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Femoral Nonunion:

Risk Factors and


Treatment Options
Abstract
Despite advances in surgical technique, fracture fixation
alternatives, and adjuncts to healing, femoral nonunion continues
to be a significant clinical problem. Femoral fractures may fail to
unite because of the severity of the injury, damage to the
surrounding soft tissues, inadequate initial fixation, and
demographic characteristics of the patient, including nicotine use,
advanced age, and medical comorbidities. Femoral nonunion is a
functional and economical challenge for the patient, as well as a
treatment dilemma for the surgeon. Surgeons should understand
the various treatment alternatives and their role in achieving the
goals of deformity correction, infection management, and
optimization of muscle strength and rehabilitation. Used
appropriately, nail dynamization, exchange nailing, and plate
osteosynthesis can help minimize pain and disability by promoting
osseous union. A review of the potential risk factors and treatment
alternatives should provide insight into the etiology and required
treatment of femoral nonunion.
M
anagement of femoral diaphy-
seal fractures with a medul-
lary device typically results in union
rates ranging between 90% and
100%.
1-3
Nevertheless, femoral non-
union does occur. The incidence
may be higher than previously re-
ported, given the greater likelihood
of survival of the polytraumatized
patient and improved limb salvage
techniques. The patient with femo-
ral nonunion is faced with signifi-
cant functional and economic prob-
lems, including persistent disability,
gait abnormality, and prolonged
physical and psychological disabili-
ty. Some of the currently available
treatment techniques are successful
in achieving union in only 50% to
80% of patients,
4-6
which is much
lower than indicated by the older lit-
erature.
7,8
These relatively poor re-
sults have sparked interest in the de-
velopment of newer implants
9
and
biologic agents.
10,11
Surgeons must
counsel patients appropriately and
choose the optimal intervention for
the specific characteristics of the pa-
tient and nature of the injury.
Definition of Nonunion
The definition of nonunion typically
hinges on three important variables:
the duration of time since the injury,
characteristics of the fracture noted
on serial radiographs, and clinical pa-
rameters that the treating surgeon
can identify with a careful history
and thorough physical examination.
Currently, the US Food and Drug Ad-
ministration (FDA) defines nonunion
Joseph R. Lynch, MD
Lisa A. Taitsman, MD, MPH
David P. Barei, MD
Sean E. Nork, MD
Dr. Lynch is Fellow and Acting Instructor,
Department of Orthopaedics and Sports
Medicine, University of Washington
School of Medicine, Seattle, WA. Dr.
Taitsman is Assistant Professor,
Department of Orthopaedics and Sports
Medicine, University of Washington
School of Medicine. Dr. Barei is
Associate Professor, Department of
Orthopaedics and Sports Medicine,
University of Washington School of
Medicine. Dr. Nork is Associate
Professor, Department of Orthopaedics
and Sports Medicine, University of
Washington School of Medicine.
None of the following authors or a
member of their immediate families has
received anything of value from or owns
stock in a commercial company or
institution related directly or indirectly to
the subject of this article: Dr. Lynch, Dr.
Taitsman, Dr. Barei, and Dr. Nork.
Reprint requests: Dr. Lynch, Department
of Orthopaedics and Sports Medicine,
University of Washington Medical
Center, Box 356500, 1959 NE Pacific
Street, Seattle, WA 98195.
J Am Acad Orthop Surg 2008;16:
88-97
Copyright 2008 by the American
Academy of Orthopaedic Surgeons.
88 Journal of the American Academy of Orthopaedic Surgeons
as a fractured bone that has not com-
pletely healed within 9 months of
injury and that has not shown pro-
gression toward healing over 3 con-
secutive months on serial radio-
graphs.
12
Many authors suggest that
the optimal time for healing is from
4 to 12 months, depending on the
bone in question, the location of the
fracture, the nature of the injury, and
the quality of the soft tissues.
5,7,8,13-18
The time it takes a bone to heal is
variable and depends not only on the
aforementioned factors but on the
physiologic capability of the individ-
ual patient.
