Collagen/Nano-hydroxyapatite Composite Scaffold Application with Exchange Reamed Nailing Accelerates Bone Union and Improves Quality of Life in Atrophic Femoral Shaft Nonunions: A Retrospective Comparative Study

Abstract

Background: Our aim in this study was to evaluate the effect of exchange intramedullary nailing in femoral shaft atrophic nonunions and the use of collagen/nano-hydroxyapatite composite scaffold applied in addition to the cancellous iliac crest autograft on the union, return to work, and quality of life.

Materials and methods: Fifty-four patients with an atrophic nonunion in the isthmic region of the femoral shaft were included in the study. The patients were divided into two groups. Group A consisted of 24 patients who underwent collagen/nano-hydroxyapatite composite scaffold in addition to exchange intramedullary nailing and iliac autograft, while group B consisted of 30 patients without scaffold. Short Form-36 (SF-36) questionnaire scores, union rates, time to union, return to work were complications were compared.

Results: Mean age of patients was 47.5 ± 14.1. The mean follow-up period was 3.56 ± 1.88 years. There was no statistically significant difference between Group A and B in terms of age, gender, smoking and alcohol use, and trauma mechanism. Time to union and return to work were statistically significantly shorter in Group A than in Group B (p = 0.004, p = 0.001). All of the SF-36 survey scores at month six were better in Group A. In the first year, mental health and general health perception were still statistically better in group A (p = 0.009, p = 0.008).

Conclusion: In the treatment of atrophic nonunions of the femoral shaft isthmic region, the use of collagen/nano-hydroxyapatite composite scaffolds together with exchange intramedullary nailing affects the union positively. This positive effect also brings about earlier return to work and better quality of life.

Keywords: Collagen; Exchange nailing; Femur; Hydroxyapatite; Nonunion; Scaffold.

Fig. 1

X-ray image of atrophic nonunion in the femoral shaft of a patient who was treated with an intramedullary femoral nail 13 months ago due to a traffic accident

Fig. 2

Atrophic nonunion without callus tissue is seen at the intraoperative fracture ends

Fig. 3

The intramedullary nail was compressed in the axial plane. Afterwards, the cancellous autograft harvested from the iliac crest was impacted at the nonunion site for filling fracture gap, intraoperative view

Fig. 4

Intraoperative view of collagen/nano-hydroxyapatite composite scaffold, which wrapped circumferentially to the fracture line without requiring any stabilization after application

Fig. 5

Line diagram of the stages of cancellous iliac crest bone graft and scaffold application

Fig. 6

Anteroposterior and lateral X-ray images of the solid union of femoral nonunion at 6 months postoperatively