Exchange nailing for femoral diaphyseal fracture non-unions: Risk factors for failure

Is there a role for suppression of infection in managing fracture-related infection following intra-medullary nailing?

BACKGROUND

The management of fracture-related infection has undergone radical progress following the development of international guidelines. However, there is limited consideration to the realities of healthcare in low-resource environments due to a lack of available evidence in the literature from these settings. Initial antimicrobial suppression to support fracture union is frequently used in low- and middle-income countries despite the lack of published clinical evidence to support its practice. This study aimed to evaluate the outcomes following initial antimicrobial suppression to support fracture union in the management of fracture-related infection.

METHODS

A retrospective review of consecutive patients treated with initial antimicrobial suppression to support fracture healing followed by definitive eradication surgery to manage fracture-related infections following intramedullary fixation was performed. Indications for this approach were; a soft tissue envelope not requiring reconstructive surgery, radiographic evidence of stable fixation with adequate alignment, and progression towards fracture union.

RESULTS

This approach was associated with successful treatment in 51/55 (93 %) patients. Fracture union was achieved in 52/55 (95 %) patients with antimicrobial suppression alone. Remission of infection was achieved in 54/55 (98 %) patients following definitive infection eradication surgery. Following antibiotic suppression, 6/46 (13 %) pathogens isolated from intra-operative samples demonstrated multi-drug resistance.

CONCLUSION

Initial antimicrobial suppression to support fracture healing followed by definitive infection eradication surgery was associated with successful treatment in 93 % of patients. The likelihood of remission of infection increases when eradication surgery is performed in a healed bone. This approach was not associated with an increased risk of developing multi-drug-resistant infections compared to contemporary bone infection cohorts in the published literature.

LEVEL OF EVIDENCE

IV.

Effect of Interlocking Mode on the Outcomes of Exchange Nailing for the Treatment of Aseptic Femoral Shaft Nonunion

Background

Exchange nailing is a standard treatment for femoral shaft nonunion after intramedullary nailing. However, substantial uncertainty and controversy remain regarding the mode of interlocking fixation. This study aimed to compare the success rate and time to union of exchange nailing based on interlocking modes.

Methods

We retrospectively analyzed all consecutive patients who underwent exchange nailing for aseptic femoral shaft nonunion between February 2000 and February 2021. Patients who underwent exchange nailing using the dynamically locked mode and statically locked mode constituted the dynamic group and static group, respectively. We compared the success rates of the index surgery and the time to union between the groups and measured the extent of interlocking screw migration on the dynamic oblong hole in the dynamic group.

Results

The dynamic group and static group comprised 17 patients and 18 patients, respectively. All patients in the dynamic group achieved bone union, whereas 5 patients in the static group did not and underwent additional intervention. The success rate of the index surgery was significantly higher in the dynamic group than in the static group (100% vs. 72.2%, p = 0.045). Four of the 5 failed unions in the static group achieved bone union after dynamization. The median time to union was significantly shorter in the dynamic group than in the static group (6.0 months [range, 4.0-6.0] vs. 12.0 months [range, 3.7-21.7], p = 0.035). In the dynamic group, 3 of 17 patients exhibited interlocking screw migration ranging from 1.1 to 4.1 mm.

Conclusions

Exchange nailing with dynamic mode yields a higher success rate and shorter time to union in aseptic femoral shaft nonunion than that with static mode, without the risk of excessive shortening.

Paediatric Femoral Diaphyseal Fractures in a South Wales Tertiary Centre: An Account of Trend in Management and Complications Over 16 Years

Femoral shaft fractures in children have seen a number of interesting developments over the past 20 years. This is a retrospective cohort study looking into epidemiological and outcomes data of femoral shaft fractures in children treated at a tertiary centre in Wales from 2005-2021. Over a period of 16 years, there has been a significant increase in the number of rigid or elastic nailing and submuscular plating, coinciding with a dramatic reduction of external fixation for definitive treatment of diaphyseal femoral fractures. All patients above five years of age underwent operative fixation, with elastic or rigid intramedullary nailing the treatment of choice. Following multiple linear regression with 16 possible explanatory factors, this study found a statistically significant increase in time to union for open fractures, pre-operative translation, and operation time. Furthermore, there was a significant increase in post-operative leg length discrepancy for right versus left-sided fractures. Overall complication rates were 4% for minor and 8% for major complications. Complication rates were lowest for rigid intramedullary nailing and highest for external fixation. No cases of avascular necrosis were found for 27 rigid intramedullary nails inserted. Overall this study reports treatment choices and outcomes in keeping with current trends in management for paediatric femoral shaft fractures.

