High success rate with exchange nailing to treat a tibial shaft aseptic nonunion

A systematic review and meta-analysis:comparing the efficacy of the Ilizarov technique alone with lengthening over a nail for lower extremity bone defects

PURPOSE

The task faced by surgeons becomes significantly more challenging when they encounter lower extremity bone defects due to a variety of causes requiring lengthening. The most discussed and successful approach is the Illizarov technique, or lengthening over a nail (LON):distraction osteogenesis is also widely performed with monoliteral external fixators and intramedullarylengthening nails have increasingly been used in the last decade.

METHODS

The data were collected from PubMed, Cochrane Library, Embase, and the Web of Science for all available studies comparing the outcomes of Ilizarov technique alone and LON technique (from January 1, 1997, to November 30, 2023). The outcomes of interest encompassed the external fixation index (EFI) (month/cm), mean duration of follow-up (MFT) (month), length gained (LG) (cm), consolidation index (CIx) (month/cm), and bone healing index (BHI) (month/cm).Complications include pin tract infection rate (PTI), axial deviation rate (AD), occurrence of intramedullary infection (II), delayed consolidation rate (DC), as well as data categorized into three levels of problems, obstacles, and sequelae based on the severity of complications.Two reviewers independently assessed each study for quality and extracted data. The case-control or respective cohort studies were evaluated using the Newcastle-Ottawa scale (NOS) to determine their techniqueological rigor.The Cochrane Collaboration's risk assessment tool was employed to perform quality evaluations for randomized controlled trials.

RESULTS

This review included thirteen studies comprising a total of 629 patients.The external fixation index (month/cm) was significantly smaller in the LON technique compared to the Ilizarov technique alone [Mean Difference(MD) = -29.59, 95% CI -39.68--19.49, P < 0.00001].In terms of the mean follow-up time(month) (MD = -0.92, 95% CI -3.49-1.65, P = 0.57), length gained (cm) (MD = -0.87, 95%CI -2.80-1.07, P = 0.38), consolidation index (month/cm) (MD = 0.66, 95% CI -3.44-4.77, P = 0.75), and bone healing index (month/cm) (MD = -3.33, 95% CI -13.07-6.41, P = 0.5), there were no significant differences observed. The LON technique exhibited a lower incidence of axial deviation [Odds Ratio(OR) = 0.06, 95%CI 0.03-0.16, P < 0.00001] and pin tract infection (OR = 0.30, 95%CI 0.18-0.50, P < 0.00001) compared to the Ilizarov technique alone.The remaining complications, such as intramedullary infection rate (OR = 0.93, 95%CI 0.42-2.06, P = 0.85) and delayed consolidation rate(OR = 0.61, 95%CI 0.20-1.86, P = 0.38), did not exhibit statistically significant differences.Our findings demonstrated that the LON technique results in lower incidences of problems (38.5%vs.58.6%) and sequelae (16.6% vs.30.9%) when compared to the Ilizarov technique alone. However, the rates of obstacles (32.4% vs.32.3%) were comparable between the two methods.

CONCLUSIONS

Our findings indicate that patients treated with the LON technique experienced significantly shorter external fixation durations and a lower incidence of complications (e.g., pin tract infections and axial deviation) compared to those treated with the Ilizarov technique alone. Other outcome metrics showed no significant differences between the two techniques. However, the LON technique offers substantial benefits, including reduced external fixation times and increased comfort, which enhance patient compliance. In conclusion, the LON technique is a safe, reliable, and effective method for treating tibial and femoral defects.

Risk factors associated with delayed and aseptic nonunion following tibial diaphyseal fractures managed with intramedullary nailing

Aims

The primary aim of this study was to identify independent predictors associated with nonunion and delayed union of tibial diaphyseal fractures treated with intramedullary nailing. The secondary aim was to assess the Radiological Union Scale for Tibial fractures (RUST) score as an early predictor of tibial fracture nonunion.

Methods

A consecutive series of 647 patients who underwent intramedullary nailing for tibial diaphyseal fractures were identified from a trauma database. Demographic data, comorbidities, smoking status, alcohol consumption, use of non-steroidal anti-inflammatory drugs (NSAIDs), and steroid use were documented. Details regarding mechanism of injury, fracture classification, complications, and further surgery were recorded. Nonunion was defined as the requirement for revision surgery to achieve union. Delayed union was defined as a RUST score < 10 at six months postoperatively.

Results

There were 41 nonunions (6.3%), of which 13 were infected (31.7%), and 77 delayed unions (11.9%). There were 127 open fractures (19.6%). Adjusting for confounding variables, NSAID use (odds ratio (OR) 3.50; p = 0.042), superficial infection (OR 3.00; p = 0.026), open fractures (OR 5.44; p < 0.001), and high-energy mechanism (OR 2.51; p = 0.040) were independently associated with nonunion. Smoking (OR 1.76; p = 0.034), open fracture (OR 2.82; p = 0.001), and high-energy mechanism (OR 1.81; p = 0.030) were independent predictors associated with delayed union. The RUST score at six-week follow-up was highly predictive of nonunion (sensitivity and specificity of 75%).