Radiographic criteria that support
the diagnosis of nonunion include
the absence of bone crossing the
fracture site (bridging trabeculae),
sclerotic fracture edges, persistent
fracture lines, and lack of evidence
of progressive change toward union
on serial radiographs. The presence
or absence of callus is less reliable as
an indicator of nonunion; its useful-
ness is dependent on the index treat-
ment chosen by the surgeon. Callus
formation associated with secondary
bone healing is expected in a diaphy-
seal femoral fracture treated with a
bridging implant (eg, medullary
nail); thus, the absence of a callus
may be indicative of nonunion.
However, the surgeon should expect
primary bone healing in the fracture
treated with compression plate os-
teosynthesis in which absolute sta-
bility was achieved. In this instance,
the absence of callus would not nec-
essarily be suggestive of nonunion.
Clinically, nonunion may pro-
duce persistent pain or motion at the
fracture site, both of which may be
elicited by either direct manipula-
tion during physical examination or
with attempted weight bearing. A
patient may demonstrate an antalgic
gait and require narcotic pain medi-
cation and ambulatory assistive de-
vices (eg, cane, crutches). These ra-
diographic and clinical criteria are
important in accurately diagnosing
femoral nonunion.
Classification
Femoral nonunions can be classified
according to the criteria described by
Weber and Cech.
19
This classification
is based on the principle of osseous
viability, with fractures divided into
viable and nonviable subtypes. A vi-
able nonunion has an intact blood
supply and is capable of mounting
a healing response to injury. Subtypes
within this classification include
hypertrophic nonunion and oligo-
trophic nonunion. A hypertrophic
nonunion displays exuberant callus
on anteroposterior (AP) and lateral ra-
diographs, demonstrates increased
uptake on radionuclide scans, and
represents inadequate stability in the
setting of an adequate blood supply
and healing response (Figure 1, A). In
contrast, oligotrophic nonunion,
which also has an intact blood sup-
ply and demonstrates radiotracer up-
take on radionuclide scans, differs in
that it possesses an inadequate heal-
ing response characterized by evi-
dence of little or no callus on AP and
lateral radiographs (Figure 1, B).
A nonviable femoral nonunion is
often called an atrophic or avascular
nonunion. These nonunions demon-
strate ischemic or cold radionuclide
scans, indicating a complete lack of
the normal biologic response to inju-
ry. Radiographically, atrophic non-
unions demonstrate eburnated, os-
teopenic, and/or sclerotic bone ends.
On occasion, these injuries are radio-
graphically similar, if not indistin-
guishable, from oligotrophic non-
unions (Figure 2). In clinical practice,
viable and nonviable nonunions
usually are identified based on
characteristics observed on serial ra-
diographs. Radionuclide scans are
infrequently used. Nevertheless, dis-
Figure 1
A, Lateral radiograph of a viable hypertrophic nonunion of the distal femoral
diaphysis demonstrating abundant fracture callus and an adequate healing
response to the original injury in the setting of inadequate stability. B, Lateral
radiograph of a viable oligotrophic nonunion of the femoral diaphysis demonstrating
little to no fracture callus and an inadequate healing response to the original injury
in the setting of adequate stability. A technetium bone scan would show increased
uptake in this case.
Joseph R. Lynch, MD, et al
Volume 16, Number 2, February 2008 89
tinction is important because this
classification can help guide appro-
priate treatment.
Diagnosis and
Evaluation
The diagnosis and evaluation of fem-
oral nonunion begins with the pa-
tient history and a careful account of
the original injury, including identi-
fication of any associated traumatic
open wounds. The patients charac-
terization of pain and fracture site
mobility is important in understand-
ing the nature of the nonunion. De-
mographic and patient characteristics
that are potential risk factors for non-
union (eg, tobacco use, peripheral
vascular disease, use of nonsteroidal
anti-inflammatory drugs [NSAIDs])
should be recognized. Additionally, it
is important to identify clinical
symptoms of infection, such as mal-
aise, fever, fatigue, night pain, and/or
a history of wound healing problems
(eg, persistent drainage).
The physical examination should
identify deformity, pain at the frac-
ture site, disruption of the soft tis-
sues, warmth, erythema, and drain-
age. Fracture site stability and pain
on manipulation should be assessed.