Plate Augmentation in Aseptic Femoral Shaft Nonunion after Intramedullary Nailing: A Literature Review

Background: Femoral shaft fractures (FSFs) are a frequent injury in traumatology for which intramedullary nailing (IMN) is considered the gold standard treatment. Nonunion (NU) is one of the most frequent complications in FSF treated with IMN, with a percentage from 1.1% to 14%. Plate augmentation (PA), the addition of a compression plate and screws, with or without bone graft has been described as an effective option for the treatment of NU, improving the biomechanical conditions at the fracture site. The aim of this review was to analyze the literature relating to the use of PA in NU after IMN in FSFs to assess the efficacy of the technique. Methods: An electronic search on PubMed, Google Scholar, and Web of Science was conducted to search for all studies concerning PA of femoral shaft NUs after IMN. Results: Twenty-four studies were included in the review comprising a total of 502 patients with a mean age of 39.5 years. Of these, 200 hundred patients had atrophic pseudoarthrosis and 123 had hypertrophic pseudoarthrosis, while in 179, the type of pseudoarthrosis was not reported. The most frequently used plate for PA was the dynamic compression plate (DCP); in 87.1% of the cases, the authors added a bone graft to the plate fixation. In 98.0% of the patients, a complete bone union was achieved in a mean time of 5.8 ± 2.12 months. Conclusion: The patients treated with PA included in this review showed a good rate of consolidation in the femoral shaft NUs, with good functional recovery and a low incidence of complications.

Nonunion of the femoral shaft associated with limb shortening treated with a combined technique of external fixation over an intramedullary nail versus the Ilizarov method

INTRODUCTION

Post-traumatic nonunion of the femur remains a challenging problem even for experienced orthopedic surgeons. The main question is the choice of the optimal surgical tool.

MATERIALS AND METHODS

Management of 20 patients with nonunion of the femoral diaphysis associated with anatomical shortening was retrospectively analyzed. Group A (n = 14) was treated with a hybrid technique that combined the Ilizarov external fixation and intramedullary nailing. The Ilizarov bone transport was used in group B (n = 6). Patients of both groups had aseptic post-traumatic nonunion. Mean shortening was 4.5 ± 0.4 cm in group A and 4.8 ± 1.0 cm in group B (p = 0.459959).

RESULTS

Union was achieved in 85.7% of group A and 100% of group B patients. External fixation was repeated in two cases of group A and achieved consolidation. Deep infection developed in one case of group A after 15 months post-frame with the nail in. It was resolved by nail removal, surgical debridement and external fixation. Limb shortening was fully eliminated in eleven cases of group A and four patients of group B. The average duration of distraction was 35.3 ± 1.7 days in group A and 47.8 ± 9.3 days in group B. The total duration of external fixation was 49.1 ± 3.5 and 177.2 ± 21.9 days with an external fixation index of 13.1 ± 1.2 and 52.4 ± 6.4 days/cm, respectively. Distraction regenerate consolidated in all the cases.

CONCLUSION

Hybrid technique provides bone union with compensation of limb shortening and reduces the treatment period as compared with the Ilizarov method used alone. However, deep infection may happen.

Risk Factors for Development of a Recalcitrant Femoral Nonunion: A Single Surgeon Experience in 122 Patients

OBJECTIVES

The goals of the study were (1) to document the healing rates of femoral nonunions stratified by those that healed as intended, healed after a subsequent intervention, and those that did not heal; (2) to report the prevalence of recalcitrant femoral nonunions and (3) to identify specific demographic, injury, and treatment-related risk factors for the development of a recalcitrant nonunion.

