Top

Strategies in Trauma and Limb Reconstruction

Published in:

Open Access 01-08-2013 | Review

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

Authors: Matthijs P. Somford, Michel P. J. van den Bekerom, Peter Kloen

Published in: Strategies in Trauma and Limb Reconstruction | Issue 2/2013

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.

Küntscher G, Maatz R (1945) Technik der Marknagelung. Georg Thieme Verlag, Leipzig

Böhler L (1943) Vorschlag zur Marknagelung nach Küntscher bei frischen Oberschenkelschussbrüchen. Der Chirurg 15–1:8–13

Canadian Orthopaedic Trauma Society (2003) Non-union following intramedullary nailing of the femur with and without reaming. Results of a multicenter randomized clinical trial. J Bone Joint Surg Am 85A(11):2093–2096

Attal R, Blauth M (2010) Unreamed intramedullary nailing. Orthopade 39–2:182–191CrossRef

Brinker MR (2003) Skeletal trauma: basic science management, and reconstruction, 3 edn. Saunders, Philadelphia

Yu CW, Wu CC, Chen WJ (2002) Aseptic non-union of a femoral shaft treated using exchange nailing. Chang Gung Med J 25–9:591–598

Shroeder JE, Mosheiff R, Khoury A et al (2009) The outcome of closed, intramedullary exchange nailing with reamed insertion in the treatment of femoral shaft non-unions. J Orthop Trauma 23–9:653–657CrossRef

Richardson JB, Gardner TN, Hardy JR et al (1995) Dynamisation of tibial fractures. J Bone Joint Surg Br 77–3:412–416

Wu CC, Lee ZL (2005) Low success rate of non-intervention after breakage of interlocking nails. Int Orthop 29–2:105–108CrossRef

10.

Pihlajamaki HK, Salminen ST, Bostman OM (2002) The treatment of non-unions following intramedullary nailing of femoral shaft fractures. J Orthop Trauma 16–6:394–402CrossRef

11.

Wu CC, Shih CH, Chen WJ et al (1999) Effect of reaming bone grafting on treating femoral shaft aseptic non-union after plating. Arch Orthop Trauma Surg 119:303–307PubMedCrossRef

12.

Wu CC (2001) Treatment of femoral shaft aseptic non-union associated with plating failure: emphasis on the situation of screw breakage. J Trauma 51–4:710–713CrossRef

13.

Emara KM, Allam MF (2008) Intramedullary fixation of failed plated femoral diaphyseal fractures: are bone grafts necessary? J Trauma 65–3:692–697CrossRef

14.

Megas P, Syggelos SA, Kontakis G et al (2009) Intramedullary nailing for the treatment of aseptic femoral shaft non-unions after plating failure: effectiveness and timing. Injury 40–7:732–737CrossRef

15.

Furlong AJ, Giannoudis PV, DeBoer P et al (1999) Exchange nailing for femoral shaft aseptic non-union. Injury 30–4:245–249CrossRef

16.

Wu CC, Chen WJ (1997) Treatment of femoral shaft aseptic non-unions: comparison between closed and open bone-grafting techniques. J Trauma 43–1:112–116CrossRef

17.

Wu CC, Shih CH, Chen WJ et al (1999) Treatment of ununited femoral shaft fractures associated with locked nail breakage: comparison between closed and open revision techniques. J Orthop Trauma 13–7:494–500CrossRef

18.

Weresh MJ, Hakanson R, Stover MD et al (2000) Failure of exchange reamed intramedullary nails for ununited femoral shaft fractures. J Orthop Trauma 14–5:335–338CrossRef

19.

Hak DJ, Lee SS, Goulet JA (2000) Success of exchange reamed intramedullary nailing for femoral shaft non-union or delayed union. J Orthop Trauma 14–3:178–182CrossRef

20.

Wu CC, Chen WJ (2002) Exchange nailing for aseptic non-union of the femoral shaft. Int Orthop 26–2:80–84

21.

Banaszkiewicz PA, Sabboubeh A, McLeod I et al (2003) Femoral exchange nailing for aseptic non-union: not the end to all problems. Injury 34–5:349–356CrossRef

22.

Wu CC (2007) Exchange nailing for aseptic non-union of femoral shaft: a retrospective cohort study for effect of reaming size. J Trauma 63–4:859–865CrossRef

23.

Wu CC, Lee ZL (2005) Treatment of femoral shaft aseptic non-union associated with broken distal locked screws and shortening. J Trauma 58–4:837–840CrossRef

24.