Conclusion

NSAID use, high-energy mechanisms, open fractures, and superficial infection were independently associated with nonunion in patients with tibial diaphyseal fractures treated with intramedullary nailing. The six-week RUST score may be useful in identifying patients at risk of nonunion.

Cite this article: Bone Jt Open 2021;2(4):227–235.

The induced membrane technique for bone defects: Basic science, clinical evidence, and technical tips

The clinical management of large bone defects continues to be a difficult clinical problem to manage for treating surgeons. The induced membrane technique is a commonly employed strategy to manage these complex injuries and achieve bone union. Basic science and clinical evidence continue to expand to address questions related to the biology of the membrane and how interventions may impact clinical outcomes. In this review, we discuss the basic science and clinical evidence for the induced membrane technique as well as provide indications for the procedure and technical tips for performing the induced membrane technique.

The diaphyseal aseptic tibial nonunions after failed previous treatment options managed with the reamed intramedullary locking nail

BACKGROUND

The nonunion of open and closed tibial shaft fractures continues to be a common complication of fractures. Tibial nonunions constitute the majority of long bone nonunions seen by orthopaedic surgeons. In this article, we present our approach to the surgical treatment of noninfected tibial shaft nonunions.

METHODS

Between 2008 and 2014, 33 patients with aseptic diaphyseal tibial nonunion was treated by reamed intramedullary nailing and were retrospectively reviewed. The initial fracture management consisted of external fixation (27 patients), plate fixation (2 patients) and cast treatment (4 patients). All patients, preoperatively, were evaluated for the signs of the infection, by the same protocol. There were 13 hypertrophic, 16 oligotrophic (atrophic) and 4 defect nonunions registered in our material. The primary goal was to perform a closed intramedullary nailing on antegrade manner. An open procedure was only unavoidable when implants had to be removed or an osteotomy had to be performed to improve the alignment. Functional rehabilitation was encouraged with the assistance of a physiotherapist early postoperative. Patients were examined regularly during followed-up for a minimum of 12 months period for clinical and radiological signs of union, infection, malunion, malalignment, limb shortening, and implant failure.

RESULTS

The time that elapsed from injury to intramedullary nailing ranged from 9 months to 48 months (mean 17 months).Open intramedullary nailing was unavoidable in 25 cases (75,75%), while closed nailing was performed in 8 patients (24,25%). Osteotomy or resection of the fibula was performed in 78,8% of the cases. All patients were followed up in average period of 2 years postoperative (range 1-4 years), and 31(93,9%) patients achieved a solid union within the first 8 months. Mean union time was 5±0.8 months. Complications included 2 (6,06%) patients, one with deep infection and another case with absence of bone healing. Anatomical alignment has been achieved in the majority of patients, 28 patients (84,8%). The additionally autogenous bone chips were added in 4 patients (12,1%) where cortical defect was greater than 50% of the bone circumference.

CONCLUSION

In conclusion, a reamed intramedullary nail provides optimal conditions for stable fixation, good rotational control, adequate alignment, early weight-bearing and a high union rate of tibial non-unions. Reaming of the medullary canal with preservation of periosteal sleeve create the "breeding ground" for sound healing of tibial shaft nonunions. Additionally cancellous bone grafting is recommended only in the case of defect nonunion.

Outcomes of Presumed Aseptic Long-Bone Nonunions With Positive Intraoperative Cultures Through a Single-Stage Surgical Protocol

OBJECTIVE

To evaluate the outcomes of a single-stage surgical protocol to treat a presumed aseptic long-bone nonunion with positive intraoperative cultures obtained at the time of surgery.

DESIGN

Retrospective comparative series.

SETTING

Orthopaedic specialty hospital.

PATIENTS AND METHODS

We retrospectively identified 77 patients with long-bone nonunions thought to be aseptic preoperatively, which grew bacteria from cultures obtained at the time of index nonunion surgery.

INTERVENTION

Fifty (65%) patients underwent open debridement of the nonunion site followed by surgical stabilization through plates and screws. Twenty-seven (35%) patients underwent exchange nailing with canal reamings used for cultures.

MAIN OUTCOME MEASUREMENT

Rate of radiographic union, time to clinical and radiographic union, nonunion rate after index nonunion surgery, and final union rate after revision procedures.

RESULTS

Osseous union after the index nonunion surgery was achieved in 84% of the patients (65 of 77). Time to clinical union was 6.3 months (range, 1-24 months), and time to radiographic union was 7.4 months (range, 2-24 months). Eighteen percent (14 of 77 patients) did not heal after the index nonunion surgery and required additional surgeries. The final union rate after revision surgery was 99% (76 of 77 patients).

CONCLUSIONS

Eighty-four percent of presumed aseptic nonunions of long-bone fractures with positive intraoperative cultures fully healed after a single-stage surgical protocol and long-term antibiotic when appropriate. When patients are diagnosed with a subclinical infected nonunion, they should be counseled about the higher likelihood of reoperation, but in most cases can expect excellent union rates after 1 additional surgery.

