Reamed intramedullary exchange nailing: treatment of choice of aseptic femoral shaft nonunion

Abstract

Background: The aim of this study was to evaluate a standardized method of treatment of femoral nonunion of the isthmal femur excluding non-united metaphyseal fractures.

Methods: Between 2003 and 2010, 72 consecutive patients with nonunion of the femoral shaft were operated using a standardized protocol in our trauma department and followed up for successful union and functional result.

Results: Osseous healing was observed in 71 patients (98%). Only one patient was lacking bone healing following a time period of 24 months after the first exchange nailing and 5 months after the second exchange nailing. In 59 patients (82%), uneventful and timely bone healing after exchange nailing was detected. In 18% of patients (n = 13), delayed bone healing was observed and required additional therapy. In the majority of patients (61%), bone healing occurred within the first 2 to 5 months, only 18% of patients' duration of bone healing exceeded 8 months. In 62 patients (86%), no relevant or clinically apparent leg-length discrepancy prior to and after exchange nailing was detected as well as no significant axis deviation or malrotation. Functional studies including simple clinical gait and standing analysis, return to activities of daily life, return to sports activities, and return to work were all reached on a satisfying level.

Discussion: Reamed intramedullary exchange nailing as described in this study is the treatment of choice for aseptic femoral shaft nonunion with a high rate of bone healing and a low rate of complications including length discrepancy or malrotation and a good functional outcome.

Figure 1

Distribution of patients with primary and secondary bone healing. Distribution of patients with primary bone healing after a single operation and secondary bone healing requiring additional therapies following reamed intramedullary exchange nailing of femoral shaft nonunion.

Figure 2

Time to bone healing of 72 patients with a femoral nonunion treated with reamed intramedullary exchange nailing.

Figure 3

Leg-length discrepancy after exchange nailing of 72 patients with a femoral nonunion treated with reamed intramedullary exchange nailing. Note that a variation of 1 cm was accepted as normal.

Figure 4

Clinical example of a patient with a combined varus axis deviation (A) and a rotational difference of 15° (B) prior to reamed intramedullary exchange nailing of a femoral nonunion. After 6 months, osseous healing could be achieved (C).