|Year : 2016 | Volume
| Issue : 4 | Page : 297-302
Plate augmentation leaving the nail in situ and bone grafting for the treatment of nonunited diaphyseal fractures
Hosam M Khairy
Department of Orthopedic Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt
|Date of Submission||16-Feb-2014|
|Date of Acceptance||16-Mar-2014|
|Date of Web Publication||27-Jun-2017|
Hosam M Khairy
Department of Orthopedic Surgery, Faculty of Medicine, Zagazig University, Montaza Square, Zagazig
Source of Support: None, Conflict of Interest: None
Background Intramedullary nailing (IMN) is now the standard treatment for diaphyseal fractures. Despite recent advances in nailing techniques and designs, some cases of nonunion are still encountered. There are different lines of treatment for nonunion over IMN such as nail conversion to plate, exchange nailing, augmentation plating with bone grafting, and external fixation with nail retention. The aim of our study is to evaluate augmentation plating and bone grafting as a method of treatment for nonunited diaphyseal fractures over IMN.
Patients and methods Eleven patients were included in this study. They were nine men and two women; their ages averaged 41 (18–54) years. The femur was affected in three cases, the tibia in six cases, and the humerus in two cases; all of them were treated by augmentation plating and bone graft.
Results The follow-up duration averaged 14 (range: 9–24) months; union was achieved in all cases without complications of infection, implant failure, nonunion, or joint stiffness.
Conclusion Augmentation plating and bone graft represents a good solution for the treatment of nonunited diaphyseal fractures over IMN
Keywords: augmentation plating, intramedullary nails, nonunion
|How to cite this article:|
Khairy HM. Plate augmentation leaving the nail in situ and bone grafting for the treatment of nonunited diaphyseal fractures. Egypt Orthop J 2016;51:297-302
|How to cite this URL:|
Khairy HM. Plate augmentation leaving the nail in situ and bone grafting for the treatment of nonunited diaphyseal fractures. Egypt Orthop J [serial online] 2016 [cited 2017 Sep 26];51:297-302. Available from: http://www.eoj.eg.net/text.asp?2016/51/4/297/208997
| Introduction|| |
Intramedullary nails (IMN) are now the standard treatment for diaphyseal fractures of long bones; despite recent advances in techniques and designs of nails, some cases of nonunion are still encountered. The causes of nonunion following IMN as summarized by Said et al.  are unstable fixation because of undersized nails, comminution, or poor reduction or devitalization of the soft tissue envelope by trauma or surgery. Choi and Kim  concluded that the most important factor of the nonunion over IMN was instability at the fracture site. Many lines of treatment have been described for the treatment of nonunited diaphyseal fractures over IMN. Conversion of nail to plate with grafting was first described for excision of nonunion, closure of gaps, and rigid fixation . Exchange nailing is the most accepted line of treatment; it obviates the need for graft, and the retained nail maintains alignment and stability of the fracture ,,,. Augmentation plating with grafting combines the advantage of retaining the nail with its role in intramedullary stability and alignment and the rigidity of fixation with plates ,,,,. Park et al. , in their cadaveric study on a fracture model of the femur fixed with IMN in one group and IMN and an augmentation plate in the other group, found a 2.5-fold increase in bending stiffness and a 3.3-fold increase in torsional stiffness in plate augmentation, leaving the nail in situ compared with an interlocking nail only in the distal third fracture of the femur. Augmentative Ilizarov external fixation is retained for resistant cases of nonunion for closure of large gaps from without and in the presence of excessive scarring . In our study, we used augmentation plating with bone grafting for the treatment of nonunited diaphyseal fractures over IMN.
| Patients and methods|| |
Eleven cases with nonunited diaphyseal fractures fixed with IMN were included in this study ([Table 1]); all of them were operated by augmentation plates and bone graft between January 2010 and January 2012 in the Orthopedic Surgery Department, Zagazig University. In three of these patients, the first operation of IMN was performed in our department and the remaining eight cases were referred from other hospitals. The average age of the patients was 41 (range: 18–54) years; there were nine men and two women. The femur was affected in three cases, the tibia in six cases, and the humerus in three cases. A nonunion was defined by persistent pain at the fracture site combined with the absence of progressive healing on three consecutive radiographs taken at 1-month intervals or failure to unite at 6 months after surgery. The presence of infection was excluded by preoperative laboratory investigations (erythrocyte sedimentation rate and C-reactive protein). The nonunion was hypertrophic in one case and oligotrophic in 10 cases. The mean time from primary nailing to plate augmentation and bone grafting averaged 8 (range: 5–14) months. All our cases were operated by plating and corticocancellous bone grafts. Dynamic compression plates (DCP) were used in 10 cases and a locked plate in one case.
