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Duke Orthopaedics
Wheeless' Textbook of Orthopaedics

Femoral Shaft Nonunion

- Discussion:
    - general discussion of non union / infected femoral nails
    - femoral shaft that has not healed in 26 wks signals a delayed union;
    - may be more common in segmental fractures and in winquest type IV fractures
    - most common iatrogenic risk factor is failure to ream the canal; (see femoral reaming)
    - references:
           - Nonunion of the femoral diaphysis. The influence of reaming and non-steroidal anti-inflammatory drugs.
           - Human atrophic fracture non-unions are not avascular.
           - Antegrade or retrograde reamed femoral nailing. A prospective, randomised trial.
           - Nonunion following intramedullary nailing of the femur with and without reaming. Results of a multicenter randomized clinical trial. 
           - Retrograde dynamic locked nailing for femoral supracondylar nonunions after plating.

- Treatment Options: 
    - see bone graft menu
    - Exchange Nailing:
            - consider removing nail, reaming of canal, & inserting larger nail;
            - difficulty passing guide wire across a dense sclerotic nonunion may require special instrumentation or opening of the frx site;
            - consider reaming to 2 mm above the previous size, & delivering bone graft to site of non union thru a chest tube, and inserting larger IM nail;
            - in the report by Giannoudis, et al, the authors emphasize the importance of avoiding NSAIDS, using bone grafting, as well as reaming
                    above the previous nail size;
            - in the report by Weresh MJ et al, the authors noted that a significant number of patients undergoing reamed exchange nailing of femoral
                    shaft non unions required additional procedures to achieve fracture healing;
                    - they noted that exchange nailing by itself may not be sufficient for fracture healing; 
            - retrograde IM nailing: may be useful for distal femur frx, treated with prior antegrade nailing;
            - references:   
                    - Nonunion of the femoral diaphysis. The influence of reaming and non-steroidal anti-inflammatory drugs. 
                    - The treatment of nonunions following intramedullary nailing of femoral shaft fractures.
                    - Simple approach to the management of aseptic non-union of the shaft of long bones.
                    - Exchange nailing for femoral shaft aseptic non-union.
                    - [Treatment results of aseptic non-unions of long bones with medullary canal reaming followed by intramedullary nailing] 
                    - Success of exchange reamed intramedullary nailing for femoral shaft nonunion or delayed union. 
                    - Failure of exchange reamed intramedullary nails for ununited femoral shaft fractures.
                    - The treatment of noninfected pseudarthrosis of the femur and tibia with locked intramedullary nailing.
                    - Treatment of infected pseudarthrosis of the femur and tibia with an interlocking nail.
                    - Intramedullary nailing and reaming for delayed union or nonunion of the femoral shaft. A report of 105 consecutive cases. 
                    - Distal femoral nonunion treated with interlocking nailing.
                    - Treatment of femoral and tibial diaphyseal nonunions using reamed intramedullary nailing without bone graft
                    - Femoral exchange nailing for aseptic non-union: not the end to all problems. 
                    - The outcome of closed, intramedullary exchange nailing with reamed insertion in the treatment of femoral shaft nonunions.
                    - Retrograde dynamic locked nailing for aseptic nonunion of femoral supracondyle after antegrade locked nailing 
                    - Nonisthmal femoral shaft nonunion as a risk factor for exchange nailing failure
                    - Effectiveness of plate augmentation for femoral shaft nonunion after nailing.
                    - The Results of a Systematic Approach to Exchange Nailing for the Treatment of Aseptic Femoral Nonunions.
            - nail dynamization:
            - plate augmentation (over nail):
                  - references:
                          - Augmentation Plate Fixation for the Treatment of Femoral and Tibial Nonunion After Intramedullary Nailing 
                          - Effectiveness of plate augmentation for femoral shaft nonunion after nailing
                          - The treatment of nonisthmal femoral shaft nonunions with im nail exchange versus augmentation plating
                          - Plate fixation of femoral nonunions over an intramedullary nail with autogenous bone grafting
                          - Use of locking compression plates for long bone nonunions without removing existing intramedullary nail: review of literature and our experience.
                          - Indications and outcomes of augmentation plating with decortication and autogenous bone grafting for femoral shaft nonunions 

    - plate fixation: (see synthes distal femoral plate and discussion of plates)
           - allows direct debridement of non union ends, anatomic reduction, bone grafting and compression;
           - in the report by Bellabarba C, et al, the authors report on a consectutive series of 23 femoral non unions of femoral shaft fractures
                   treated by previous IM nailing;
                   - surgical treatment consisted of indirect fracture reduction techniques using 95 deg condylar blade plate;
                   - 21 of 23 non unions healed without further intervention (two other fractures had hardware failure);
           - references: 
                   - Results of indirect reduction and plating of femoral shaft nonunions after intramedullary nailing
                   - Plate augmentation leaving the nail in situ and bone grafting for non-union of femoral shaft fractures.
                   - Mechanical comparison of a distal femoral side plate and a retrograde intramedullary nail.
                   - The use of a locked plate in the treatment of ununited femoral shaft fractures.
                   - The evolution of femoral shaft plating technique.
                   - Augmentative plate fixation for the management of femoral nonunion after intramedullary nailing.
                   - Plate augmentation leaving the nail in situ and bone grafting for non-union of femoral shaft fractures.
                   - Open reduction and internal fixation of distal femoral nonunions: long-term functional outcomes following a treatment protocol.
                   - Management of infected femoral nonunions with a single-staged protocol utilizing internal fixation.
                   - Treatment of the femoral shaft nonunion with double plate fixation and bone grafting: A case series of 14 patients.

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Saturday, May 9, 2015 8:49 am

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