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Meta-Analysis
. 2025 May;28(3):164-174.
doi: 10.1016/j.cjtee.2024.04.004. Epub 2024 Apr 27.

Effectiveness and safety of augmentative plating technique in managing nonunion following intramedullary nailing of long bones in the lower extremity: A systematic review and meta-analysis

Cong-Xiao Fu  1 , Hao Gao  2 , Jun Ren  3 , Hu Wang  1 , Shuai-Kun Lu  2 , Guo-Liang Wang  2 , Zhen-Feng Zhu  2 , Yun-Yan Liu  2 , Wen Luo  4 , Yong Zhang  2 , Yun-Fei Zhang  5
Affiliations
Meta-Analysis

Effectiveness and safety of augmentative plating technique in managing nonunion following intramedullary nailing of long bones in the lower extremity: A systematic review and meta-analysis

Cong-Xiao Fu et al. Chin J Traumatol. 2025 May.

Abstract

Purpose: To methodically assess the effectiveness of augmentative plating (AP) and exchange nailing (EN) in managing nonunion following intramedullary nailing for long bone fractures of the lower extremity.

Methods: PubMed, EMBASE, Web of Science, and the Cochrane Library were searched to gather clinical studies regarding the use of AP and EN techniques in the treatment of nonunion following intramedullary nailing of lower extremity long bones. The search was conducted up until May 2023. The original studies underwent an independent assessment of their quality, a process conducted utilizing the Newcastle-Ottawa scale. Data were retrieved from these studies, and meta-analysis was executed utilizing Review Manager 5.3.

Results: This meta-analysis included 8 studies involving 661 participants, with 305 in the AP group and 356 in the EN group. The results of the meta-analysis demonstrated that the AP group exhibited a higher rate of union (odds ratio: 8.61, 95% confidence intervals (CI): 4.12 - 17.99, p < 0.001), shorter union time (standardized mean difference (SMD): -1.08, 95% CI: -1.79 - -0.37, p = 0.003), reduced duration of the surgical procedure (SMD: -0.56, 95% CI: -0.93 - -0.19, p = 0.003), less bleeding (SMD: -1.5, 95% CI: -2.81 - -0.18, p = 0.03), and a lower incidence of complications (relative risk: -0.17, 95% CI: -0.27 - -0.06, p = 0.001). In the subgroup analysis, the time for union in the AP group in nonisthmal and isthmal nonunion of lower extremity long bones was shorter compared to the EN group (nonisthmal SMD: -1.94, 95% CI: -3.28 - -0.61, p < 0.001; isthmal SMD: -1.08, 95% CI: -1.64 - -0.52, p = 0.002).

Conclusion: In the treatment of nonunion in diaphyseal fractures of the long bones in the lower extremity, the AP approach is superior to EN, both intraoperatively (with reduced duration of the surgical procedure and diminished blood loss) and postoperatively (with an elevated union rate, shorter union time, and lower incidence of complications). Specifically, in the management of nonunion of lower extremity long bones with non-isthmal and isthmal intramedullary nails, AP demonstrated shorter union time in comparison to EN.

Keywords: Augmentative plating; Exchange nailing; Intramedullary nail; Lower extremity long bone fractures; Nonunion.

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Conflict of interest statement

Declaration of competing interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Fig. 1
Fig. 1
The flowchart of article screening.
Fig. 2
Fig. 2
Newcastle-Ottawa scale for assessing the quality of studies.
Fig. 3
Fig. 3
Forest plot for union rates in the AP and EN groups AP: augmentative plating; EN: exchange nailing; CI: confidence intervals.
Fig. 4
Fig. 4
Forest plot for union time in the AP and EN groups. AP: augmentative plating; EN: exchange nailing; CI: confidence intervals.
Fig. 5
Fig. 5
Forest plot for operation time in the AP and EN groups. AP: augmentative plating; EN: exchange nailing; CI: confidence intervals.
Fig. 6
Fig. 6
Forest plot for blood loss in the AP group and EN groups. AP: augmentative plating; EN: exchange nailing; CI: confidence intervals.
Fig. 7
Fig. 7
Forest plot for the incidence of complications in AP group and EN groups. AP: augmentative plating; EN: exchange nailing; CI: confidence intervals.
Fig. 8
Fig. 8
Forest plot for union rates of nonisthmal femoral shaft nonunion in AP and EN groups. AP: augmentative plating; EN: exchange nailing; CI: confidence intervals.
Fig. 9
Fig. 9
Forest plot for union rate of isthmal femoral shaft nonunion in AP and EN groups. AP: augmentative plating; EN: exchange nailing; CI: confidence intervals.
Fig. 10
Fig. 10
Forest plot for non-isthmic union time in AP and EN groups. AP: augmentative plating; EN: exchange nailing; CI: confidence intervals.
Fig. 11
Fig. 11
Forest plot for isthmic union time in AP and EN groups. AP: augmentative plating; EN: exchange nailing; CI: confidence intervals.
Fig. 12
Fig. 12
Forest plot for operation time of the non-isthmal emoral shaft nonunion in AP group and EN groups. AP: augmentative plating; EN: exchange nailing; CI: confidence intervals.
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