An objective evaluation of limb vas-
cularity should document distal
pulses, skin temperature, and hair
distribution. A more formal assess-
ment of vascular integrity may be
warranted for the patient with a his-
tory of vascular injury during either
the initial injury or subsequent
treatment. This may be done with
measurement of the ankle-brachial
index or an arterial duplex examina-
tion.
20
The initial radiographic evalua-
tion includes AP, lateral, and oblique
views (45 internal and external) of
the affected limb. In most patients,
this is sufficient to confirm the ra-
diographic diagnosis of nonunion.
The character of the nonunion (via-
ble versus nonviable), measurement
of the mechanical and anatomic
axes, and preoperative planning can
be determined from these studies.
Examination under fluoroscopy to
assess motion can occasionally be
helpful when the clinical and radio-
graphic diagnoses are inconclusive.
Occasionally, a technetium bone
scan is useful for distinguishing be-
tween viable and nonviable non-
unions, for diagnosing an occult
nonunion, and for helping choose an
appropriate treatment modality.
This distinction between viable and
nonviable is important when deter-
mining the appropriate treatment for
an individual patient. For a patient
with oligotrophic nonunion, the sur-
geon may opt to attempt a minimal-
ly invasive (eg, nail dynamization) or
a noninvasive (eg, ultrasound) tech-
nique to achieve union. For a truly
atrophic or nonviable nonunion, os-
teogenic techniques combined with
an open procedure and skeletal stabi-
lization are recommended.
Computed tomography has been
shown to be more accurate than
plain radiography in the diagnosis of
tibial nonunion.
21
Although limited
by metal artifact, it can accurately
assess the integrity of bridging cal-
lus, the presence and character of a
pseudarthrosis, and the location and
size of sequestrumin cases associat-
ed with infection.
Infection should be a consider-
ation in all cases of femoral non-
union. Thus, preoperative laboratory
analysis should include a complete
blood count with differential, eryth-
rocyte sedimentation rate, and
C-reactive protein level. When the
clinical presentation and laboratory
analysis are suggestive of infection,
radionuclide and indium 111la-
beled leukocyte scans may be help-
ful in localizing the extent of dis-
ease.
22
The benchmark for diagnosis
of infection is tissue culture at the
time of a secondary surgical proce-
dure.
23
Antibiotics should be discon-
tinued 7 to 14 days before surgery to
improve the yield of the intraopera-
tive cultures. Intraoperative speci-
mens should be evaluated with a
Gram stain and processed for aero-
bic, anaerobic, and fungal cultures,
as well as acid-fast stain.
Risk Factors
The four main causes of nonunion
are motion (inadequate fracture sta-
bility), avascularity (open fracture,
stripping during surgery), fracture
gap (bone loss, nailing in distrac-
tion), and infection. Excessive mo-
tion in surgically managed fractures
may result from inadequate initial
fixation and/or implant failure. In
the setting of adequate vascularity,
excessive motion typically results in
hypertrophic nonunion, character-
ized by an abundance of callus, wid-
ening of the fracture site, and failure
of fibrocartilage mineralization.
Avascularity resulting from open
fractures, aggressive reaming, and
excessive surgical stripping may
contribute to the development of a
Figure 2
Anteroposterior radiograph of a
nonviable nonunion of the femoral
diaphysis demonstrating an atrophic
and osteopenic fracture with no callus
formation, indicating a lack of an
appropriate healing response to the
original injury. A technetium bone scan
would show decreased uptake in a
case such as this.
Femoral Nonunion: Risk Factors and Treatment Options
90 Journal of the American Academy of Orthopaedic Surgeons
nonunion by injuring the periosteal
and endosteal blood supply.
24,25
Open
fractures
26
have been associated with
femoral nonunion, as has the need
for open reduction during closed
nailing.
15
Multivariate analyses indi-
cate that open femur fractures with
significant comminution, indicating
greater soft-tissue stripping, have an
increased risk of nonunion.
16
The ef-
fect of reaming before nailing is less
clear. Although vascular studies
demonstrate that reaming has a neg-
ative impact on endosteal circula-
tion, these studies also demonstrate
a paradoxical rise in periosteal circu-
lation, which is thought to play a
larger role in callus formation.