Operative technique: the fracture was exposed, surfaces rawed, bone ends were curetted, and intervening soft tissues were removed. Plates were applied over the retained IMN. On exposure of the fracture, visible motion was noted at the fracture site that disappeared after application of the plate. In femoral cases, broad DCP 6–10 holes were used and the eccentric position of holes enabled the placement of screws on both sides of the nail, especially in the undersized nail ([Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5]). In the tibia, narrow DCP 6–8 was used in all cases, except in one case, where a long anatomical locked plate was used ([Figure 6],[Figure 7],[Figure 8],[Figure 9],[Figure 10],[Figure 11]). In the case of a locked plate when the screw heads are locked in the threaded holes, the purchase of screws in the bone cannot be guaranteed. In the case of two humeral nonunions, narrow DCP 4 and 6 holes were used; in one case, oblique position of the plate facilitated the placement of screws to one side of the nail proximal to the fracture and on the other side distally. All cases were followed up monthly until complete union; the average follow-up period was 14 (range: 9–24) months.
|Figure 1 Comminuted fracture femur fixed with an undersized interlocking nail.|
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|Figure 2 Three months after the operation, with delayed union and implant failure. (A&B) Three months after the operation, with delayed union and implant failure.|
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|Figure 3 Twelve months after the operative, with hypertrophic nonunion and implant failure.|
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|Figure 4 Augmentation plate with a bone graft − 6 months after the operation.|
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|Figure 7 Fixation with interlocking nail and circulage − 6 months after the operation.|
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|Figure 9 Augmentation with a lock plate and a bone graft − 6 weeks after the operation.|
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| Results|| |
For augmentation plating and grafting, the operative time averaged 75, (range: 50–120) min, and blood loss averaged 300 (range: 200–500) ml. There were no intraoperative complications of drill or tape breakage. Follow-up duration averaged 14 (range: 9–24) months. Union occurred in all 11 (100%) cases without any further surgical intervention. Pain and tenderness around the fracture site improved within an average of 2 (average: 2–3 months), callus appeared within an average of 2.5 (range: 2–4) months, and solid union occurred within an average of 4.7 (range 4–6) months. No cases of infection, implant failure, nonunion, or joint stiffness were encountered in our study.
| Discussion|| |
Nonunion over IMN is a challenge; many factors have been considered to cause nonunion such as lack of stability because of comminution or a wide medullary canal around an undersized nail or devitalization of soft tissue envelope in high-velocity trauma. In our study, both factors were encountered: lack of stability with visible motion at the fracture site in all cases ([Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5]) and soft tissue devitalization in some cases ([Figure 6],[Figure 7],[Figure 8],[Figure 9],[Figure 10],[Figure 11]).
Many lines of treatment have been described for the treatment of nonunion over IMN. Exchange nailing is the most accepted line of treatment; it obviates the need for grafting, there is less blood loss, less extensive dissection, and rapid rehabilitation, but it is not suitable when there is comminution or gap nonunion. Conversion of a nail to a plate is more extensive, there is more blood loss, and lost previous stability by nail. External fixation with Ilizarov with the nail in situ is suitable in large defects and poor soft tissue envelope. The use of an augmentation plate has the advantage of conferring more interfragmentary stability as the retained nail maintains axial stability and alignment of the bone and there are less dissection and blood loss as in ordinary planting. Also, the presence of a team, composed of two surgeons for exposure of the fracture and obtaining the iliac graft, shortens the operative time and reduces blood loss.
All of our cases achieved radiological union on an average of 4.7 months and this is nearly comparable with the results obtained by Said et al.  in their study of 14 cases of nonunited femoral fractures over IMN and union occurred on average at 4.3 months; the difference may be related to the fact that our study included not only femoral cases but also tibial and humeral cases, and the tibia is famous of delayed union.
Choi and Kim , in their study on 15 cases of nonunited femoral fractures over IMN, reported achievement of radiological union in their patients on average at 7.2 months; this longer duration may be related to difficulty in the cases included in their study. Patients included in their study had undergone about 1–3 previous operations and had been operated on average 10 months after the primary nailing.
In our study and studies carried out by Said et al. , Nadkarni et al. , and Choi and Kim , healing occurred in all cases (100%) without any further surgical intervention, with some difference in the duration of healing, but in studies carried out on exchange nailing by Hak et al. , Furlong et al. , and Weresh et al. , nonunion ranged from 4 to 53% and all of these patients required further surgical intervention. This finding confirms the superiority of augmentation plating and grafting over exchange nailing only.