LEVEL OF EVIDENCE

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

[Intramedullary nailing in bifocal leg fractures: about 16 cases]

We conducted a retrospective study of bifocal closed fractures of the tibia in order to assess the severity of this unusual lesion. We analyzed the entry point for intramedullary nailing as well as the different therapeutic options. Sixteen patients with AO type 42C2 bifocal leg fractures were treated in our Traumatology-Orthopedics Unit A at the University Hospital Hassan II, Fez. The subjects were young, victims of medium to high energy trauma. Five subjects were polytraumatized patients and two were poly-traumatized patients with fractures. Six patients underwent locked intramedullary nailing with reaming while seven patients underwent intramedullary nailing without reaming. Two cases of compartment syndrome were recorded after nailing. Mean fracture consolidation time was twelve months. Two cases of pseudarthroses were successfully treated by nailing with reaming. Bifocal leg fractures pose many challenges for the surgeon due to weak vascular supply of the intermediate segment and to severe deterioration of the surrounding soft tissues. They should be detected among the leg fractures based on their context of occurrence, difficulties in fixation as well as slow consolidation time.

Reamed intramedullary exchange nailing in the operative treatment of aseptic tibial shaft nonunion

PURPOSE

The aim of this study was to evaluate a standardized treatment protocol regarding the rate of secondary bone union, complications, and functional outcome.

METHODS

This study was started as a prospective study in a single Level I Trauma Centre between 2003 and 2012. The study group consisted of 188 patients with the diagnosis of an aseptic tibial shaft nonunion. Exchange nailing was performed following a standardized surgical protocol. Long-term follow-up was analyzed for rate of bone healing and functional outcome.

RESULTS

Osseous healing was achieved in 182 out of 188 patients (97 %). In 165 out of 188 patients (88 %), bone healing was observed timely and uneventfully after a single exchange nailing procedure. An open approach was necessary in 32 patients (17 %). Twenty-three patients (12 %) required additional therapy such as extracorporeal shock wave therapy. Post-operative complications were observed in seven patients (4 %). Almost all patients demonstrated osseous healing within 12 months, with the majority of osseous healing occurring within six months. A relevant shortening of the fractured tibia was observed in 20 out of 188 patients (11 %). After a median follow-up of 23 months (range 12-45 months), outcome was evaluated using the assessment system of Friedman/Wyman. In summary, 154 out of 188 patients (82 %) had a good functional long-term result.

DISCUSSION

Reamed intramedullary exchange nailing including correction of axis alignment is a safe and effective treatment of aseptic tibial shaft nonunion with a high rate of bone healing and a good radiological and functional long-term outcome.

Exchange nailing for nonunion of diaphyseal fractures of the tibia

Aims

The aim of this study was to identify risk factors for the failure of exchange nailing in nonunion of tibial diaphyseal fractures.

Patients and Methods

A cohort of 102 tibial diaphyseal nonunions in 101 patients with a mean age of 36.9 years (15 to 74) were treated between January 1992 and December 2012 by exchange nailing. Of which 33 (32%) were initially open injuries. The median time from primary fixation to exchange nailing was 6.5 months (interquartile range (IQR) 4.3 to 9.8 months). The main outcome measures were union, number of secondary fixation procedures required to achieve union and time to union. Univariate analysis and multiple regression were used to identify risk factors for failure to achieve union.

Results

Multiple causes for the primary nonunion were found for 28 (27%) tibiae, with infection present in 32 (31%). Six patients were lost to follow-up. Further surgical procedures were required in 35 (36%) nonunions. Other fixation modalities were required in five fractures. A single nail exchange procedure achieved union in 60/96 (63%) of all nonunions. Only 11 out of 31 infected nonunions (35.4%) healed after one exchange nail procedure. Up to five repeated exchange nailings, with or without bone grafting, ultimately achieved union in 89 (93%) fractures. The median time to union after exchange nailing was 8.7 months (IQR 5.7 to 14.0 months). Univariate analysis confirmed that an oligotrophic/atrophic pattern of nonunion (p = 0.002), a bone gap of 5 mm or more (p = 0.04) and infection (p < 0.001), were predictive for failure of exchange nailing Multiple regression analysis found that infection was the strongest predictor of failure (p < 0.001).

Conclusion

Exchange nailing is an effective treatment for aseptic tibial diaphyseal nonunion. However, in the presence of severe infection with a highly resistant organism, or extensive sclerosis of the bone, other fixation modalities, such as Ilizarov treatment, should be considered. Take home message: Exchange nailing is an effective treatment for aseptic tibial diaphyseal nonunion. Cite this article: Bone Joint J 2016;98-B:534–41.

Results of a systematic approach to exchange nailing for the treatment of aseptic femoral nonunions

OBJECTIVES

To evaluate the radiographic and clinical outcomes of a systematic approach to exchange nailing for the treatment of aseptic femoral nonunions previously treated with an intramedullary nail.

