The Use of a Free Fibular Strut as a "Biological Intramedullary Nail" for the Treatment of Complex Nonunion of Long Bones

Abstract

Background: Nonunion of long-bone fractures is difficult to treat, especially when the bones are osteoporotic or there is a large bone gap as a result of repeated failure of the metallic nails or implants. In such cases, the use of an autologous intramedullary fibular strut graft may be a viable treatment option.

Methods: Twenty-two patients with a complex nonunion of the shaft of the femur, humerus, or tibia were managed with a free autologous fibular strut graft for intramedullary fixation with use of closed or open methods. All patients had evidence of moderate to severe local osteoporosis and had a bone gap ranging from 4 to 20 mm. Nineteen patients had had 1 to 4 prior operations. The mean age was 51.5 years. The duration of nonunion ranged from 9 months to 4 years.

Results: The mean time to union was 17 weeks (range, 8 to 26 weeks), and the mean duration of follow-up was 4 years (range, 6 months to 17 years). All but 2 patients had healing at the time of the latest follow-up.

Conclusions: The identification of a viable option for the treatment of difficult nonunion in osteoporotic bones has been a challenge. The insertion of a free autologous intramedullary fibular strut graft provided mechanical stability, and osteogenesis occurred inside the medullary canal of the host bone.

Level of evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Fig. 1-A

Anteroposterior radiographs showing a subtrochanteric nonunion after 4 surgical procedures, including 2 attempted applications (and subsequent removals) of plate and nail fixation.

Fig. 1-B

Anteroposterior radiographs made 3 weeks after treatment with a fibular graft, showing signs of healing. At the time of the procedure, a Kirschner wire was passed through the fibular graft, and the graft was then inserted into the femur. Black and white arrows indicate the location of the fibular strut in the femur.

Fig. 1-C

Radiographs made 11 weeks postoperatively, showing complete union.

Fig. 2-A

Preoperative photographs.

Fig. 2-B

Anteroposterior (left and middle panels) and lateral (right panel) radiographs showing gap nonunion with severe osteoporosis.

Fig. 2-C

Anteroposterior and lateral radiographs (left) and clinical photographs (right), made 18 months after the insertion of the fibular strut. Before surgery a full-thickness skin graft had been attempted. The clinical photographs show that the patient had an equinus deformity, which compensated for the limb-shortening on the involved side. The patient was satisfied with the results of treatment and refused any further surgical intervention.

Fig. 3-A

Fig. 3-B

Fig. 3-C

Intraoperative photographs showing the host site and insertion of the strut graft.

Fig. 3-D

Fig. 3-E

Radiographs made 10 weeks after placement of the fibular struts at the fracture site.

Fig. 4-A

Clinical photograph and radiographs of a 64-year-old man with a humeral fracture who initially received local treatment and was subsequently treated with use of a Kuntscher nail. The radiographs show a loose Kuntscher nail and gross osteoporosis.

Fig. 4-B

Immediate postoperative (left) and follow-up (right) radiographs made after the patient was managed with a fibular strut graft and a long Kirschner wire for the treatment of nonunion of the osteoporotic humeral shaft. The follow-up radiographs, made at 11 weeks, show union at the fracture site.

Fig. 5-A

Preoperative and immediate postoperative radiographs. During the procedure, an autologous fibular graft was inserted at the fracture site; however, because the medullary canal was very wide, the fibular strut was a loose fit. The site was fixed with 2 cortical screws to achieve 4-cortex fixation.

Fig. 5-B

Radiographs demonstrating fracture healing at 10 weeks.