral shaft nonunion after intramedullary nailing: a multicenter retrospective study. Arch Orthop Trauma Surg 144, 1259–1268 (2024). https://doi.org/10.1007/s00402-023-05183-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00402-023-05183-4

Keywords

Search

Navigation