DESIGN

Retrospective cohort.

SETTING

Tertiary referral center.

PATIENTS

Fifty aseptic femoral nonunions in 49 patients who presented with an intramedullary nail in situ an average of 25 months after the initial fracture nailing were evaluated.

INTERVENTION

Our systematic approach includes inserting an exchange nail at least 2 mm larger in diameter than the in situ nail, using a different manufacturer's nail, static interlocking, correction of any metabolic and endocrine abnormalities, and secondary nail dynamization in cases showing slow progression toward healing.

MAIN OUTCOMES MEASUREMENTS

The outcome measures were radiographic and clinical evidence of nonunion healing and time to union.

RESULTS

All 50 femoral nonunions (100%) healed after this systematic approach to exchange nailing. The average time to achieve union was 7 months (range, 3-26 months).

CONCLUSIONS

Utilization of this systematic approach of exchange nailing for the treatment of aseptic femoral nonunions resulted in a 100% healing rate.

LEVEL OF EVIDENCE

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

Results of a systematic approach to exchange nailing for the treatment of aseptic tibial nonunions

OBJECTIVES

The purpose of this study was to evaluate the effectiveness of a systematic approach to exchange nailing for the treatment of aseptic tibial nonunion.

DESIGN

Retrospective cohort.

SETTING

Tertiary referral center.

PATIENTS

Forty-six aseptic tibial nonunion sites in 40 patients (2 bilateral and 4 segmental) who presented with an intramedullary nail on an average of 16 months after the initial treatment were presented in this study.

INTERVENTION

Insertion of an exchange nail of at least >2-mm diameter than the prior nail using a different manufacturer's nail, static interlocking, partial fibulectomy in a select group of patients, and correction of underlying metabolic and endocrine abnormalities.

MAIN OUTCOME MEASUREMENTS

Union rate, time to union.

RESULTS

Forty-five of 46 tibial nonunion sites (98%) healed at an average of 4.8 months.

CONCLUSIONS

Patient selection criteria and a systematic approach to exchange nailing for tibial nonunion is highly successful.

LEVEL OF EVIDENCE

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

A single-stage treatment protocol for presumptive aseptic diaphyseal nonunions: a review of outcomes

OBJECTIVE

To review the results of a single-stage treatment protocol for presumptive aseptic diaphyseal nonunion with a well-healed wound and no infection history.

DESIGN

Retrospective comparative study.

SETTING

Tertiary referral center.

PATIENTS AND METHODS

We retrospectively reviewed all presumptive aseptic diaphyseal nonunions treated by a single-stage protocol. There were 104 patients who met the inclusion criteria. Eighty-seven patients were available for follow-up through to complete healing (83.7% follow-up rate).

INTERVENTION

The protocol entails withholding preoperative antibiotics, removing the implant, performing open debridement or canal reaming, taking 5 cultures of the nonunion site or canal reamings, followed by antibiotic administration, and revision open reduction and internal fixation or exchange nailing. If intraoperative cultures are positive, long-term antibiotics are begun specific to organism sensitivities.

MAIN OUTCOME MEASUREMENTS

To analyze the rate of positive cultures and to compare the rate of secondary surgery to promote healing in positive and negative culture groups.

RESULTS

Intraoperative cultures were positive in 28.7% (25/87) of patients with complete follow-up. The overall rate of secondary surgery for persistence of nonunion was 12.6% (11/87). In patients with positive intraoperative cultures, rate of secondary surgery was 28% (7/25) versus 6.4% (4/62) in the group without positive intraoperative cultures (P = 0.01).

CONCLUSION

A single-stage treatment protocol for presumptive aseptic diaphyseal nonunions was effective in obviating further revision surgery in 93.6% of truly aseptic cases and in 72% of positive culture cases and is still employed at our institution.

Exchange reamed nailing compared to augmentation compression plating leaving the inserted nail in situ in the treatment of aseptic tibial non-union: a two-centre study

BACKGROUND

A remarkable number of investigations are available treating tibial non-unions by exchange reamed nailing (ERN). Only few authors reported positive results after augmentation compression plating (ACP) for the same entity. To our knowledge no systematic study is published comparing ERN vs. ACP, so that this trial compares ACP leaving the already inserted un-reamed nail in situ against ERN in the treatment of aseptic tibial non-union, analysing success rate, time for union and operation time.

PATIENTS AND METHODS

Forty-eight patients with aseptic hypertrophic diaphyseal tibial non-union treated previously by un-reamed nailing were included retrospectively in this two-centre study. Group A consisted of 25 patients with ERN and group B of 23 patients with ACP leaving the underlying un-reamed nail in situ.

RESULTS

Mean follow-up was 3.8 years. Union was achieved in 24 out of 25 cases (96 %) for group A and in 22 out of 23 cases (95.6 %) for group B. Time needed for union varied; an average of 29 weeks for group A and 14 weeks for group B. The mean operation time for group A was 99 min, while it was 65 min for group B.

