Nonunion and shortening after femoral fracture treated with one-stage lengthening using locked nailing technique. Good results in 48/51 patients

Chipping and lengthening over nailing technique for femoral shaft nonunion with shortening

PURPOSE

Chipping and lengthening over nailing (CLON) technique was developed to treat femoral shaft nonunion with shortening more than 10 mm. The purpose of the current retrospective case series was to clarify the effectiveness of the CLON technique on the femoral shaft nonunion following intramedullary nailing.

METHODS

Clinical and radiological outcomes in the patients receiving operative treatment for femoral shaft nonunion between August 2012 and December 2016 were retrospectively reviewed using the Refractory Fracture Data Registry at the authors' institution. The CLON technique was indicated for patients with the femoral shaft nonunion with shortening more than 10 mm.

RESULTS

Five patients with median follow-up of 32 months (range, 14 to 50 months) were included in this study. All patients achieved bone union at the median of 8 months after the CLON technique. The median limb length discrepancy was 2.0 mm at the most recent follow-up.

CONCLUSIONS

The present study demonstrated that the CLON technique for femoral shaft nonunion may be the first choice as operative treatment for femoral shaft nonunion with shortening more than 10 mm.

Combined tibial lengthening and ankle arthrodesis for patients with certain type of sequelae of poliomyelitis

PURPOSE

Following far advancement of modern medicine and technology, functional disability in a certain type of sequelae of poliomyelitis may be effectively improved.

METHODS

Eight consecutive adult patients with unilateral sequelae of poliomyelitis were treated. These patients had shortened lower extremity of an average of 4.8 cm (range, 4.0-5.5 cm) in the lesion side. Muscle power of the ipsilateral knee was nearly intact (grade 4 or 5) but the ankle extension was completely flaccid. The tibia was osteotomized and lengthened with external fixation. Consequently, all external fixators were converted to plates supplemented with autogenous corticocancellous bone graft and bone graft substitute. Ankle arthrodesis was performed concomitantly.

RESULTS

Seven patients were followed up for an average of 3.7 years (range, 2.2-5.4 years). All seven lengthened sites healed with an average union time of 3.9 months (range, 3.5-4.5 months) after plating. One ankle infection occurred. Gait function significantly improved by modified Mazur scoring evaluation ( p = 0.02). At the latest follow-up, all patients had a minimal or unnoticed limp in level walking.

CONCLUSION

The described combined techniques may be an excellent alternate for treating selected patients with sequelae of poliomyelitis. The procedure is not complex but the efficiency is extremely prominent.

A novel approach for evaluating acceptable intra-operative correction of lower limb alignment in femoral and tibial malunion using the deviation angle of the normal contralateral knee

BACKGROUND

A simple and appropriate approach for evaluating an acceptable alignment of bone around the knee during operation has not yet been reported.

METHODS

Thirty-five men and 35 women presenting with nonunion or malunion of the unilateral femoral shaft were included in the first study. Using the standing scanograph, the contralateral normal lower extremity was measured to determine the normal deviation angle (DA) of the medial malleolus when the medial aspect of the knee was placed in the midline of the body. In the second study, the normal DA from individual patients was used as a reference to evaluate knee alignment during operation in 40 other patients presenting with distal femoral or proximal tibial nonunion or malunion. The clinical and knee functional outcomes of these 40 patients were investigated.

RESULTS

The average normal DA was 4.2° in men and 6.0° in women (p<0.001). Thirty-four of the 40 patients presenting with disorders around the knee were followed up for an average of 3.6 years (range, 1.1-6.5 years). Thirty fractures healed with a union rate of 88% and an average union period of 4.2 months (range, 2.5-6.5 months). Ideal knee alignment was maintained in all 30 patients with fracture union. Satisfactory function of the knee was achieved in 28 patients (82%, p<0.001).

CONCLUSIONS

Using a normal DA as a reference may be a feasible and effective technique for evaluating an acceptable alignment of bone around the knee during operation.

LEVELS OF EVIDENCE

Level IV, Case series.

External fixator followed by a plate for distraction, reduction, and fixation in neglected femoral diaphyseal fractures

INTRODUCTION

This study aims to investigate the outcome of a two-stage surgery in the treatment of neglected femoral diaphyseal fractures which are not uncommon in developing nations.

PATIENTS AND METHODS

Ten patients with neglected or late-presenting femoral diaphyseal fractures were considered in this study. All patients underwent a two-stage surgery, which consisted of distraction by an external fixator and open reduction by internal plate fixation. All patients received a supervised regimen of physiotherapy. Patients were followed up clinically and with radiographs at 2 months to assess union and at monthly intervals thereafter.