Finkemeier CG, Chapman MW (2002) Treatment of femoral diaphyseal non-unions. Clin Orthop Relat Res 398:223–234PubMedCrossRef

25.

Weber BG, Čech O (1973) Pseudarthrosen. Hans Huber, Bern

26.

Nadkarni B, Srivastav S, Mittal V et al (2008) Use of locking compression plates for long bone non-unions without removing existing intramedullary nail: review of literature and our experience. J Trauma 65–2:482–486CrossRef

27.

Park J, Kim SG, Yoon HK et al (2010) The treatment of nonisthmal femoral shaft non-unions with im nail exchange versus augmentation plating. J Orthop Trauma 24–2:89–94CrossRef

28.

Ueng SW, Chao EK, Lee SS et al (1997) Augmentative plate fixation for the management of femoral non-union after intramedullary nailing. J Trauma 43–4:640–644CrossRef

29.

Choi YS, Kim KS (2005) Plate augmentation leaving the nail in situ and bone grafting for non-union of femoral shaft fractures. Int Orthop 29–5:287–290CrossRef

30.

Roetman B, Scholz N, Muhr G et al (2008) Augmentive plate fixation in femoral non-unions after intramedullary nailing. Strategy after unsuccessful intramedullary nailing of the femur. Z Orthop Unfall 146–5:586–590

31.

Chen CM, Su YP, Hung SH et al (2010) Dynamic compression plate and cancellous bone graft for aseptic non-union after intramedullary nailing of femoral fracture. Orthopedics 33–6:393

32.

Marti RK, Kloen P (2011) Concepts and cases in non-union treatment, 1st edn. Georg Thieme Verlag, Stuttgart, pp 20–150

33.

Blatter G, Weber BG (1990) Wave plate osteosynthesis as a salvage procedure. Arch Orthop Trauma Surg 109–6:330–333CrossRef

34.

Ring D, Jupiter JB, Sanders RA et al (1997) Complex non-union of fractures of the femoral shaft treated by wave-plate osteosynthesis. J Bone Joint Surg Br 79–2:289–294CrossRef

35.

Schulz AP, Faschingbauer M, Seide K et al (2009) Is the wave plate still a salvage procedure for femoral non-union? Results of 75 cases treated with a locked wave plate. Eur J Trauma Emerg Surg 35–2:127–131CrossRef

36.

Prasarn ML, Ahn J, Achor T et al (2009) Management of infected femoral non-unions with a single-staged protocol utilizing internal fixation. Injury 40–11:1220–1225CrossRef

37.

Cove JA, Lhowe DW, Jupiter JB et al (1997) The management of femoral diaphyseal non-unions. J Orthop Trauma 11–7:513–520CrossRef

38.

Oh I, Nahigian SH, Rascher JJ et al (1975) Closed intramedullary nailing for ununited femoral shaft fractures. Clin Orthop Relat Res 106:206–215PubMedCrossRef

39.

Harper MC (1984) Ununited fractures of the femur stabilized with the fluted rod. Clin Orthop Relat Res 190:273–278PubMed

40.

Heiple KG, Figgie HE 3rd, Lacey SH et al (1985) Femoral shaft non-union treated by a fluted intramedullary rod. Clin Orthop Relat Res 194:218–225PubMed

41.

Webb LX, Winquist RA, Hansen ST (1986) Intramedullary nailing and reaming for delayed union or non-union of the femoral shaft. A report of 105 consecutive cases. Clin Orthop Relat Res 212:133–141PubMed

42.

Kempf I, Grosse A, Rigaut P (1986) The treatment of noninfected pseudarthrosis of the femur and tibia with locked intramedullary nailing. Clin Orthop Relat Res 212:142–154PubMed

43.

Jupiter JB, Bour CJ, May JW Jr (1987) The reconstruction of defects in the femoral shaft with vascularized transfers of fibular bone. J Bone Joint Surg Am 69(3):365–374PubMed

44.

Johnson EE (1988) Custom titanium plating for failed non-union or delayed internal fixation of femoral fractures. Clin Orthop Relat Res 234:195–203PubMed

45.

Barquet A, Silva R, Massaferro J et al (1988) The AO tubular external fixator in the treatment of open fractures and infected non-unions of the shaft of the femur. Injury 19(6):415–420PubMedCrossRef

46.