CONCLUSIONS

ERN and ACP with remaining pre-existing nail in situ are both safe and straightforward surgical procedures with equivalent high success rates of about 95 %. ACP has the advantage of less time for union and operating time in this series, but is associated with the disadvantage of requiring an additional incision and complaints associated to the plate requiring implant removal.

High success rate for augmentation compression plating leaving the nail in situ for aseptic diaphyseal tibial nonunions

OBJECTIVES

To evaluate adjunctive compression plating leaving the previously unreamed inserted intramedullary nail (URIMN) in situ for treating a resultant diaphyseal tibial nonunion.

DESIGN

Retrospective study.

SETTING

Level 1 trauma center (University Hospital).

PATIENTS/PARTICIPANTS

Patients treated by URIMN for diaphyseal tibial fractures that developed an aseptic hypertrophic nonunion.

INTERVENTION

Dynamization of the nail and compression plating leaving the URIMN in situ.

MAIN OUTCOME MEASUREMENTS

Radiographic and clinical parameters.

RESULTS

The mean follow-up was 3.8 years (range 2-7 years). Mean time for healing was 15 weeks with a mean operation time of 63 minutes. Union occurred in 27/28 (96.4%). There were no infections.

CONCLUSIONS

This simple technique seems to have a high success rate and should be considered when a nonunion occurs after URIMN. The need for an additional incision and removal of symptomatic implants remains a disadvantage.

LEVEL OF EVIDENCE

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

Single-stage surgical treatment of infected nonunion of the distal tibia

OBJECTIVE

An infected nonunion of the distal tibia after plating is uncommon, and the traditional methods for its treatment have unique disadvantages (time-consuming and patient discomfort being great). A single-stage surgical technique was developed to improve the outcome in this situation.

DESIGN

Retrospective.

SETTING

University hospital.

PATIENTS AND METHODS

We treated 25 consecutive adult patients with 25 infected nonunions of the distal tibia after plating. The inclusion criteria consisted of infected nonunions of the distal tibia with an intact ankle space and a plate in situ. The surgical technique used with all participants called for the removal of all implants, intra-/extramedullary débridement, and placement of cancellous bone graft and antibiotics (vancomycin and gentamicin) followed by the application of an Ilizarov external fixator. Postoperatively, patients ambulated early with protected weightbearing and performed range-of-motion exercises of the ankle.

RESULTS

Twenty-two patients were followed up for at least 2 years (range, 2.0-4.5 years; median, 3.2 years). All infected nonunions healed without recurrence of infection. The median time to union was 4.5 months (range, 3.5-6.0 months). Eighteen cultures had single bacterial flora, whereas five cultures had mixed flora. Two cultures showed no growth of microorganisms. All bacteria were sensitive to vancomycin or gentamicin. Methicillin-resistant Staphylococcus aureus (13 of 25) and methicillin-sensitive S. aureus (seven of 25) were the most commonly detected microorganisms. Patients' ankle function improved with "satisfactory" grades increasing from 0% preoperatively to 86% postoperatively (P < 0.001).

CONCLUSIONS

This single-stage surgical technique had a high success rate with significant reduction in patient discomfort during the course of treatment. However, further revision of the technique may be necessary to ensure high success rates in further series.

Autologous bone graft: when shall we add growth factors?

Although the unquestionable value of autologous bone grafting and the analogous value of the reaming by-products in nonunion treatment have been mentioned extensively in the literature, there is ongoing vivid discussion for the treatment of those case scenarios where the fracture nonunion is complicated by other local environment adverse circumstances. The graft expansion with growth factors as the bone morphogenetic proteins (BMPs) offers the possibility to reduce the number of operative procedures, complications, length of hospital stay, and time to union. In this article, we consider the potential clinical scenarios for graft expansion with BMPs.

Extracorporeal shock wave therapy: current evidence

OBJECTIVES

The aim of this article is to provide a concise review of the basic science of extracorporeal shock wave therapy (ESWT) and to perform a systematic review of the literature for the use of ESWT in the treatment of fractures and delayed unions/nonunions.

DATA SOURCES

Articles in the English or German language were identified for the systematic review by searching PubMed-MEDLINE from 1966 until 2008, Cochrane Database of Systematic Reviews, Cochrane Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, and relevant meeting abstracts from 2007 to 2008. Moreover, the bibliographies of the identified articles were reviewed.

STUDY SELECTION

We included clinical outcome studies of ESWT in the treatment of fractures and delayed unions/nonunions. Reports with less than 10 patients were excluded. Nonunions after corrective osteotomies or arthrodeses were excluded.

DATA EXTRACTION

Sample size, level of evidence, definition of delayed union, definition of nonunion, time from injury to shock wave treatment, location of fracture, union rate, and complications were extracted from the identified articles.

DATA SYNTHESIS

Data of 924 patients undergoing ESWT for delayed union/nonunion were extracted from 10 studies. All articles were graded as level 4 studies. The overall union rate was 76% (95% confidence interval 73%-79%). The union rate was significantly higher in hypertrophic nonunions than in atrophic nonunions.