RESULTS

All patients achieved bony union in an average of 3.7 months (2-6 months) with no one lost follow-up. Seven patients regained full range of motion, and the mean knee range of motion was 139.5°. No wound related or neurovascular complications were detected. One patient with stiff knee was re-admitted 1 year after surgery for metal removal, arthrolysis and quadricepsplasty for improving knee range of motion to 90° flexion.

CONCLUSIONS

We conclude that the treating of neglected femoral diaphyseal fractures with a two-stage surgery is a satisfactory therapy showing reliable bony union, however continuing medical education is necessary for physicians in primary medical facilities as well as for patients with traditional views.

Locked plating for proximal humeral fractures: differences between the deltopectoral and deltoid-splitting approaches

BACKGROUND

Locking proximal humerus plate (LPHP) fixation has recently become available for the treatment of proximal humeral fractures. However, the preliminary results were contradictory. The technical requirements for success when using LPHP remain to be defined. Maybe the approach to the proximal humerus plays an important role, not the implants. We analyzed two surgical approaches to proximal humeral fractures.

METHODS

Between April 2004 and October 2007, 63 consecutive patients with displaced proximal humeral fractures who underwent LPHP osteosynthesis in our institute were classified to two treatment groups retrospectively: the deltopectoral incision and the deltoid-splitting incision according to surgeon's preference. The Constant and Disabilities of the Arm, Shoulder and Hand scores were recorded for clinical assessment. Quality of reduction, fracture union, and radiographic complications were recorded for radiographic assessment. Electrophysiological abnormalities were also assessed.

RESULTS

There were no significant differences between the groups with regard to demographic data, preoperative radiographic findings, and duration of follow-up. There were also no significant differences between the groups with regard to operative time (p = 0.918), blood loss (p = 0.407), hospital stay (p = 0.431), postoperative head-shaft angle (p = 0.769), union time (p = 0.246), final head-shaft angle (p = 0.533), Constant score (p = 0.677), Disabilities of the Arm, Shoulder and Hand score (p = 0.833), radiographic complications (p = 1.000), and presence of electrophysiological abnormalities (p = 0.296). Avascular necrosis of the humeral head was found in three patients, all of whom in the deltopectoral approach group.

CONCLUSION

We found no statistically significant difference in clinical, radiographic, and electrophysiological outcomes between the deltopectoral approach and deltoid-splitting approach while surgical treatment of proximal humeral fractures.

Reverse LISS plates for unstable proximal femoral fractures

The best treatment for unstable proximal femoral fractures is controversial. In this prospective study, we assessed the outcomes of reverse less invasive stabilisation system (LISS) plates for treatment of unstable proximal femoral fractures that are expected to be difficult to nail. From April 2004 to January 2007, 20 patients with unstable proximal femoral fractures that were assessed to be difficult to nail were managed with reverse less invasive stabilisation system-distal femur (LISS-DF) plates, which included (1) subtrochanteric fractures with extension into the piriform fossa, (2) short skeletons with narrow femoral canals, (3) adolescents with open physes and (4) severely bowed or deformed femurs. These patients were enrolled in this study. There were 11 females and nine males, with a median age of 58 years (range, 14-95 years). The average follow-up period was 24 (range, 12-32) months. Functional recovery (Parker and Palmer mobility score), pain, bony union, varus deformity, implant failure and leg length discrepancy were assessed. The fractures united at a median of 7 months (range, 3-15 months) postoperatively. Parker and Palmer mobility scores were 9 points for 17 patients and 6 points for three patients. Pain was absent in 15, mild in three, and moderate in two patients. Patients with poor quality of reduction were more likely to have pain results (p=0.009). Although patients with advanced age were not more likely to have pain results, they were more likely to have 'delayed union' radiographic results (p=0.033). Two limbs were shortened by 1.5 and 2 cm, respectively. Reverse LISS plate fixation led to complete union of unstable proximal femoral fractures without additional procedures. The surgical technique was simple and safe. We recommend considering the use of this locked-plate device as the alternative management of unstable proximal femoral fractures that are unsuitable for nailing procedures.

Exchange nailing for aseptic nonunion of femoral shaft: a retrospective cohort study for effect of reaming size

BACKGROUND

Exchange nailing has been the favored method to treat aseptic nonunions of the femoral shaft. The recommended amount of over-reaming is at least 2 mm. The purpose of this study was to determine whether the effectiveness of nonunion treatment is greatly reduced with less than 2 mm of over-reaming.

METHODS

Aseptic nonunions of the femoral shaft were treated by exchange nailing with 1 mm (n = 37) or at least 2 mm (n = 44) of over-reaming. Union rates, union periods, and complications were compared. Indications for exchange nailing were aseptic nonunions of the femoral shaft with an inserted intramedullary nail, shortening of less than 1.5 cm, and a fracture gap of less than 5 mm.

