Femoral Shaft Nonunion

- Discussion:
    - general discussion of non union
    - femoral shaft that has not healed in 26 wks signals a delayed union;
    - may be more common in segmental fractures and in winquest type IV fractures; 
    - most common iatrogenic risk factor is failure to ream the canal;
    - references:
         - Nonunion of the femoral diaphysis. The influence of reaming and non-steroidal anti-inflammatory drugs.
         - Human atrophic fracture non-unions are not avascular.
         - Antegrade or retrograde reamed femoral nailing. A prospective, randomised trial.
         - Nonunion following intramedullary nailing of the femur with and without reaming. Results of a multicenter randomized clinical trial. 
         - Retrograde dynamic locked nailing for femoral supracondylar nonunions after plating.
  

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- Treatment Options: 
    - see bone graft menu
    - Exchange Nailing:
            - consider removing nail, reaming of canal, & inserting larger nail;
            - difficulty passing guide wire across a dense sclerotic nonunion may require special instrumentation or opening of the frx site;
            - consider reaming to 2 mm above the previous size, & delivering bone graft to site of non union thru a chest tube, and inserting larger IM nail;
           - in the report by Giannoudis et al (JBJS in press), the authors emphasize the importance of avoiding NSAIDS, using bone grafting, as well
                   as reaming above the previous nail size;
           - in the report by MJ Weresh et al (Journal of Orthop Trauma Vol 14. No 5. p 335), the authors noted that a significant number of patients undergoing
                   reamed exchange nailing of femoral shaft non unions required additional procedures to achieve fracture healing;
                   - they noted that exchange nailing by itself may not be sufficient for fracture healing;
           - references:  
                   - The treatment of nonunions following intramedullary nailing of femoral shaft fractures.
                   - Simple approach to the management of aseptic non-union of the shaft of long bones.
                   - Exchange nailing for femoral shaft aseptic non-union.
                   - Treatment results of aseptic non-unions of long bones with medullary canal reaming followed by intramedullary nailing
                   - The treatment of nonunions following intramedullary nailing of femoral shaft fractures.
                   - Success of exchange reamed intramedullary nailing for femoral shaft nonunion or delayed union.
                   - Failure of exchange reamed intramedullary nails for ununited femoral shaft fractures.
                   - The treatment of noninfected pseudarthrosis of the femur and tibia with locked intramedullary nailing.
                   - Treatment of infected pseudarthrosis of the femur and tibia with an interlocking nail.
                   - Intramedullary nailing and reaming for delayed union or nonunion of the femoral shaft. A report of 105 consecutive cases.
                   - Distal femoral nonunion treated with interlocking nailing.
                   - Treatment of femoral and tibial diaphyseal nonunions using reamed intramedullary nailing without bone graft
                   - Femoral exchange nailing for aseptic non-union: not the end to all problems. 

    - dynamization:
          - The effect of dynamization on slowing the healing of femur shaft fractures after interlocking nailing.
          - The treatment of nonunions following intramedullary nailing of femoral shaft fractures.
          - Healing of 56 segmental femoral shaft fractures after locked nailing. Poor results of dynamization.
 
    - plate fixation: (see synthes distal femoral plate)
           - allows direct debridement of non union ends, anatomic reduction, bone grafting and compression;
           - in the report by C. Bellabarba et al, the authors report on a consectutive series of 23 femoral non unions of femoral shaft fractures treated by previous IM nailing;
                   - surgical treatment consisted of indirect fracture reduction techniques using 95 deg condylar blade plate;
                   - 21 of 23 non unions healed without further intervention (two other fractures had hardware failure);
           - references:
                   - Plate augmentation leaving the nail in situ and bone grafting for non-union of femoral shaft fractures.
                   - Mechanical comparison of a distal femoral side plate and a retrograde intramedullary nail.
                   - The use of a locked plate in the treatment of ununited femoral shaft fractures.
                   - The evolution of femoral shaft plating technique.
                   - Augmentative plate fixation for the management of femoral nonunion after intramedullary nailing.
                   - Plate augmentation leaving the nail in situ and bone grafting for non-union of femoral shaft fractures.
                   - Open reduction and internal fixation of distal femoral nonunions: long-term functional outcomes following a treatment protocol.

 
Management of infected femoral nonunions with a single-staged protocol utilizing internal fixation.





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