25
Clinical studies analyzing the effects
of reaming for femoral shaft frac-
tures have shown a significantly
greater risk of femoral nonunion
when a nail is inserted without
reaming (7.5%) compared with cases
in which the canal is reamed before
nail insertion (1.7%; P = 0.049).
1
The presence of a gap, either be-
cause of traumatic bone loss or the
treatment used (nailing in distrac-
tion, bony dbridement) also may
contribute to the development of
nonunion.
17
Any gap present after
definitive treatment must be bridged
by fracture callus during the healing
process. When bridging cannot oc-
cur, further intervention is required
to manage the resulting cortical de-
fect. The magnitude of this defect is
variable and depends on the constel-
lation of injury characteristics as
well as the physiologic capability of
the patient.
Infection can occur as a complica-
tion of the injury (eg, open fracture)
or as a complication of treatment.
Infection typically results in the for-
mation of necrotic bone (seques-
trum), ingrowth of granulation tis-
sue, osteolysis, and excessive
fracture motion secondary to im-
plant loosening or failure.
Recent studies have demonstrat-
ed associations between nonunion
and specific patient variables, such
as tobacco use, NSAIDs, and medi-
cal comorbidities. In a review ana-
lyzing the Ilizarov technique for re-
construction of the femur and tibia,
McKee et al
27
demonstrated signifi-
cant associations between smoking
and the development of nonunion
(P = 0.031). Retrospective clinical
studies have demonstrated a greater
union rate in nonsmokers (84%)
compared with smokers (58%).
28
In a
case-control study of 32 femoral di-
aphyseal nonunions, Giannoudis et
al
14
demonstrated no significant as-
sociation between smoking and the
development of nonunion. However,
they did find that the use of NSAIDs
increased the relative odds of non-
union dramatically (OR, 10.75; CI,
3.5 to 33.2). In a case-control study
of diaphyseal injuries involving the
femur, tibia, and humerus, Malik et
al
15
demonstrated that a higher
American Society of Anesthesiolo-
gists (ASA) score (a surrogate for
medical comorbidities; P < 0.001)
was predictive of nonunion.
Treatment of Nonunion
of the Femur
Achieving osseous union without
complications is the ultimate goal of
treatment, but it is not the only goal.
Correction of malalignment, eradi-
cation of infection, optimization of
muscle strength, and rehabilitation
are also important. All of these ob-
jectives should be considered when
planning a treatment strategy. Be-
yond a well-planned and executed
surgical procedure, the patients
medical comorbidities and nutri-
tional status should be optimized to
maximize the chances for success.
Additionally, nicotine use and other
medications (eg, NSAIDs, metho-
trexate) that may negatively affect os-
teogenesis should be stopped or mod-
ified. Treatment options include nail
dynamization, exchange nailing, plate
osteosynthesis, external fixation, and
adjuvant alternatives (eg, electrical
stimulation, bone grafting, bone mor-
phogenetic proteins [BMPs]).
Nail Dynamization
Dynamizationrefers to the conver-
sion of a statically locked nail to a dy-
namically locked nail. This is accom-
plished by the removal of some
combination of the proximal or dis-
tal interlocking screws, thereby al-
lowing for controlled axial instability
of the bone-implant construct. Inthe-
ory, dynamization allows transfer of
weight-bearing forces to the non-
unionsite, thereby stimulating osteo-
genesis and fracture union
29
(Figure 3).
The stimulus of weight bearing and
intermittent loading in a fracture not
previously subjected to loading may
be sufficient to induce healing.
30
This
treatment alternative is relatively
simple to perform and may be effec-
tive in axially stable injuries origi-
nally managed with statically locked
medullary nails.
18
The current literature suggests
that dynamization has a 50%success
rate of achieving union.
17,18,31
How-
ever, a significant prevalence of com-
plications has been reported. The
most notable is shortening of >2 cm,
which is estimated to occur in 20%
of patients treated with nail dynam-
ization.
17,18,31
Fracture characteristics
associated with shortening and treat-
ment failure include long oblique,
spiral, and highly comminuted frac-
tures. Close follow-up is recom-
mended for patients with these frac-
ture characteristics who are treated
with nail dynamization, and careful
consideration should be given to al-
ternative treatment.