RESULTS

After a mean follow-up of 3.6 years (range, 1.1-7.1 years), union rates were 31 (91.2%) of 34 nonunions with over-reaming of 1 mm and 37 (92.5%) of 40 nonunions with over-reaming of 2 mm or more (p = 0.32). The mean union periods were 4.4 months (range, 2.5-8 months) and 4.4 months (range, 3-8 months), respectively (p = 0.83). Except for persistent nonunions, no significant complications occurred.

CONCLUSIONS

Exchange nailing can be considered the first choice to treat aseptic nonunions of the femoral shaft. The diameter of the new intramedullary nail should be as large as possible to reinforce the mechanical strength of the repair. The osteogenic potential stimulated by the reaming of cancellous bone graft was similar with over-reaming of 1 mm and with over-reaming of 2 mm or more.

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.

Treatment of femoral nonunions by using cyclic compression and distraction

Eleven patients with femoral diaphyseal nonunions after intramedullary nailing were treated with cyclic compression and distraction with an external fixator over the nail. We evaluated the limitations of this technique and whether patients having this closed procedure could achieve union without additional operative procedures. Patients with hypertrophic nonunions (n = 4) were treated with gradual compression of the nonunion site. Cyclic compression and distraction was done in patients with oligotrophic (n = 2) or atrophic nonunions (n = 5) to stimulate consolidation. The average age of the patients was 32.9 years (range, 21-48 years), and the average followup was 40.5 months (range, 24-64 months). Union was achieved in an average of 5.8 months in all patients after one operation and without additional surgical intervention. However, pain necessitating strong analgesic agents and pin-related complications consisting of osteomyelitis, septic arthritis, and pin breakage in the atrophic nonunion group were a major limitation of this technique. Based on our study, the cyclic compression and distraction technique can be used in hypertrophic and oligotrophic nonunions that have failed one or more prior exchange nailings. However, it might not be an option for treatment of patients with atrophic nonunions unless pin-site problems are resolved.

LEVEL OF EVIDENCE

Therapeutic study, Level IV (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

Treatment of femoral shaft aseptic nonunion associated with broken distal locked screws and shortening

BACKGROUND

This retrospective study investigated the treatment of femoral shaft aseptic nonunions associated with broken distal locked screws and shortening.

METHODS

In this study, 11 femoral shaft aseptic nonunions associated with both broken distal locked screws and shortening in 11 consecutive adult patients were treated. All nonunions were associated with at least 1.5 cm (range, 1.5-3.5 cm) shortening. These nonunions were treated by removal of locked nails, one-stage femoral lengthening, static locked nail stabilization, and corticocancellous bone graft supplementation. Postoperatively, ambulation with protected weightbearing was encouraged as early as possible.

RESULTS

Ten nonunions were followed up for a median of 4.1 years (range, 1.8-5.5 years), and nine fractures healed at a median of 4 months (range, 3-6 months). The nonunion case had broken locked screws again at 5 months and was treated with exchange nailing. The fracture healed uneventfully at 4 months. No other complications occurred.

CONCLUSIONS

The key to removal of broken screws is withdrawal of the nail slightly to release the incarcerated broken screw end. The screw end then is pushed out with a used Knowles' pin or a smaller screwdriver under image intensifier guidance. Concomitant one-stage femoral lengthening to treat nonunion with shortening has a high success rate.

One-stage lengthening using a locked nailing technique for distal femoral shaft nonunions associated with shortening

OBJECTIVE

To assess the effectiveness of a one-stage lengthening using a locked nail technique for the treatment of distal femoral shaft nonunions associated with shortening.

DESIGN

Retrospective.

SETTING

University hospital.

PATIENTS AND METHODS

During a 6-year period, 36 distal femoral shaft nonunions associated with shortening (>1.5 cm) were treated by the one-stage lengthening technique. Indications for this technique were distal femoral shaft aseptic or quiescent infected nonunions, 1.5-5 cm shortening, and a fracture level suitable for the insertion of two distal locked screws. The surgical technique involved skeletal traction using the femoral condyle, local débridement, lengthening by <or=4 cm aided by a laminar spreader, insertion of a static locked nail, and grafting of corticocancellous bone. Mize's classification for clinical function was used for final patient evaluation.

RESULTS

A total of 32 nonunions were followed-up for at least 1 year (median 3.8 years; range 1.2-6.9 years), and 29 fractures healed. The median union period was 4.5 months (range 3-6 months). Three fractures persistently failed to heal. One was treated successfully with exchange nailing, and the remaining two patients were followed annually and had no symptoms. At the latest follow-up, all 32 patients had achieved a satisfactory outcome. The average lengthening was 2.5 cm (range 1.5-3.5 cm).

CONCLUSIONS

One-stage lengthening using the locked nailing technique to treat distal femoral shaft nonunions associated with shortening can achieve a high success rate and low complication rate. The key to successful treatment is the patient's complete cooperation with strictly protected weight bearing until the fracture has healed.