Treatment of femoral fracture with nonunion

Thirty-four patients with femoral nonunion were managed by autogenous and/or allogenous bone graft alone, or internal fixation (including DCP or intramedullary nail) combined with bone graft, or external fixation in Taichung Veterans General hospital. Adequate follow-up study was obtained in 32 patients; two patients were unable to be contacted for follow-up. All 32 patients had received one or more operations. All but four patients showed clinical and radiological union, with an overall union rate 87.5%. Twenty-five patients (89.3%) returned to work, but half of these patients changed jobs. All twenty-eight patients with solid unions could walk, but eleven patients (39.3%) had a slight limp. Twenty-two patients (78.6%) could squat, and all patients could straighten their knees. Fourteen patients (50%) complained of occasional soreness over the operated area. In our limited experience, most femoral nonunions result from (1) inappropriate selection and usage of internal fixator, (2) severe stripping of soft tissue around the fracture site, or inappropriate usage of cerclage wire, and (3) infection. Treatment must depend on the causes and types of nonunion. In this study, a high union rate and good functional recovery were achieved with interlocking nails with or without autogenous bone graft. Plating would extend the time for union to take place, and even resulted in refracture of the plate by contact with the medial cortex when there was no medial buttress. In general, detailed planning before operation, skilled surgical techniques and aseptic procedures are essential in the prevention and treatment of nonunion.