Delayed union of multifragmentary diaphyseal fractures after bridge-plate fixation

Concomitant intramedullary nailing and plate augmentation as a single-stage procedure in treating complicated nonunited femoral shaft fractures

Background and Purpose:

Complicated femur fracture represents a major challenge for the orthopedic surgeon, with failed internal fixation, nonunion with broken intramedullary nail (IMN), and infected nonunion among the complications. Mechanical instability, as well as the poor biological environment, is considered as a concern when treating these cases. The purpose of this study was to evaluate concomitant IMN and plate augmentation as a single-stage procedure for the management of multiply operated nonunited femoral shaft fractures.

Materials and Methods:

Between January 2015 and May 2018, nine patients (eight men) with an average age of 40.8 years (range 25–70) diagnosed as nonunion femoral fractures after an average of four previous surgeries (range 2–6). All patients were available for follow-up with an average of 22 months (range 12–36).

Results:

The average time for fracture union was 6.7 months (range 3–12); five patients needed bone grafting to compensate for the bone defect encountered during the initial procedure, and two patients required secondary bone grafting after 6 months follow-up. Two patients presented with surgical site infection which was treated by antibiotics and daily dressing. The average leg length discrepancy at last follow-up was 1 cm (range 0.5–1.5). No patient had a metalwork failure or needed removal of the implants.

Conclusion:

In treating complicated multiply operated nonunited femoral shaft fractures, we believe that this technique can provide a robust mechanical foundation as well as an improved biological environment for such nonunited fractures to heal.

Percutaneous autologous bone marrow transplantation for the treatment of delayed union of limb bone in children

Background and purpose

Percutaneous autologous bone marrow transplantation (PABMT) is a minimally invasive therapeutic strategy for the treatment of delayed bone union in adults, which has been confirmed by many studies. However, there is no report on PABMT application in pediatric orthopedic surgery. The aim of this article was to analyze the therapeutic effect of PABMT in children with delayed union of limb bone and its influence in relation to delayed bone union therapy, transplantation period, patients’ sex, fracture location, and fracture fixation.

Methods

In this study, 53 patients (aged 3–16 years, with an average age of 6.7 years) with delayed union of long bone (20 femurs, 12 tibiae, 10 humeri, 5 radiuses, 5 ulnas, and 1 fibula) were treated using PABMT. Clinical examination and X-ray were integrated to evaluate the therapeutic effect.

Results

All 53 patients were followed up for 2–6 years (average time, 3.5 years). Of the 53 patients, 47 (88.7%) were healed, whereas the other 6 (11.3%) were not, and were subsequently treated by autologous bone grafting. In 30 patients who received their first PABMT treatment 6–8 months after fixation, the clinical cure rate, operation times, and healing time were 83.3%, 5.8±0.5 months, and 2.5±0.6, respectively. In the other 23 patients, whose first PABMT treatments were started within 4 to 6 months after fixation, the clinical cure rate, operation times, and healing time were 95.7% (P=0.167), 3.2±0.3 months (P=0.001), and 1.3±0.6 (P=0.001), respectively. The patients’ sex, fracture location, and fracture fixation did not have statistical influence on the clinical efficacy.

Conclusion

PABMT is a minimally invasive and effective strategy for the treatment of delayed union of limb bone in children. The early surgical treatment facilitates the fracture healing, reduces the number of transplantation, and shortens the course of treatment.

Non-anatomical surgical solutions for difficult non-unions: case series

ABSTRACT

Non-union occurs when bone healing ceases and does not continue without some type of intervention. Classification of non-union is traditionally based on the amount of callus or bone healing at the fracture site. Successful treatment of non-union often depends on appropriate reduction and realignment of the fracture, bone grafting if necessary, and stabilization. This may not be possible in some neglected and complicated non-unions. Under these circumstances, modification of the standard techniques or a limited surgical interference, that might not be anatomical, may succeed in improving function. We present four cases of non-anatomical salvage solutions for difficult long bone non-unions with satisfactory functional outcome.

Fibula-pro-tibia in plating tibial non-unions

PURPOSE

Plating non-unions of the tibial diaphysis often presents the technical problem of poor purchase of screws due to osteoporosis. To improve the stabilization, insertion of one or more screws through the plate across the tibio-fibular space to the fibula (fibula-pro-tibia plating) has been practiced. The aim of this study is to evaluate the effectiveness of the fibula-pro-tibia plating technique in managing difficult diaphyseal tibial non-unions.

METHODS

Between 2000 and 2008, 30 patients with diaphyseal non-union of tibia were managed with this technique. The time between injury and index operation ranged between six and 24 months (average, 11 months). Sixteen patients had three surgical procedures before the index operation, ten had two procedures and four patients had one.

RESULTS

The duration of follow-up ranged between ten and 38 months (average 26 months). The mean healing time was 3.5 months. Complications were minimal and included two cases of delayed union which required regrafting after four months and two cases, which had infected nonunion, had reactivation of the infection, which resolved completely after achieving union and removing the plates. There was no negative effect from this fixation technique on the ankle joint motion.

CONCLUSION

The fibula-pro-tibia plating technique is an effective variation in plating diaphyseal tibial non-unions.

Failed intramedullary nailing of femur: open reduction and plate augmentation with the nail in situ

METHODS

Fourteen patients with aseptic fractures that failed to unite after intramedullary nailing (IMN) of the femur were treated by augmentation of fixation by dynamic compression plate (DCP) with the nail in situ. In six of them that had axial or rotational malalignment, direct reduction of the bone fragments and plating were done. Iliac bone grafting was performed in nine cases, when there were gaps between the fragments and in atrophic non-unions. Patients were followed-up for an average of 26 months.

RESULTS

All patients had radiological union in an average of 4.3 months with an improvement in alignment, range of motion and shortening.

CONCLUSIONS

For failed IMN of the femur, augmentation of fixation by compression plate, with the nail in situ, is a good line of treatment. In cases with malalignment, correction was possible followed by plate augmentation.