Cause and Treatment of the Nonunion of Femoral Shaft Fracture after Interlocking Intramedullary Nailing

Sung-Soo Kim; Sung-Keun Sohn; Chul-Hong Kim; Myung-Jin Lee; Lih Wang

doi:10.12671/jkfs.2007.20.2.141

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Kim, Sohn, Kim, Lee, and Wang: Cause and Treatment of the Nonunion of Femoral Shaft Fracture after Interlocking Intramedullary Nailing

Original Article

J Korean Fract Soc 2007;20(2):141-148.

Published online: 10 April 2007

DOI: https://doi.org/10.12671/jkfs.2007.20.2.141

Cause and Treatment of the Nonunion of Femoral Shaft Fracture after Interlocking Intramedullary Nailing

Sung-Soo Kim, M.D., Sung-Keun Sohn, M.D., Chul-Hong Kim, M.D., Myung-Jin Lee, M.D., Lih Wang, M.D.

Department of Orthopedic Surgery, College of Medicine, Donga University, Busan, Korea

Address reprint requests to: Myung-Jin Lee, M.D. Department of Orthopedic Surgery, College of Medicine, Donga University, 1, Dongdaesin-dong, 3-ga, Seo-gu, Busan 602-714, Korea Tel:82-51-240-5167․Fax:82-51-254-6757 E-mail: tynitus@dau.ac.kr

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To analyze the causes and the clinical results of treatment for the nonunion of femur shaft fractures that occurred after interlocking intramedullary nail fixation.

Materials and Methods

We reviewed 19 cases of aseptic nonunion of femur shaft fracture in 174 patients after interlocking IM nailing from March 1999 to February 2004 and followed up for more than one year. First we investigated the factors causing nonunion. For operative options, two methods about exchange nailing and exchange nailing with bone graft were performed. Finally clinical results were analyzed with bone union rate by treatment methods and compared with the nonunion factors statistically.

Results

According to the causes and types of nonunion, we performed larger IM nail change in 10 cases and IM nail change with bone graft in 9 cases. Bone union was achieved in all cases. Average bone union period were 18.5 weeks in exchange group and 16.1 weeks in exchange with bone graft group. There are significant difference between treatment methods statistically (p＜0.05). Compared with the nonunion factors, initial open fracture and smoking groups showed late union rate statistically.

Conclusion

Based on our analysis, IM nail change is a useful method for nonunion after initial IM nailing in femoral shaft fracture, and additional bone graft that according to the radiologic pattern and stability, especially the fracture gap is also a useful option for nonunion treatment.

Keywords: Femur shaft fracture, Nonunion, Interlocking intramedullary nail, Smoking

References

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Fig. 1.

(A) A 35 years old male with hypervascular nonunion of femur fracture. (B) After over reaming and exchanging large nail. (C) Post-operative 18 weeks, radiograph shows solid union.

Fig. 2.

(A) A 29 years old male with hypervascular nonunion of femur fracture. (B) After over reaming and exchanging large nail with autoiliac bone graft. (C) Post-operative 16 weeks, radiograph shows solid union.

Table 1.

Factors associated with the nonunion of femur shaft fracture after intramedullary nailing

1) Patient age & sex

2) Smoking history

3) The usage of NSAID

4) Mechanism of injury

5) Associated injury

6) The pattern of fracture

7) The type of nonunion

8) The type fo surgical technique

Table 2.

Schatzker & Lambert criteria

Excellent	All of the following
	Loss of flexion of less than 10 degrees
	Full extension
	No varus, valgus or rotational deformity
	No pain
	Perfect joint congruity
Good	Not more than of the following
	Loss of flexion of more than 20 degrees
	Loss of extension of more than 10 degrees
	Varus or valfus deformity of more than 10 degrees
	Minimum pain
Fair	Any two of the criteria listed in the previous category
Poor	Any of the following
	Flexion to 90 degrees or less
	Varus or valfus deformity exceeding 15 degrees
	Joint incongruity
	Disabling pain
	No matter how perfect the radiographic appearance

Table 3.

Operative method versus average bone union period

Operative method	Number/Percentage	Average bone union period (weeks)
IM nail	10 (52.6%)	18.5
IM nail+BG	9 (47.4%)	16.1

p＜0.05 (student-t test).

Table 4.

Initial fraccture type according th the Winquist-Hansen classification versus average bone union period

Type of fracture	Number/Percentage	Average bone union period (weeks)
1	2 (10.5%)	18.5
2	5 (26.3%)	16.6
3	4 (21.1%)	19.2
4	8 (42.1%)	17.8
p＞0.05 (student-t test).
Open	13 (68.4%)	19.9
Closed	6 (31.6%)	16.4
p＜0.05 (student-t test).

Table 5.

Type of nonunion according to the Weber & Brunner classification versus average bone union period

Type of nonunion	Number	Average bone union period (weeks)
Hypervascular (hypertrophic)	10	17.6
Elephant foot	2
Horse foot	0
Oligotrophic	8
Avascular (atrophic)	9	18.1
Torsion wedge	9
Comminuted	0
Defect	0
Atrophic	0

p＞0.05 (student-t test).

Table 6.

Initial useage of reamed or unreamed nail versus average bone union period

Type of reaming	Number/Percentage	Average bone union period (weeks)
Reamed	8 (42%)	16.8
Unreamed	11 (58%)	18.6

p＞0.05 (student-t test).

Table 7.

Smoking history versus average bone union period

Smoking history	Number/Percentage	Average bone union period (weeks)
Smoker	12 (63%)	19.2
Nonsmoker	7 (37%)	15.7

p＜0.05 (student-t test).

Table 8.

Clinical results according to the Schatzker & Lambert criteria

	Excellent	Good	Fair	Poor
IM nail	5	4	1	0
IM nail+BG	5	2	1	1

Excellent+Good: 84.2%

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