CONCLUSION

Data from level 4 studies suggest that shock wave therapy seems to stimulate the healing process in delayed unions/nonunions. However, further investigations are required.

Autologous bone graft: when shall we add growth factors?

Although the unquestionable value of autologous bone grafting and the analogous value of the reaming by-products in nonunion treatment have been mentioned extensively in the literature, there is ongoing vivid discussion for the treatment of those case scenarios where the fracture nonunion is complicated by other local environment adverse circumstances. The graft expansion with growth factors as the bone morphogenetic proteins (BMPs) offers the possibility to reduce the number of operative procedures, complications, length of hospital stay, and time to union. In this article, we consider the potential clinical scenarios for graft expansion with BMPs.

Central bone grafting for nonunion of fractures of the tibia

Nonunion of the tibia associated with bone loss, previous infection, obliteration of the intramedullary canal or located in the distal metaphysis poses a challenge to the surgeon and significant morbidity to patients. We retrospectively reviewed the records of 24 patients who were treated by central bone grafting and compared them to those of 20 who were treated with a traditional posterolateral graft. Central bone grafting entails a lateral approach, anterior to the fibula and interosseous membrane which is used to create a central space filled with cancellous iliac crest autograft. Upon consolidation, a tibiofibular synostosis is formed that is strong enough for weight-bearing. This procedure has advantages over other methods of treatment for selected nonunions.

Of the 24 patients with central bone grafting, 23 went on to radiographic and clinical union without further intervention. All healed within a mean of 20 weeks (10 to 48). No further bone grafts were required, and few complications were encountered. These results were comparable to those of the 20 patients who underwent posterolateral bone grafting who united at a mean of 31.3 weeks (16 to 60) but one of whom required below-knee amputation for intractable sepsis.

Central bone grafting is a safe and effective treatment for difficult nonunions of the tibia.

Treatment of diaphyseal nonunion of the femur and tibia using an expandable nailing system

INTRODUCTION

We evaluated the efficacy of the expandable nailing system for treating femur and tibia shaft nonunions.

PATIENTS AND METHODS

Records of 24 patients (25 fractures) were retrospectively reviewed: 16 with femur and 8 with tibia nonunions. The bones underwent reaming, and the largest possible nail sizes were inserted during re-operation. Bone debris obtained from the reaming was used for bone graft at the site of the nonunion.

RESULTS

The mean age of the patients was 32 years for the tibia group and 49 years for the femur group. The respective intervals between trauma and re-operation were 11 and 13 months, the operation times 60 and 78 min, and the fluoroscopy times 21 and 32s. Twenty-four of the 25 nonunions healed satisfactorily without requiring additional procedures. In 1 case, demineralised bone matrix was injected percutaneously and the femoral nonunion resolved. Healing time was 23 weeks (6-52) and 17 weeks (6-40) in the tibia and femur groups, respectively. We were able to reduce the need of an autologous bone graft to only two cases by using reamed debris in 17 of the 19 patients who required grafting.

CONCLUSIONS

Our results demonstrated satisfactory healing for the treatment of diaphyseal nonunions of the femur and tibia. The expandable nail offers the theoretical advantages of improved load sharing and rotational control without the need for interlocking screws. We recommend expandable nail systems for femur and tibia shaft nonunions and the use of reamed debris in order to decrease the use of autogenous bone graft.

Limb lengthening and then insertion of an intramedullary nail: a case-matched comparison

Distraction osteogenesis is an effective method for lengthening, deformity correction, and treatment of nonunions and bone defects. The classic method uses an external fixator for both distraction and consolidation leading to lengthy times in frames and there is a risk of refracture after frame removal. We suggest a new technique: lengthening and then nailing (LATN) technique in which the frame is used for gradual distraction and then a reamed intramedullary nail inserted to support the bone during the consolidation phase, allowing early removal of the external fixator. We performed a retrospective case-matched comparison of patients lengthened with LATN (39 limbs in 27 patients) technique versus the classic (34 limbs in 27 patients). The LATN group wore the external fixator for less time than the classic group (12 versus 29 weeks). The LATN group had a lower external fixation index (0.5 versus 1.9) and a lower bone healing index (0.8 versus 1.9) than the classic group. LATN confers advantages over the classic method including shorter times needed in external fixation, quicker bone healing, and protection against refracture. There are also advantages over the lengthening over a nail and internal lengthening nail techniques.

LEVEL OF EVIDENCE

Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Treatment of femoral and tibial diaphyseal nonunions using reamed intramedullary nailing without bone graft

INTRODUCTION

Intramedullary nailing has long been used successfully in the treatment of aseptic nonunions of the femur and tibia. However, recently the efficacy of reamed intramedullary nailing in the treatment of nonunions of the femur has been questioned by some publications reporting unfavourable results. The purpose of this study is to evaluate the treatment results of femoral and tibial diaphyseal nonunions with intramedullary nailing.