18
Nail dynam-
ization is best reserved for the axially
stable femoral shaft nonunion. The
use of the dynamic locking hole is
advocated to minimize anticipated
shortening and maintain rotational
stability. Dynamization may be more
effective when performed early (3 to
6 months after injury) rather than
late (ie, with established nonunion).
Exchange Nailing
Exchange nailing refers to the
practice of removing an already
present medullary implant, reaming
the medullary canal to a larger diam-
Joseph R. Lynch, MD, et al
Volume 16, Number 2, February 2008 91
eter, and inserting a larger-diameter
nail (Figure 4). This technique stim-
ulates bone union mechanically and
biologically. Sequential reaming en-
larges the medullary canal and facil-
itates insertion of a larger and stiffer
implant. Additionally, exchange
nailing affords greater stability by in-
creasing the length of the isthmic
portion of the medullary canal,
which increases the implant-
endosteal contact area. The biologic
stimuli that promote union follow-
ing exchange nailing include the
deposition of autogenous bone graft
at the nonunion site and the stimu-
lation of a periosteal healing re-
sponse through the process of fem-
oral canal reaming. The actual
amount of reamings that are depos-
ited at the site of the nonunion is un-
known but likely is minimal.
Variable rates of fracture consoli-
dation have been reported after ex-
change nailing for primary treatment
of femoral diaphyseal nonunion.
4,7,8,13
Kempf et al
7
reported a 93% union
rate in their review of 27 patients
with femoral nonunion who were
treated with exchange nailing. Webb
et al
8
reported a 97% union rate. In
this series, the fractures that did not
heal following the first exchange
nailing did so after a repeat exchange
nailing procedure. More recent series
demonstrate much lower union rates
following exchange nailing for fem-
oral nonunion.
5,13,32
In these series, a
higher prevalence of persistent non-
union among smokers was reported,
but the authors were unable to dem-
onstrate a statistically significant
correlation with other factors, in-
cluding type of nonunion, fracture lo-
cation, type of nail, and the use of
statically or dynamically locked
nails.
4,5,13
In a retrospective reviewof
19 femoral nonunions managed with
exchange nailing, Weresh et al
5
re-
ported a persistent nonunion rate of
53% at 35 weeks, which challenges
the efficacy of exchange nailing as a
panacea for femoral nonunion. In this
series, 47% of patients required an
additional procedure, including open
autogenous bone grafting, to achieve
osseous union.
An attempt should be made to ex-
change the existing implant for a nail
that is both larger in diameter (by 1
to 2 mm) and stiffer by increasing the
nail diameter or wall thickness, or
both. The canal should be reamed un-
til osseous chatter is heard; the goal
is to ream1 to 1.5 mmlarger than the
anticipated implant. In axially stable
patterns, consideration should be
given to placing nails in a dynami-
cally locked fashion using the dy-
namic holes currently available in
most nail designs. Unless significant
atrophic changes are noted on preop-
erative radiographs, adjuvant open
bone grafting procedures generally are
not performed during the first at-
Figure 3
Anteroposterior (A) and lateral (B) radiographs of femoral diaphyseal nonunion in a 26-year-old man who was treated with a
reamed antegrade statically locked medullary nail. At 7 months following fracture, he presented with an antalgic gait.
Anteroposterior (C) and lateral (D) radiographs demonstrating healing of the femoral diaphyseal nonunion 6 months following
nail dynamization.
Femoral Nonunion: Risk Factors and Treatment Options
92 Journal of the American Academy of Orthopaedic Surgeons
tempt at exchange nailing. Openbone
grafting with autogenous graft, how-
ever, should be considered when re-
peat exchange nailing is attempted af-
ter failure of one exchange nailing.
Despite union rates that are more
modest than initially reported, ex-
change nailing for femoral nonunions
allows early weight bearing and un-
restricted motion of adjacent joints,
while typically producing higher rates
of fracture consolidation than do less
invasive techniques such as nail dy-
namization.
Reamed nailing also may be used
as a salvage procedure for nonunion
following plate fixation of the fe-
mur.
33
Following plate removal, an
appropriately sized locked reamed
nail is placed in the usual fashion.