DESIGN

Longitudinal observational cohort study.

SETTING

Academic Level 1 trauma center.

PATIENTS/PARTICIPANTS

One hundred twenty-two femoral nonunions treated with either a plate or intramedullary nail by a single surgeon between 1991 and 2018.

INTERVENTION

Bivariate and multivariate regression analysis were performed to identify specific demographic, injury, and treatment factors in patients who developed a recalcitrant nonunion.

RESULTS

Although 83.6% of the femoral nonunions eventually healed, only 66% "healed as intended" with 17.2% requiring 1 or more additional procedures to consolidate and 16.4% of nonunions failing to unite. There were no statistically significant differences in the recalcitrance rate when we compared treatment with conventional versus locked plates or primary versus exchange nailing. Risk factors for developing a recalcitrant nonunion were deep infection, current smokers, metabolic bone disease, and patients who had undergone 3 or more prior surgical procedures.

CONCLUSIONS

The use of both intramedullary nails and modern plates were associated with a high rate of recalcitrance. Infection, current smokers, metabolic bone disease, and 3 or more prior surgical procedures were predictors for the development of a recalcitrant nonunion.

LEVEL OF EVIDENCE

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

Fracture nonunion in long bones: A literature review of risk factors and surgical management

Nonunion following a long bone fracture causes considerable morbidity when it occurs. Risk factors depend on specific fractures but there is a complex interplay of injury severity, comorbidities, patient medication and infection. The majority of nonunions occur after long bone fractures with the tibia, femur, forearm, humerus and clavicle predominating. Despite interest in the biological augmentation of fracture healing, the majority of nonunions can be effectively managed with conventional surgical techniques. In this review we present a review of risk factors for nonunion and the outcome following surgical management.

Predicting Functional Outcomes Following Fracture Nonunion Repair-Development and Validation of a Risk Profiling Tool

OBJECTIVES

To develop a tool that can be used preoperatively to identify patients at risk of poor functional outcome following operative repair of fracture nonunion.

DESIGN

Retrospective analysis of prospectively collected data.

SETTING

Academic medical center.

PATIENTS/PARTICIPANTS

Three hundred twenty-eight patients who underwent operative repair of a fracture nonunion were prospectively followed for a minimum of 12 months post-operatively.

INTERVENTION

After randomization, 223 (68%) patients comprised an experimental cohort and 105 (32%) patients comprised a separate validation cohort. Within the experimental cohort, forward stepwise multivariate logistic regression was applied to 17 independent variables to generate a predictive model identifying patients at risk of having a poor functional outcome [Predicting Risk of Function in Trauma-Nonunion (PRoFiT-NU) Score].

MAIN OUTCOME MEASUREMENTS

Functional outcomes were assessed using the Short Musculoskeletal Function Assessment (SMFA). Poor outcome was defined as an SMFA function index greater than 10 points above the mean at 12 months post-operatively.

RESULTS

Significant predictors of poor outcome were lower extremity nonunion [odds ratio (OR) = 3.082; P = 0.021], tobacco use (OR = 2.994; P = 0.009), worker's compensation insurance (OR = 3.986; P = 0.005), radiographic bone loss (OR = 2.397; P = 0.040), and preoperative SMFA function index (OR = 1.027; P = 0.001). The PRoFiT-NU model was significant and a good predictor of poor functional outcome (χ(5) = 51.98, P < 0.0005; area under the receiver operating curve = 0.79). Within the separate validation cohort, 16% of patients had a poor outcome at a PRoFiT-NU score below 25% (low risk), 39% of patients had a poor outcome at a PRoFiT-NU score between 25% and 50% (intermediate risk), and 63% of patients had a poor outcome at a PRoFiT-NU score above 50% (high risk).

CONCLUSIONS

The PRoFiT-NU score is an accurate predictor of poor functional outcome following fracture nonunion repair.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence description of levels of evidence.

