Orthogonal double plate fixation for long bone fracture nonunion

The treatment of long bone diaphyseal fracture-nonunion is challenging. While taking into account biological needs, a stable mechanical environment is pertinent for fracture healing. This work aims at evaluating the surgical management of stubborn ununited fractures using orthogonal double plating of diaphyseal fractures with limited periosteal stripping and soft tissue dissection.

Retrospective analysis in a level I trauma center. Between the years 2007-2009, 22 patients were treated with double plating due to nonunion of long bone fractures. Long bones included three clavicles, six humeri, three femora, seven ulnae, two tibiae and one radius. The mean period between index procedures (if existed) and revision procedures was 53.35 weeks (range 6 months-3 years). The same surgical technique, independent on the anatomical location was utilized. Perioperative intravenous antibiotics were withheld until intraoperative cultures were obtained in all patients. An approach to the fracture site was performed with removal of all previous existing hardware, including aggressive debridement of the nonunion site while keeping stripping to the necessary minimum. After primary plate fixation of the fracture with adequate compression, a second plate, with at least two well spaced screws on each side, was placed at a ninety degree angle to the primary plate. Autologous bone graft or bone graft substitute was placed in most, but not all cases. All procedures and assessment of union were done by fellowship trained trauma surgeons. In the infected cases, culture specific intravenous antibiotics were administered for six weeks. Quality of life measures included DASH score of the upper extremity, lower extremity functional score (LEFS) for the lower extremity and Short From 12 (SF-12) for all patients.

Union was achieved in all patients, with an average time to union of 5.8 months (range 2-24 months). One patient healed after a repeat double plating, since the first procedure was unsuccessful. Tissue culture were positive in 11 out of 22 patients. One clavicular plate was removed, due to irritation. No hardware failure was noted in these cases. Mean LEFS was 59%, quick DASH score -18.5 20 and SF-12 MCS and PCS were 50.37 15.22 and 49.96 8.5 receptively.

Double plating is a biomechanically sound option for treating long bone fracture nonunion with reasonable results, provided adequate biological conditions are met including eradication of infection.