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Tratamiento de la no unión en fracturas diafisarias de fémur con placa antirrotatoria *
Abstract
Introduction
Every year, there are 250 patients admitted with femoral shaft fracture at our institution. For patients treated with reamed and locked femoral nails, the non-union rate is between 10 to 15%, similar to worldwide incidence. Treating non-union is a challenge because healing rates are of only 50–80% with actual techniques. A novel technique is presented: augmentation with an antirotatory plate.
Materials and methods
We conducted a case series study at two university hospitals, collecting information from patients with diaphyseal femur fracture non-union, treated with antirotatory plate and bone grafts between 1997 and 2008. Clinical and radiological variables were assessed.
Results
47 patients entered the study, with 48 nonunion fractures of the femoral shaft that had been treated with reamed intramedullary interlocking nail. 30 fractures (62%) had required an open reduction. The average age was 37 years. 44 fractures (92%) healed 6 months after treatment with antirotatory plate and autologous bone grafts.
Discussion
This method promotes both biology and mechanics in the fracture site, allowing bone healing and return to normal activities in a high percentage. We recommend it for the treatment of femoral non-union. Further prospective research may confirm the safety and effectivity of this treatment.
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This retrospective, multicentre study aimed to evaluate reamed intramedullary nailing (IMN) for the treatment of 30 cases of aseptic femoral shaft non-union after plating failure. Following nailing, 29 non-unions had healed by a mean 7.93 months. In one case a hypertrophic non-union required renailing after 8 months, using a nail of greater diameter, and united within five further months. Healing times were not related to whether the fracture was open or closed, the type non-union or the type of fracture. The delay from the initial plating to intramedullary nailing had a statistically significant effect on healing time and final outcome. This treatment is cost effective and should be implemented as soon as the non-union is diagnosed.
After the publication of the AO book Technique of Internal Fixation of Fractures (Miiller, Allgower and Willenegger, Springer-Verlag, 1965), the authors decided after considerable discussion amongst themselves and other members of the Swiss AO that the next edition would appear in three volumes. In 1969, the first volume was published (the English edition, Manual of Internal Fixation, appeared in 1970). This was a manual of surgical technique which discussed implants and instruments and in which the problems of internal fixation were presented schematically without radio logical illustrations. The second volume was to be a treatise on the biomechanical basis of internal fixation as elucidated by the work done in the laboratory for experi mental surgery in Davos. The third volume was planned as the culminating effort based upon the first two volumes, treating the problems of specific fractures and richly illustrated with clinical and radiological examples. It was also to discuss results of treatment, comparing the results obtained with the AO method with other methods. The second and third volumes were never published. The second edition of the AO Manual appeared in 1977. It dealt in greater detail with the problems discussed in the first edition, although it still lacked clinical exam ples and any discussion of indications for surgery. Like the first edition, it was trans lated into many languages and was well received. Finally, after 22 years, the much discussed and much needed third volume has appeared.
Since its initial publication in 1987, The Rationale of Operative Fracture Care has enjoyed tremendous popularity. So much so, that the second edition was also published in Spanish, Portuguese, Japanese, and Greek. It is a book written by surgeons for surgeons. It explains in clear terms the logical progression of problem-solving in the evolution of a treatment rationale. First identify the problem and then logically outline its various potential solutions. This provides a basis for deciding which is best from a technical perspective and which will lead to the best outcome for the patient. Then choose from the available armamentarium the most suitable surgical technique and implant. All the chapters in the volume have been carefully revised to reflect the state of the art in biology, in biomechanics, in the understanding of the biology of injuries and surgical wounds, and in stabilization systems. The book should continue to serve the surgical community well, both in the most advanced teaching environments and at the forefront of care, in the community hospital practice of surgeons. © Springer-Verlag Berlin Heidelberg 2005. All rights are reserved.
Fracture non-unions often complicate orthopaedic trauma. BMPs (bone morphogenetic proteins) are currently considered the most appealing osteoinductive agents. Applications of BMP-7 since January 2004 were prospectively recorded in a multicentre registry of aseptic femoral non-unions. The study included 30 patients who had undergone a median of 1 revision operation before BMP-7 application and who were followed up for a median 24 months. In 23/30 cases the application of BMP-7 was combined with revision of the fixation, and in 12 it was combined also with autograft. Non-union healing was verified in 26/30 cases in a median period of 6 months. No adverse events were associated with BMP-7 application. Our case series supports the safety and efficacy of BMP-7 in femoral non-unions. Multicentre networks and systematic, long-term follow-up of patients may improve understanding of this promising osteoinductive bone substitute.
Stabilisation of fractures with an intramedullary nail is a widespread technique in the treatment of femoral shaft fractures in adults. To ream or not to ream is still debated. The primary objective of this study was to determine the incidence of non-union following unreamed intramedullary stabilisation of femoral fractures. Secondary objectives were intra- and postoperative complications and implant failure.
Between March 1995 and June 2005, 125 patients with 129 traumatic femoral shaft fractures were treated with as unreamed femoral nail. From this retrospective single centre study, 18 patients were excluded due to insufficient follow up data, including 1 patient who died within 2 days after severe head injury. Sixty-six patients had suffered multiple injuries. 21 fractures were open. According to the AO classification, there were 54 type A, 42 type B, and 14 type C fractures. Dynamic proximal locking was performed in 44 cases (36 type A and 8 type B fractures).
Non-union occurred in two patients (1.9%; one type B and one type C fractures). Intra-operative complications were seen in three patients (2.8%). Postoperative in-hospital complications occurred in 29 patients (27%). Local superficial infection occurred in two patients (1.9%), there were no cases of deep infection. Implant failure occurred in three patients (2.8%): nail breakage was seen in two patients.
