J Korean Fract Soc.  2007 Apr;20(2):141-148. 10.12671/jkfs.2007.20.2.141.

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

• Kim SS
• Sohn SK
• Kim CH
• Lee MJ
• Wang L

• KMID: 2295571
• DOI: http://doi.org/10.12671/jkfs.2007.20.2.141

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.

Keyword

Femur shaft fracture; Nonunion; Interlocking intramedullary nail; Smoking

MeSH Terms

Femur
Fracture Fixation, Intramedullary*
Fractures, Open
Humans
Methods
Smoke
Smoking
Transplants
Smoke

Figure

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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.

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  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.

Reference

References

1). Ashcroft GP, Evans NT, Roeda D, et al. Measurement of blood flow in tibial fracture patients using positron emission tomography. J Bone Joint Surg Br. 74:673–677. 1992.

2). Boyd HB. Causes and treatments of nonunion of the shafts of long bones with a review of 741 patients. Instructional Course Lecture, AAOS, ST Louis, CV Mosby. 30:152–156. 1981.

3). Boyd HB, Anderson LD, Johnston DS. Closed or open intramedullary nailing of the femoral shaft fractures. J Bone Joint Surg Am. 51:313–323. 1969.

4). Bostman O, Varjonen L, Vainionopaa S, Majola A, Rokkanen P. Incidence of local complications after intramedullary nailing and after plate fixation of femoral shaft fracture. J Trauma. 29:639–645. 1989.

5). Brighton CT, Black J, Friedenberg ZB, Esterhai JL, Day LJ, Connolly JF. A multicenter study of the treatment of nonunion with constant direct current. J Bone Joint Surg Am. 63:2–13. 1981.

6). Brighton CT, Krebs AG. Oxygen tension of healing fractures in the rabbit. J Bone Joint Surg Am. 54:323–332. 1972.

7). Brumback RJ, Uwagie-Ero S, Lakatos RP, Poka A, Bathon GH, Burgess AR. Intramedullary nailing of femoral shaft fractures. Part II: fracture-healing with static interlocking fixation. J Bone Joint Surg Am. 70:1453–1462. 1988.

8). Choi CU, Rah SK, Kim YI, Choi HS, Moon DH. Metallic failure of intramedullary nailing in treatment of femoral shaft fracture – 10 cases. J Korean Orthop Assoc. 24:954–960. 1989.

9). Choo SK, Kim BJ, Ko HS, Seo JG, Kim JG, Chang JW. Use of interlocking intramedullary nail in treatment of delayed union or nonunion of the long bone fractures. J Korean Fracture Soc. 11:761–768. 1988.

10). Chun CH, Kim SS, Kim DC and You HJ. The treatment of Nonunion of Femoral Fractures with an Interlocking Nailing. J Korean Soc Fractures. 8:497–504. 1995.

11). Connolly JF. Selection, evaluation, and indications for electrical stimulation of ununited fractures. Clin Orthop Relat Res. 161:39–53. 1981.

12). Cove JA, Lhowe DW, Jupiter LB, Siliski JM. The management of femoral diaphyseal nonunions. J Orthop Trauma. 11:513–520. 1997.

13). Dintenfass L. Elevation of blood viscosity, aggregation of red cells, haematocrit values and fibrinogen levels with cigarette smokers. Med J Aust. 1:617–620. 1975.

14). Fang MA, Frost PJ, Iida-Klein A, Hahn TJ. Effects of nicotine on cellular function in UMR 106–01 osteoblast-like cells. Bone. 12:283–286. 1991.

15). Giannoudis PV, MacDonald DA, Matthews SJ, et al. Nonunion of the femoral diaphysis. The influence of reaming and nonsteroidal anti-inflammatory drugs. J Bone Joint Surg Br. 82:655–658. 2000.

16). Gong HS, Kim HJ, Kim HS, et al. Surgical treatment of femoral nonunion. J Korean Fracture Soc. 12:1–5. 1999.

17). Gustilo RB. Management of open fractures and complications. Instr Course Lect. 31:64–75. 1982.