Non-union: Indications for external fixation

External fixation is currently used as the definitive mode of fracture stabilisation in the management of ˜50% of long-bone non-unions. Distinction between non-union and delayed union is a diagnostic dilemma especially in fractures healing by primary bone repair. This distinction is important, as non-unions are not necessarily part of the same spectrum as delayed unions. The aetiology of a fracture non-union is usually multifactorial and the factors can be broadly categorized into mechanical factors, biological (local and systemic) factors, and infection. Infection is present in ˜40% of fracture non-unions, often after open fractures or impaired wound healing, but in 5% of all non-unions infection is present without any clinical or serological suspicion. General indications for external fixation include clinical scenarios where; 1) percutaneous correction of alignment, or mechanical stimulation of the non-union site is required; 2) fixation of juxta-articular or 'emmental' bone fragments is necessary; and 3) staged bone or soft tissue reconstruction is anticipated. Specific anatomical indications include infected non-unions of the tibia, humerus, and juxta-articular bone. External fixation is an essential tool in the management of fracture non-unions. However, with greater understanding of the outcomes associated with both external and internal fixation the relative indications are now being refined.

Uniting the un-united: should established non-unions of femoral shaft fractures initially treated with IM nails be treated by plate augmentation instead of exchange IM nailing? A systematic review

The majority of femoral fractures are surgically treated with intramedullary nails. Non-union rate is low but challenging and costly if it occurs. There have been encouraging results from the use of augmentative plating as a treatment for non-union of femoral fractures. We performed a systematic review of the literature to compare union rates, time to union and complications between exchange nailing and augmentative plating as a primary procedure following a diagnosis of femoral non-union following initial nailing. We found a total of 21 papers, which found the mean union rate of augmentative plating to be 99.8% compared to 74% (P = 2.05⁻¹²) found for exchange nailing. Times to union were comparable at 5.9 months for augmentative plating and 6.3 months for exchange nailing (P = 0.68916), and complication rate was 4% for augmentative plating compared to 20% for exchange nailing. From the evidence available, plate augmentation provides a more reliable union rate if used as the first operative intervention on a non-union of a femoral fracture compared to exchange nailing.

Level of Evidence IV Systematic review of therapeutic studies.

Systematic review of dynamization vs exchange nailing for delayed/non-union femoral fractures

AIM

To analyze the literature on efficacy of dynamamization vs exchange nailing in treatment of delayed and non-union femur fractures.

METHODS

Ultimately, 31 peer-reviewed articles with 644 exchanged nailing patients and 131 dynamization patients were identified and analyzed. The following key words were inputted in different combinations in order to search the field of publications in its entirety: “non-union”, “delayed union”, “ununited”, “femur fracture”, “femoral fracture”, “exchange nailing”, “dynaiz(s)ation”, “secondary nailing”, “dynamic”, “static”, and “nail revision”. The initial search yielded over 150 results, and was refined based on the inclusion criteria: Only studies reporting on humans, non-unions and delayed unions, and the usage of exchange nailing and/or dynamization as a secondary treatment after failed IM nailing. The resulting 66 articles were obtained through online journal access. The results were filtered further based on the exclusion criteria: No articles that failed to report overall union rates, differentiate between success rates of their reported techniques, or articles that analyzed less than 5 patients.

RESULTS

Exchange nailing lead to fracture union in 84.785% of patients compared to the 66.412% of dynamization with statistically comparable durations until union (5.193 ± 2.310 mo and 4.769 ± 1.986 mo respectively). Dynamically locking exchange nails resulted in an average union time of 5.208 ± 2.475 mo compared to 5.149 ± 2.366 mo (P = 0.8682) in statically locked exchange nails. The overall union rate of the two procedures, statically and dynamically locked exchange nailing yielded union rates of 84.259% and 82.381% respectively. Therefore, there was no significant difference between the different locking methods of exchange nailing for union rate or time to union at a significance value of P < 0.05. The analysis showed exchange nailing to be the more successful choice in the treatment of femoral non-unions in respect to its higher success rate (491/567 EN, 24/57 dynam, P < 0.0001). However, there was no significant difference between the success rates of the two procedures for delayed union fractures (25/27 EN, 45/55 dynam, P = 0.3299). Nevertheless, dynamization was more efficient in the treatment of delayed unions (at rates comparable to exchange nailing) than in the treatment of non-unions.