In this study, the incidence of non-union following unreamed intramedullary nailing is low (1.9%) and comparable with the best results of reamed nailing in the literature.
Seventeen femoral nonunions after intramedullary nail internal fixation were treated with augmentative plate internal fixation. Six of them were initially managed with a Küntscher nail internal fixation; the other 11 fractures were managed with a locked nail internal fixation. All the femoral nonunions were caused by insecure fixation of the intramedullary nailing, in which a rotational instability of the fracture site was verified in all cases during operation. Leaving the intramedullary nail in situ, an augmentative plate fixation was applied to the fracture site to counter the rotational instability. A simultaneous bone grafting was performed in seven of them to repair the bony defect. All these patients walked bearing full weight on the extremity without aching at the fracture site within 3 months and all these 17 fractures obtained a bony union within an average of 7 months after this treatment. From our experience, we have found this method is a useful treatment for the nonunion of the femoral shaft fracture after an intramedullary nail internal fixation. The technique is simple and does not require any special instrument. It facilitates an early weight bearing and gives a quick recovery from nonunion.
Five patients with femoral nonunion and a broken interlocking nail were treated with the augmentative plating procedure. This group included two male and three female patients whose average age was 25 years (range, 21-35 years). All of the injuries resulted from traffic accidents and were closed fractures. Four of the injuries were initially managed with a Grosse-Kempf interlocking nailing system, and one case was managed with an AO interlocking nailing system. The broken interlocking nail was left in place in situ, and an augmentative plate fixation was applied to the fracture site to provide a rigid fixation. Simultaneous bone grafting was performed in three of the patients to repair the bony defect. All of these patients walked bearing full weight on the extremity without aching at the fracture site within 3 months, and all of these five fractures obtained a bony union within an average of 5.4 months after this treatment. From our experience, we have found this method to be a useful treatment for the nonunion of femoral shaft fracture with a broken interlocking nail.
Although rare, non-union of femoral shaft fractures is a cause of significant morbidity. In aseptic non-union, excellent union rates have historically been reported following reamed exchange femoral nailing. However, recently, a high incidence of failure requiring additional procedures has been reported. In light of these concerns and a recent change in our practice to the use of thin solid nails we undertook a retrospective study to determine the efficacy of exchange nailing with these modern nails in our hands. We reviewed records and radiographs of 25 patients who had a reamed exchange femoral nailing for established aseptic non-union. 24 patients (96%) united after exchange without the need for an additional procedure. The mean time to union was 29.75 weeks. Patients who had open bone grafting performed at the same procedure tended to unite quicker, but this did not achieve statistical significance (p = 0.14). Union times were not affected by smoking habits or nail type. This study demonstrates that reamed exchange nailing for aseptic femoral non-union remains an effective treatment. We believe that the nail type is less important than the biological effects of reaming, bone grafting and dynamization.
We report the results of a single centre prospective study of exchange nailing for aseptic non-union of a femoral fracture. Eighteen patients with 19 aseptic femoral non-unions had exchange nailing performed in our institution. We collected data on mechanism of injury, original fracture type, and indication for exchange nailing, further surgery and major complications. In 11 non-unions (58%), the exchange nail procedure alone resulted in fracture union with a mean time to radiographic union of 9 months (range 3-24 months). The non-union did not heal in five patients, two patients developed an infected non-union, and one patient required dynamisation of the exchange nail. Fracture healing was eventually achieved in 18 non-unions (95%). Complications following exchange nailing occurred in 11 fractures (58%), in which further surgery was required (four repeat exchange nailings, two Ilizarov frame applications and five nail removals). The role of reamed exchange nailing in the treatment of femoral non-union needs to be re-evaluated. Although fracture healing is eventually achieved in most patients, a significant number of them required additional surgery to achieve union or to deal with complications arising from the exchange nailing.
Exchange nailing is most appropriate for a nonunion without substantial bone loss. There is no clear consensus regarding the use of exchange nailing in the presence of active, purulent infection. The exchange nail should be at least 1 mm larger in diameter than the nail being removed, and it has been recommended that it be up to 4 mm larger when the nail being removed was greatly undersized. Canal reaming should progress until osseous tissue is observed in the reaming flutes. Exchange nailing is an excellent choice for aseptic nonunions of noncomminuted diaphyseal femoral fractures, with union rates reported to range from 72% to 100%. On the basis of the available literature, exchange nailing cannot be recommended for distal femoral nonunions at this time. Exchange nailing is an excellent choice for aseptic nonunions of noncomminuted diaphyseal tibial fractures, with union rates reported to range from 76% to 96%. On the basis of the available literature, exchange nailing is generally not indicated for humeral nonunions.
Despite advances in surgical technique, fracture fixation alternatives, and adjuncts to healing, femoral nonunion continues to be a significant clinical problem. Femoral fractures may fail to unite because of the severity of the injury, damage to the surrounding soft tissues, inadequate initial fixation, and demographic characteristics of the patient, including nicotine use, advanced age, and medical comorbidities. Femoral nonunion is a functional and economical challenge for the patient, as well as a treatment dilemma for the surgeon. Surgeons should understand the various treatment alternatives and their role in achieving the goals of deformity correction, infection management, and optimization of muscle strength and rehabilitation. Used appropriately, nail dynamization, exchange nailing, and plate osteosynthesis can help minimize pain and disability by promoting osseous union. A review of the potential risk factors and treatment alternatives should provide insight into the etiology and required treatment of femoral nonunion.
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