Effectiveness of plate augmentation for femoral shaft nonunion after nailing

Treatment options for nonunion of the femoral shaft fracture after intramedullary nail fixation are controversial. The methods of exchanging an existing nail with a larger-sized nail, dynamization, removal of the nail followed by plating, and bone grafting have all been reported. From those options, exchange nailing seems to be the most popular choice. In our study, we used plate augmentation and bone grafting with retention of the nail. The purpose of our study was to evaluate the effectiveness of this method in treating femoral shaft nonunion after open reduction and internal fixation with intramedullary nail fixation.

Between January 2003 and December 2009, 22 patients who had nonunion after open reduction and internal fixation with intramedullary nail for femoral shaft fracture were included in our study. There were 13 men and nine women participants, with a mean age of 34.3 years (range, 17-77 years). The mean period of nonunion after surgery was 20.0 months (range, 7-63 months). The patients were classified into three groups, atrophic, oligotrophic, and hypertrophic. We retained the nail and performed plate augmentation for all patients, with simultaneous autologous bone grafting as indicated. We followed up on all patients with plain film examination, and to assess functional recovery status to determine osseous union condition.

All 22 of the patients achieved postoperative bony union uneventfully at a mean time of 22.1 weeks (range, 12-40 weeks). The mean operative time was 105 minutes (range, 60-150 minutes), and the mean blood loss was 340 ml (range, 150-700 ml). All of the patients could walk bearing full weight without pain within 3 months. There were no significant complications such as broken hardware, implant back-out, axial or rotational malalignment, or deep infections.

Plate augmentation with retention of the nail with autologous bone grafting may be an effective and reliable alternative in treating nonunion of the femoral shaft fracture after open reduction and internal fixation with intramedullary nail.