PATIENTS AND METHODS

We retrospectively reviewed thirty-two patients with femoral or tibial diaphyseal nonunions who were treated with reamed intramedullary nailing between May 2002 and April 2006. Fixation status at the time of treatment were nail in twenty-eight patients (12 femurs, 16 tibiae), plate in three cases (2 femurs, 1 tibia), no implant in one femur. We used a dynamically locked, reamed intramedullary nailing. Only in bone defects greater than 50% of the cortical diameter and more than 2 cm in length was open bone grafting performed.

RESULTS

Solid union was achieved in 93% (fourteen of fifteen) of femoral nonunions and 94% (sixteen of seventeen) of tibial nonunions.

CONCLUSIONS

Our protocol with a dynamically locked, reamed nailing with the use of an oval hole and no open bone grafting for a defect less than 50% of the diameter and immediate weight bearing was successful in the treatment of femoral and tibial diaphyseal nonunions.

Outcomes of tibial nonunion in older adults following treatment using the Ilizarov method

OBJECTIVES

To describe the functional outcomes of treatment using the Ilizarov method for tibial nonunions in older patients (>60 years of age).

DESIGN

Prospective case series.

SETTING

Tertiary referral center.

PATIENTS

Twenty-three consecutive patients with an average age of 72 years (61 to 92) who had tibial nonunions for an average duration of 13 months (3 to 46). Fourteen patients had an associated deformity and eight patients had infection.

INTERVENTION

Ilizarov deformity correction, compression, or bone transport.

MAIN OUTCOME MEASUREMENTS

Brief Pain Inventory, American Academy of Orthopaedic Surgeons (AAOS) Lower Limb Core Scale, Short Form (SF)-12, quality-adjusted life years.

RESULTS

Three patients did not complete treatment: two patients died of cardiovascular disease during the treatment period and one patient demanded early removal of the Ilizarov device against medical advice. All 20 patients who completed treatment achieved bony union. Two of the 20 patients died before final follow-up, one patient was unable to participate in follow-up, and one patient was lost. At an average follow-up of 38 months (18 to 61), all of the remaining 16 patients were bearing full weight. AAOS Lower Limb Core Scale scores improved from 39 to 78 points (P < 0.001), pain intensity decreased from 3.6 to 0.9 (P = 0.001), SF-12 Physical Component Summary scores improved from 26.5 points to 35.3 points (P = 0.030), and SF-12 Mental Component Summary scores improved from 41.6 points to 48.7 points (P = 0.011). The improvement in quality of life is equivalent to 5.3 quality-adjusted life years per patient, which was larger than the average improvement in quality of life following total hip arthroplasty reported in published series.

CONCLUSIONS

Treatment using the Ilizarov method restored function and had a profoundly positive effect on quality of life in these elderly patients with tibial nonunions.

Speeded gradual lengthening and secondary angled blade plate stabilisation for proximal tibial shaft non-union with shortening

Eighteen patients with proximal tibial shaft non-union and shortening were treated. In each patient, the non-union area was débrided, realigned and stabilised with an Ilizarov lengthening frame. The tibia was gradually lengthened by 1-1.5 mm per day. After achieving the desired length, external fixation was converted to an angled blade plate and packed with cancellous bone graft. Follow-up of 16 patients for a median of 2.4 (1.2-4.5) years revealed satisfactory outcomes in all. No wound infections were noted. The described technique has a high success rate, a short treatment course and reduces patient discomfort. This method may be considered preferential treatment for all patients with the specified indications.

Biological enhancement of tibial diaphyseal aseptic non-unions: the efficacy of autologous bone grafting, BMPs and reaming by-products

The mandatory stimulus that can optimise the healing pathway can be electrical, mechanical, biological, or a combination of all these parameters. A variety of means has been utilised for biological enhancement, including extracorporeal shock wave, electrical, ultrasound stimulation, the reaming technique of IM nailing, bone graft substitutes, osteogenic cells and bioactive molecules produced by tissue engineering techniques. The aim of this study is to present a review of the existing evidence for the efficacy of reaming, autologous bone grafting and the commercially available growth factors (BMP-2 and BMP-7) for the treatment of aseptic tibial non-unions. The gold standard method of enhancing bone healing in cases of tibial non-union remains the autologous bone graft. Autogenous bone grafts possess osteoconductive, osteoinductive properties and also osteoprogenitor cells. However, their harvesting is associated with high morbidity and many complications reaching percentages of 30%. Intramedullary reamed nailing, either used as an alternative fixation method or as an exchange to a wider implant, offers the unique biomechanical advantages of an intramedullary device, together with the osteoinductive stimulus of the by-products of reaming, and the aptitude for early weight-bearing and active rehabilitation. The safety of administration of the commercial distributed growth factors (BMP-2 and BMP-7), combined with the lack of the morbidity and the quantity restrictions that characterise autologous bone grafts, have given to this family of molecules a principal role between the other bone graft substitutes. On average the union rates reported in the 20 manuscripts that have been evaluated range from 58.3% to 100%, and the average time to union from 12.5 weeks to 48.4 weeks, indicating the significant discrepancies in the reported evidence and the multiplicity of different treatment strategies.