CONCLUSION

In conclusion, after examination of factors, dynamization is recommended treatment of delayed femur fractures, while exchange nailing is the treatment of choice for non-unions.

Traction table versus double reverse traction repositor in the treatment of femoral shaft fractures

A novel reduction technique of intramedullary nailing (IMN) for femoral shaft fractures was introduced, and in this study, its therapeutic effect was compared with patients treated with the traditional traction table. From November 2012 to August 2015, the patients with femoral shaft fractures fixed with anterograde IMN were reviewed. Seventy-four patients treated with the traction table and forty-eight patients treated with the double reverse traction repositor (DRTR) met the inclusion criteria of this study. The surgical time, blood loss, open reduction rate and complications were reviewed in this study. The fracture healing was assessed by the radiographs conducted at each follow-up. The functional outcome (hip and knee flexion, Harris Hip Score, and Lysholm knee score) was evaluated at the final follow-up. Average surgical time, blood loss, hip and knee flexion, and Harris Hip Score showed no difference (P > 0.05) between the two groups. However, the DRTR was superior to the traction table in fracture healing, Lysholm knee score, open reduction and complications rate (P < 0.05). Thus, we concluded that minimally invasive treatment of femoral shaft fractures could be obtained with the DRTR.

Exchange Nailing for Hypertrophic Femoral Nonunion

Exchange nailing has proven to be a reliable surgical technique for the management of aseptic femoral shaft nonunions. Similar to primary intramedullary nail fixation for femur fractures, exchange nailing for aseptic hypertrophic nonunions of the femur relies on successful navigation of the starting point and proper nail trajectory to minimize coronal and sagittal plane deformities. Compared with the supine position, the lateral decubitus position has the advantage of allowing gravity to displace the soft tissue around the piriformis start site to facilitate nail entry. In addition, the C-arm position and access to the affected limb from both sides by the surgeon and surgical assistant facilitate visualization of existing deformities and the ability to perform correction maneuvers. The purpose of this review is to highlight technical pearls associated with exchange nailing in a lateral decubitus position. Although other techniques are available, and should be used when indicated, exchange nailing provides patients with the opportunity to an early return to activity, improvement in pain and disability, and ultimate bony union.

Effectiveness of exchange K-nail and augmented plating in aseptic femoral diaphyseal non-union

BACKGROUND

Femoral diaphyseal non-unions present difficult scenario to manage. There are multiple options but most of them still report varying incidences of failure. We combined the principles of augmented plating and exchange nailing and aim to study the effectiveness of this technique.

METHOD

A retrospective study at a tertiary trauma centre was conducted. Seventy patients (60 men, 10 women), average age 40.7±15.27 years (range 18-81 years) with diaphyseal femoral fracture non-unions treated between July 2010 and January 2015 were reviewed. The average interval between first and the last surgery was 18.07±17.65 months (range 4-96 months). Forty six patients had hypertrophic non-union and 24 patients had atrophic non-union. Twenty one patients had undergone a prior surgery for non-union, 13 dynamisation, 4 bone grafting, 1 augmented plating and 3 exchange nailing. Non-unions were treated with implant removal, freshening of bone edges and exchange K-nailing and augmented plating. Autologous bone grafting and raising of osteoperiosteal flaps was done in all cases. Outcome measures were radiographic evidence of fracture union at minimum three out of four cortices, knee range of motion as compared to opposite knee, and study of complications.

RESULTS

All patients demonstrated radiographic evidence of fracture union with an average time of 16.77±2.38 weeks (range 12-26 weeks). Mean knee range of motion of unaffected limb was 126±9.76° (range 90-140°) while in operated limb it was 121.1±11.36° (range 80-140°), p>0.01. Patients with hypertrophic non-unions, prior surgery for non-union and supra- or infra-isthmal non-unions had shorter union time. Two patients had superficial infection which was managed by superficial debridement and two patients had pain at proximal nail tip site which was managed by anti-inflammatory medication. None of the patients required additional surgery for implant removal.

