ReviewDiagnostic and treatment modalities in nonunions of the femoral shaft. A review
Introduction
Despite the advances in trauma care, improved surgical techniques, newer implants and the evolution of new adjuvants to healing, biologic agents, nonunions still occur and are often a result of a high energy initial trauma. Femoral nonunion represents a serious socioeconomic problem for the patient, associated with prolonged patient morbidity, gait abnormality, inability to return to work, re-operations and psycho-emotional impairment. It moreover stands for a treatment challenge for the orthopaedic surgeon, having to take factors into consideration such as different treatment modalities, deformity correction, treatment of infection and rapid rehabilitation of the patient.
Winquist–Hansen classification of femoral shaft fractures system takes into consideration the extend of comminution and was established to determine the need for intramedullary nail locking and the post-operative weight bearing protocol, in order to avoid the settlement of a nonunion of the femoral shaft.1
Inappropriate mechanical environment of the fracture (inadequate fracture stability), insufficient blood supply (avascularity), bone loss or presence of an infection are the main reasons for the development of a nonunion. In some cases, despite the appropriate treatment, there is no evident reason. Special categories of patients are those with co-existence of an acute spinal cord injury. Nonoperative treatment of these patients leads to a 31% higher rate of femoral nonunion.2
Several different treatment modalities are available to the surgeon, including nail dynamization, plate osteosynthesis, external fixation, exchange plating and adjuvant alternatives such as electrical or ultrasound stimulation, bone grafting with autogenous or allogenic bone grafts and Bone Morphogenetic Proteins (BMPs).3 In cases were segmental defects are present, vascularized bone transfer and distraction osteogenesis can be used.4, 5
Closed reamed intramedullary nailing combined with or without open bone grafting has been suggested by many authors as the treatment of choice for nonunions of the femoral shaft.6, 7, 8, 9 The nonunion rate in femoral shaft fractures treated with intramedullary nailing ranges between 1% and 20% depending on the type of fracture and on the technique used.1, 6, 7, 8, 10, 11 The success rate of nonunion treatment will decrease after repeated operations, primary because of repeated local, periosteal and vascular destruction, with reduced nutrition as a result.12 The reported success rate for other treatment modalities, such as exchange nailing, nail dynamization, external osteosynthesis and plate osteosynthesis, ranges between 47 and 100%.6, 7, 13, 14, 15, 16, 17, 18, 19, 20, 21
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Identification and eligibility of relevant studies
We considered all in vivo clinical studies that assessed the results of treatment of femoral nonunions. All types of studies (case series, case control, randomized controlled trials) were considered eligible for the review. Cadaveric, animal studies and morphologic articles were excluded.
MEDLINE, OVID, and Springer databases were used for the literature search covering the period from January 1950 until December 2010. Only studies in the English language were included in the search. The search
Nail dynamization
Nail dynamization is usually the first treatment option in the cases of femoral shaft nonunion where the initial treatment was intramedullary nailing in a static locking mode. The method converts the fixation from static to dynamic and promotes callus remodelling, stimulates osteogenesis and induces fracture union by allowing the weight-bearing forces to transfer through the site of nonunion.28, 29 Axial stability of the fracture is a crucial prerequisite for the effectiveness of the system.
Conclusions
Femoral nonunion represents a serious socioeconomic problem for the patient, associated with prolonged patient morbidity, gait abnormality, inability to return to work, re-operations and psycho emotional impairment. Careful selection of the used treatment method should be based on the individual characteristics of each patient. Correct and careful surgical technique is crucial for a satisfactory result. Further research is required in the fields of newer adjuvant to healing methods that will
Conflict of interest statement
The authors declare that they have not received from any organization any personal or financial benefit that could influence to the work published in this article.
Acknowledgements
The authors would like to thank G. Gouvas and Ch. Garnavos for their assistance in providing photographic documentation.
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