18). Hak DJ, Lee SS, Goulet JA. Success of exchange reamed intramedullary nailing for femoral shaft nonunion or delayed union. J Orthop Trauma. 14:178–182. 2000.

19). Heppenstall RB, Goodwin CW, Brighton CT. Fracture healing in the presence of chronic hypoxia. J Bone Joint Surg Am. 58:1153–1156. 1976.

20). Heppenstall RB, Grislis G, Hunt TK. Tissue gas tensions and oxygen consumption in healing bone defects. Clin Orthop Relat Res. 106:357–365. 1975.

21). Hwang SK, Han JB. Complication in the use of interlocking intramedullary nailing for the femoral fractures. J Korean Fracture Soc. 8:954–960. 1995.

22). Jensen JA, Goodson WH, Hopf HW, Hunt TK. Cigarette smoking decreases tissue oxygen. Ach Surg. 126:1131–1134. 1991.

23). Johnson EE. Custom titanium plating for failed nonunion or delayed internal fixation of femoral fractures. Clin Orthop Relat Res. 234:195–203. 1988.

24). Kempf I, Grosse A, Beck GF. Closed locked intramedullary nailing. Its application to comminuted fractures of the femur. J Bone Joint Surg Am. 67:709–720. 1985.

25). Kempf I, Grosse A, Beck GF. The treatment of noninfected pseudarthrosis of the femur and tibia with locked intramedullary nailing. Clin Orthop Relat Res. 212:142–154. 1986.

26). Kessler SB, Hallfeldt KK, Perren SM, Schweiberer L. The effects of reming and intramedullary nailing on fracture healing. Clin Orthop Relat Res. 212:18–25. 1986.

27). Kim MK, Kim TS, Lee SW, Kim JO, Shim JI. A clinical analysis on the treatment for nonunion of the femoral shaft fracture. J Korean Fracture Soc. 6:146–154. 1993.

28). Kim KS, Kim JO, Jung HG, Jung BO. Plate augmentaton for the nonunion of femur shaft fractures after interlocking intramedullary nail fixation. J Korean Fracture Soc. 12:21–27. 1999.

29). Konno S, Oronsky BT, Semponi AR, Wu JM. The effect of nicotine on cell proliferation and synthesis of secreted proteins in BALB/C 3T3 cells. Biochem Int. 25:7–17. 1991.

30). Lee WS, Shin KH, Lim KS. Nonunion after intramedullary nailing of femoral shaft fracture. J Korean Fracture Soc. 12:577–583. 1999.

31). Lee SC, Song MH. Nonunion of the fracture of distal one-third of femoral Shaft treated by interlocking intramedullary nailing. J Korean Fracture Soc. 12:259–266. 1999.

32). Mclaren AC, Blockker CP. Locked intramedullary fixation for metaphyseal malunion and nonunion. Clin Orthop Relat Res. 265:253–260. 1991.

33). Moon MS, Lee YK, Ha KY, Yeun G. A clinical analysis of nonunion of the long bones in lower extremity. J Korean Orthop Assoc. 24:15–26. 1989.

34). Nordenberg D, Yip R, Binkin NJ. The effect of cigarette smoking on hemoglobin levels and anemia screening. JAMA. 264:1556–1559. 1990; Orean Orthop Assoc, 4-1: 15–26, 1989.

35). Riefkohl R, Wolfe JA, Cox EB, McCarty KS Jr. Association between cutaneous occlusive vascular disease, cigarette smoking, and skin after rhytidectomy. Plast Reconstr Surg. 77:592–595. 1986.

36). Sarin CL, Austin JC, Nickel WO. Effects of smoking on digital blood-flow velocity. JAMA. 229:1327–1328. 1974.

37). Sledge SL, Johnson KD, Henley MB, Watson JT. Intramedullary nailing with reaming to treat nonunion of tibia. J Bone Joint Surg Am. 71:1004–1019. 1989.

38). Weber BG, Brunner C. The treatment of nonunions without electrical stimulation. Clin Orthop Relat Res. 161:24–32. 1981.