Wu CC, Shih CH (1992) Treatment of 84 cases of femoral non-union. Acta Orthop Scand 63(1):57–60PubMedCrossRef

47.

Wu CC, Shih CH, Lee ZL (1992) A simpler surgical technique to treat aseptic non-union-associated femoral length discrepancy. Arch Orthop Trauma Surg 111(3):160–164PubMedCrossRef

48.

Meng-Hai MH, Liu XY, Ge BF et al (1996) An implant of a composite of bovine bone morphogenetic protein and plaster of paris for treatment of femoral shaft non-unions. Int Surg 81(4):390–392

49.

Weise K, Winter E (1996) Role of intramedullary nailing in pseudarthrosis and malalignment. Orthopade 25(3):247–258PubMed

50.

Matelic TM, Monroe MT, Mast JW (1996) The use of endosteal substitution in the treatment of recalcitrant non-unions of the femur: report of seven cases. J Orthop Trauma 10(1):1–6PubMedCrossRef

51.

Bungaro P, Pascarella R, Colozza A et al (1999) Rigid fixation with plate and bone graft in failures of intramedullary osteosynthesis for the treatment of diaphyseal non-union of the femur. Chir Organi Mov 84(3):263–267PubMed

52.

Bellabarba C, Ricci WM, Bolhofner BR (2001) Results of indirect reduction and plating of femoral shaft non-unions after intramedullary nailing. J Orthop Trauma 15(4):254–263PubMedCrossRef

53.

Rompe JD, Rosendahl T, Schollner C et al (2001) High-energy extracorporeal shock wave treatment of non-unions. Clin Orthop Relat Res 387:102–111PubMedCrossRef

54.

Abdel-Aa AM, Farouk OA, Elsayed A et al (2004) The use of a locked plate in the treatment of ununited femoral shaft fractures. J Trauma 57(4):832–836PubMedCrossRef

55.

Wu CC, Lee ZL (2004) One-stage lengthening using a locked nailing technique for distal femoral shaft non-unions associated with shortening. J Orthop Trauma 18(2):75–80PubMedCrossRef

56.

Inan M, Karaoglu S, Cilli F et al (2005) Treatment of femoral non-unions by using cyclic compression and distraction. Clin Orthop Relat Res 436:222–228PubMedCrossRef

57.

Niedzwiedzki T, Brudnicki J, Niedzwiedzki L (2007) Treatment of femoral shaft union disturbances with intramedullary nailing. Treatment failure. Ortop Traumatol Rehabil 9(4):377–383PubMed

58.

Oh JK, Bae JH, Oh CW et al (2008) Treatment of femoral and tibial diaphyseal non-unions using reamed intramedullary nailing without bone graft. Injury 39(8):952–959PubMedCrossRef

59.

Steinberg EL, Keynan O, Sternheim A et al (2009) Treatment of diaphyseal non-union of the femur and tibia using an expandable nailing system. Injury 40(3):309–314PubMedCrossRef

60.

Benazzo F, Mosconi M, Bove F et al (2010) Treatment of femoral diaphyseal non-unions: our experience. Injury 41(11):1156–1160PubMedCrossRef

61.

Richter J, Schulze W, Muhr G (2000) Diaphyseal femur pseudarthroses–only a technical problem? Chirurg 71(9):1098–1106PubMedCrossRef

62.

Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6(6):e1000097. doi:10.1371/journal.pmed1000097PubMedPubMedCentralCrossRef

Title: Operative treatment for femoral shaft nonunions, a systematic review of the literature
Authors: Matthijs P. Somford
Michel P. J. van den Bekerom
Peter Kloen
Publication date: 01-08-2013
Publisher: Springer Milan
Published in: Strategies in Trauma and Limb Reconstruction / Issue 2/2013
Print ISSN: 1828-8936
Electronic ISSN: 1828-8928
DOI: https://doi.org/10.1007/s11751-013-0168-5

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

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

Abstract

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Please log in to get access to this content

Other articles of this Issue 2/2013

Pucker sign in proximal humeral fractures: implications on management

Conversion of open tibial IIIb to IIIa fractures using intentional temporary deformation and the Taylor Spatial Frame

Acute emergency tibialization of the fibula: reconstruction of a massive tibial defect in a type IIIC open fracture

Limb trauma: the use of an advanced wound care device in the treatment of full-thickness wounds

Treatment of distal radial fractures with antegrade intra-medullary Kirschner wires

Comparison between lengthening over nail and conventional Ilizarov lengthening: a prospective randomized clinical study