Nadkarni et al. , in their study of 11 cases of nonunion over IMN in femoral tibial and femoral fractures, used locked plates and bone grafting, leaving the nail in situ with union in all cases on an average of 6.2 months. We used a locked plate in one tibial fracture case and we found that a locked plate has the advantage of unicortical fixation, especially in the presence of a medullary fitting nail, but has one disadvantage that when the screw locks into the plate, the purchase of the screw in the bone cannot be guaranteed; we preferred the bone use of DCP.
In some fractures with marked comminution, healing was not anticipated after nailing, but the aim was to splint the fracture until an improvement in soft tissue condition and transformation of a multifragmentary fracture into two or three fragments; then, the procedure of augmentation plating and grafting is performed. In these situations, we can consider primary nailing and secondary plating and grafting as a two-stage operation.
There was controversy in terms of plating and periosteal stripping following IMN. According to the study by Cole , the blood supply recovered within 2 weeks in all cortical areas, including the periosteal and endosteal area, after the insertion of a reamed or an undreamed nail. Wolnisky et al.  reported that blood supply would be recovered by 6–12 weeks. Thus, problems related to insufficient blood supply will not arise if sufficient time is allowed to pass between two procedures.
| Conclusion|| |
Argumentation plating and bone graft is a good solution for the treatment of nonunited diaphyseal fractures over IMN, especially in the presence of instability at the fracture site because of an undersized nail in a wide medullary segment or the presence of comminution or gap nonunion, a situation in which exchange nailing is not sufficient.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Said GZ, Said HG, El-Sharkawy MM. Failed intramedullary nailing of femur: open reduction and plate augmentation with the nail in situ. Int Orthop 2011; 35:1089–1092.
Choi YS, Kim KS. Plate augmentation leaving the nail in situ and bone grafting for non-union of femoral shaft fractures. Int Orthop 2006; 30:430.
Crowley DJ, Kanakaris NK, Giannoudis PV. femoral diaphyseal aseptic non-unions: is there an ideal method of treatment. Injury 2007; 38(Suppl 2): S55–S63.
Hak DJ, Lee SS, Goulet JA. Success of exchange reamed intramedullary nailing for femoral shaft nonunion or delayed union. J Orthop Trauma 2000; 14:178–182.
Furlong AJ, Giannoudis PV, DeBoer P, Matthews SJ, MacDonald DA, Smith RM. Exchange nailing for femoral shaft aseptic non-union. Injury 1999; 4:245–249.
Brinker MR, O’Connor DP. Exchange nailing of ununited fractures. J Bone Joint Surg Am 2007; 89:177–188.
Naeem-ur-Razaq M, Qasim M, Sultan S. Exchange nailing for non-union of femoral shaft fractures. J Ayub Med Coll Abbottabad 2010; 22:106–109.
Nadkarni B, Srivastav S, Mittal V, Agarwal S. Use of locking compression plates for long bone nonunions without removing existing intramedullary nail: review of literature and our experience. J Trauma 2008; 65:482–486.
Ueng SW, Chao EK, Lee SS, Shih CH. Augmentative plate fixation for the management of femoral nonunion after intramedullary nailing. J Trauma 1997; 43:640–644.
Choi YS, Kim KS. Plate augmentation leaving the nail in situ and bone grafting for non-union of femoral shaft fractures. Int Orthop 2005; 29: 287–290.
Ueng SW, Shih CH. Augmentative plate fixation for the management of femoral nonunion with broken interlocking nail. J Trauma 1998; 45:747–752.
Ye J, Zheng Q. Augmentative locking compression plate fixation for the management of long bone nonunion after intramedullary nailing. Arch Orthop Trauma Surg. 2012; 132:937–940.
Park K, Kim K, Choi YS. Comparison of mechanical rigidity between plate augmentation leaving the nail in situ and interlocking nail using cadaveric fracture model of the femur. Int Orthop 2011; 35:581–585.
Menon DK, Dougall TW, Pool RD, Simonis RB. Augmentative Ilizarov external fixation after failure of diaphyseal union with intramedullary nailing. J Orthop Trauma 2002; 16:491–497.
Weresh MJ, Hakanson R, Stover MD, Sims SH, Kellam JF, Bosse MJ. Failure of exchange reamed intramedullary nails for ununited femoral shaft fractures. J Orthop Trauma 2000; 14:335–338.
Cole JD. The vascular response of bone to internal fixation. In: Brawner BD, editor. The science and practice of intramedullary nailing. 2nd ed. Lea & Febiger, Philadelphia: Williams and Wilkins; 1996. 43–69.
Wolinsky P, Tejwani N, Richmond JH, Koval KJ, Egol K, Stephen DJG. Controversies in intramedullary nailing of femoral shaft fractures. Instr Course Lect 2002; 51:291–303.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]