CONCLUSION

Exchange K nailing with Bone graft and additional plating technique for non-union diaphyseal femur fracture achieved good union rates with minimal complication. In our series none of the patient required revision and the technique probably will further minimise the revision rates compared to current options for non-union femur.

Current treatment of infected non-union after intramedullary nailing

Non-union is a devastating consequence of a fracture. Non-unions cause substantial patient morbidity with patients suffering from loss of function of the affected extremity, increased pain, and a substantial decrease in the quality of life. The management is often associated with repeated, unsuccessful operations resulting in prolonged hospital stays, which has social and economic consequences to both the patient and the healthcare system. The rates of non-union following intramedullary (IM) nailing vary according to anatomical location. There is currently no consensus regarding the treatment of infected non-unions following IM nailing, but the most common procedures reported are; exchange IM nail with antibiotic suppression or excision of the non-union, (stabilisation with external fixation or less commonly plate or IM nail) and then reconstruction of the bone defect with distraction osteogenesis or the Masquelet technique. This article explores the general principles of treatment, fixation modalities and proposes a treatment strategy for the management of infected non-unions following intramedullary nailing.

Orthopaedic biofilm infections

Many infections of the musculoskeletal system are biofilm infections that develop on non-living surfaces. Microorganisms adhere either on dead bone (sequesters) or implants. As a rule for a curative concept, chronic osteomyelitis or implant-associated bone infection must be treated with a combination of surgery and antimicrobial therapy. If an implant is kept in place, or a new device is implanted before complete healing of infection, a biofilm-active antibiotic should be used. Rifamycins are active against biofilms of staphylococci, and fluoroquinolones against those of Gram-negative bacilli. In this review, the management of chronic osteomyelitis, periprosthetic joint infection and implant-associated osteomyelitis of long bones is presented.

Osseous Hydatidosis of Femur in a Patient with Fracture Non-union: An Uncommon Entity

Hydatid disease caused by the larval form of the parasitic tapeworm, Echinococcus granulosus, commonly affects the liver and lungs. Bone involvement by Hydatid is extremely uncommon and is reported in 1-3% of cases. It is often a dormant disease, presenting at a late stage with non-specific clinical and radiological findings. Usually they occur as an isolated entity without liver/lung involvement and a clinical suspicion of this disease is not possible. We report a rare case of Hydatid cyst of femur in a 25-year-old female, with unresolving non-union of fracture for five years. The occurrence of this disease in atypical locations and lack of a specific radiological sign makes the diagnosis challenging and it is important for the orthopaedicians and pathologists to be aware of this entity for a precise diagnosis.

A report of a novel technique: The comprehensive fibular autograft with double metal locking plate fixation (cFALP) for refractory post-operative diaphyseal femur fracture non-union treatment

INTRODUCTION

The refractory post-operative diaphyseal femur fracture (DFF) non-union is extremely difficult to treat and remains severe challenges for orthopedists. Although several traditional internal fixations and novel biomedical techniques have been used in managing this complication, its treatment is still fraught with severe challenges.

PATIENTS AND METHODS

Starting from 1999, 5 patients after three previous internal fixation operations showing refractory DFF non-union underwent the comprehensive fibular autograft with double metal locking plates fixation (cFALP) surgery. The autogenous fibular was first harvested and non-evenly split into two halves in a longitudinal manner. After retracting all previous internal fixation(s), the larger half strut fibula was hammered into the femur canal while the smaller half was fragmented into small pieces and filled surrounding the DFF site. Two locking compression plate were fixed on the lateral and anterior (or antero-lateral) side of the femur, respectively.

RESULTS

The follow-up ranged from 60 to 96 weeks. All cases (100%) achieved bony union without severe complications. The mean time to union was 36±14.7 weeks (range 24-60 weeks).

CONCLUSION

The cFALP is a promising surgical modality for DFF non-union treatment. However, because fibular harvest may cause severe complications, the cFLAP should only be considered in refractory DFF non-union cases.