Exchange nailing of ununited fractures

Exchange nailing is most appropriate for a nonunion without substantial bone loss. There is no clear consensus regarding the use of exchange nailing in the presence of active, purulent infection. The exchange nail should be at least 1 mm larger in diameter than the nail being removed, and it has been recommended that it be up to 4 mm larger when the nail being removed was greatly undersized. Canal reaming should progress until osseous tissue is observed in the reaming flutes. Exchange nailing is an excellent choice for aseptic nonunions of noncomminuted diaphyseal femoral fractures, with union rates reported to range from 72% to 100%. On the basis of the available literature, exchange nailing cannot be recommended for distal femoral nonunions at this time. Exchange nailing is an excellent choice for aseptic nonunions of noncomminuted diaphyseal tibial fractures, with union rates reported to range from 76% to 96%. On the basis of the available literature, exchange nailing is generally not indicated for humeral nonunions.

Exchange nailing of ununited fractures

Exchange nailing is most appropriate for a nonunion without substantial bone loss. There is no clear consensus regarding the use of exchange nailing in the presence of active, purulent infection. The exchange nail should be at least 1 mm larger in diameter than the nail being removed, and it has been recommended that it be up to 4 mm larger when the nail being removed was greatly undersized. Canal reaming should progress until osseous tissue is observed in the reaming flutes. Exchange nailing is an excellent choice for aseptic nonunions of noncomminuted diaphyseal femoral fractures, with union rates reported to range from 72% to 100%. On the basis of the available literature, exchange nailing cannot be recommended for distal femoral nonunions at this time. Exchange nailing is an excellent choice for aseptic nonunions of noncomminuted diaphyseal tibial fractures, with union rates reported to range from 76% to 96%. On the basis of the available literature, exchange nailing is generally not indicated for humeral nonunions.

Tibial nonunion

Nonunions of the tibia represent challenging orthopedic problems, which require the surgeon to analyze numerous factors and choose an appropriate treatment. Tibial nonunion treatment requires establishing its existence and cause. The treatment algorithm necessitates consideration of a wide variety of factors: the location of the nonunion, the presence or absence of infection, and any angular or rotational deformity. Given advances in implant design and biologic agents, a wide variety of management options exist for the treatment of tibial nonunions. This article reviews surgical treatments for tibial nonunions.

Exchange reamed nailing for aseptic nonunion of the tibia

BACKGROUND

Exchange reamed nailing of the tibia is a common procedure in the treatment of an aseptic tibial nonunion. However, reports in the literature supporting this technique are limited.

METHODS

Forty patients with a tibial nonunion after initial unreamed intramedullary nailing were retrospectively assessed after an exchange reamed nailing. The main outcome measurements included radiographic and clinical union as well as time from exchange reamed nailing to union.

RESULTS

Thirty-eight patients achieved union of their fracture (95%). The average time from exchange nailing to union was 29 +/- 21 weeks. Complications included one deep vein thrombosis (2.5%) and two hardware failures (5%).

CONCLUSION

Exchange reamed nailing for nonunions of the tibia results in a high union rate and is associated with a low complication rate. This technique is recommended as a standard procedure for aseptic tibial nonunions after initial unreamed intramedullary nailing.

Augmentative Ilizarov external fixation after failure of diaphyseal union with intramedullary nailing

OBJECTIVE

To investigate the use of the Ilizarov circular fixator and nail retention in treating diaphyseal nonunion following previous intramedullary nailing.

DESIGN

Retrospectively reviewed, consecutive series. Mean duration of follow-up after achieving bone union: 19.2 months (range 6 to 33 months).

SETTING

A tertiary referral center for nonunion surgery.

PATIENTS

Nine patients (two femoral, three tibial, and four humeral nonunions) were included in the study. All patients were referred from other centers after failure to achieve union with intramedullary nailing. Patients who had nonunion with other fixation devices in situ, those with active infection and nonunion following nonoperative treatment, were excluded from the study. The patients had undergone an average of 2.4 operations (range 1 to 5 operations) before application of the Ilizarov fixator. All patients completed the study.

INTERVENTION

The circular fixator was used to compress the nonunion site from without, retaining the intramedullary nail in each case. We excluded a patient who had his nonunion site explored followed by bone excision and transport. The mean duration of fixator treatment was 6.2 months (3 to 11 months).

MAIN OUTCOME MEASUREMENTS

Clinical and x-ray evidence of bone union, infection, residual deformity, shortening, and assessment of functional outcome.

RESULTS

Bone union was achieved in all nine patients using the circular fixator over the nail. The bone results were graded as six excellent, one good, and two fair. All patients reported a reduction in pain and satisfaction with their final outcome.

CONCLUSIONS

There is a role for the use of the Ilizarov fixator with nail retention in resistant long bone diaphyseal nonunion in carefully selected patients. This method can achieve high union rates where other treatment methods have failed.