Plate augmentation and hybrid bone grafting are effective treatments for atrophic nonunion of the femur with the original intramedullary nail retained in situ

Abstract

The purpose of this study is to evaluate the efficacy of plate augmentation and hybrid bone grafting for treating atrophic nonunion of the femur with original intramedullary nail retained in situ.In this study, 36 patients with atrophic nonunion of the femur who underwent surgery using the technique of plate augmentation and a hybrid bone grafting while retaining the original intramedullary nail in situ in Xi'an Honghui Hospital from January 2019 to December 2021 were enrolled. 28 patients who met the inclusion and exclusion criteria were ultimately included in the study. These 28 patients, consisting of 20 males and 8 females with a mean age of 38 years, were evaluated based on factors such as operation time, intraoperative blood loss, the average hospitalization days. Additionally, the results and function of these patients were evaluated by union time, Wu's scores of limb function and incidence of serious complications.All 28 patients achieved bone union at the 12 month follow-up, with an average follow-up time of 14.6 ± 4.2 months.The average operation time was 68.3 ± 11.2 min, and the average intraoperative blood loss was 140 ± 22.6 ml. Patients were hospitalized for an average of 5.8 ± 1.1 days. Full clinical and radiological bone union was achieved on average at 5.1 ± 1.9 months. The mean value of Wu's scores at the 12 month follow-up was significantly higher than before the operation. Limb function was excellent in 27 patients and good in one patient at the 12 month follow-up. However, five patients experienced the lower limb vein thrombosis, including one deep vein thrombosis and four lower limb intermuscular vein thromboses. One patient had a superficial infections of the surgical incision site, while three patients reported pain and numbness where their iliac bone graft was extracted at the 12 month follow-up. The technique of plate augmentation and hybrid bone grafting, combined with retaining the original intramedullary nail in situ has been shown to be a safe, effective, simply and standardizable practice for treating atrophic femoral nonunion with an intact original IMN fixation.

Keywords: Atrophic nonunion; Femur; Hybrid bone grafting; Intramedullary nail; Plate augmentation.

Figure 1

Flow diagram shows how the patients were enrolled in the study.

Figure 2

Schematic of surgical technique: (A) nonunion of femur fracture, (B) first step and second step, (C) third step, (D) fourth step.

Figure 3

Surgical technique of typical patient. (A) All inactivated tissue in nonunion sites was completely debrided. The channel was done by the bone drill and bone knife. (B) Structural corticocancellous bone graft obtained from iliac crest was trimed to match the channel, and was impacted in channel to attach the nonunion site. (C) Lateral augmentation plate was placed on the surface of the structural bone graft to enhance the stability of fracture fixation. Then, the remaining iliac bone graft was made into about 2–4 mm³ bone particles. These cancellous bone particles were filled in the remained gap of nonunion.

Figure 4

Radiological image of typical patient with nonunion of femoral shaft. The preoperative anteroposterior X-ray (a) and The preoperative lateral X-ray (b) showed that the atrophic nonunion of femur shaft was clear. The coronal and sagittal 2d-CT images (c,d) further demonstrate the atrophic nonunion of femur shaft. An anteroposterior X-ray (e) and lateral X-ray (f) at the 2th day after the operation showed that fracture lines were clear. An anteroposterior X-ray (g) and lateral X-ray (h) at the 6th months after the operation showed that fracture lines were blurred and new callus forms at the site of the fracture. The result of X-ray shows the atrophic nonunion of femur shaft had healed well.