Consideration should be given to
closing the soft-tissue envelope fol-
lowing plate removal and before
reaming to allowfor local deposition
of the reamings.
Plate Osteosynthesis
Plate osteosynthesis offers specif-
ic advantages over nail dynamiza-
tion and exchange nailing. Plating
offers enhanced mechanical stability
for hypertrophic nonunion. For oli-
gotrophic and atrophic nonunion,
plating may be combined with bone
grafting to enhance both the biolog-
ic and the mechanical environment
for union. Although exchange nail-
ing may be considered in oligo-
trophic and atrophic nonunions,
some of the theoretical advantages
of performing a closed technique are
diminished in patients in whom ad-
junctive open bone grafting is simul-
taneously performed to enhance the
local biology. In these situations, the
surgeon should give consideration to
plate osteosynthesis. Open plating
also is indicated in some proximal
and distal metadiaphyseal nonunions
(Figure 5). These injuries can be dif-
ficult to manage withmedullary nails
because these regions of the femur
will not have direct endosteal contact
with the medullary implant, thus di-
minishing the stability of the overall
construct. Open reduction and plate
fixation facilitates correction of asso-
ciated deformity, affords better axial
and torsional stability, and allows for
the application of direct compression
across the nonunion site.
34
The treat-
ment of active or indolent infection
associated with femoral nonunion
may be facilitated with plate fixation
by allowing a thorough dbridement
of sequestrum and involucrum via
open techniques.
Bellabarba et al
35
reported a 91%
union rate at 3 months in 23 patients
treated with plating for femoral non-
union following medullary nailing.
The authors used the AO 95 condy-
lar blade plate in distal and proximal
one third nonunions of the femo-
ral shaft. They used the broad large-
fragment dynamic compression plate
Figure 4
Anteroposterior (A) and lateral (B) radiographs of a 52-year-old man with a distal one third femoral diaphyseal nonunion 6
months following treatment with a reamed antegrade statically locked medullary nail. Note the broken distal locking screws.
Anteroposterior (C) and lateral (D) radiographs demonstrating a healed femoral diaphyseal nonunion 6 months following
exchange nailing with a larger-diameter and stiffer implant placed in a dynamic fashion.
Joseph R. Lynch, MD, et al
Volume 16, Number 2, February 2008 93
in nonunions of the middle one third
of the femur and emphasized metic-
ulous attention to the protection of
soft tissues. Adjunctive autogenous
bone grafting was used for all atro-
phic nonunions and selective oli-
gotrophic nonunions that demon-
strated a significant bony defect or
unfavorable bony architecture that
would prevent compression without
significant shortening. These authors
considered this technique particu-
larly valuable in the presence of de-
formity. Abdel-Aa et al
36
reported a
100% union rate in their series of
femoral nonunions managed with
plate osteosynthesis. Severely recal-
citrant nonunions treated with the
wave plate have been reported to re-
sult in union rates between 95%and
98% at 6 to 12 months.
9,37
Although
these studies are not directly compa-
rable because of their retrospective
nature, these results are superior to
those reported for exchange nailing.
Plate osteosynthesis is not with-
out risks and disadvantages. Com-
pared with closed medullary nailing,
plate osteosynthesis has been shown
to be associated with a higher risk for
infection, greater blood loss, and fur-
ther devascularization to soft tissues
in an area that has been previously
injured.
9,35,37-39
Additionally, plate os-
teosynthesis frequently requires re-
stricted postoperative weight bearing,
possibly decreasing the benefits of
mechanical loading of the nonunion
site, as well as slowing rehabilitation.
In the study by Abdel-Aa et al,
36
13%
of patients required quadricepsplasty
and knee arthrolysis postoperatively
for significant stiffness at 1 year.
Another technique involves the
use of compressionplating around the
existing medullary implant. In three
reviews of femoral nonunions man-
aged withthis technique, a unionrate
of 100% was reported at an average
of 7 months.
39-41
This method com-
bines the advantages of medullary
nailing (eg, immediate weight bear-
ing) with the advantages of plate os-
teosynthesis (eg, the ability to apply
interfragmentary compression) and
offers improved stability in the meta-
diaphyseal regionof a long bone. If de-
sired, autogenous bone grafting may
be performed through the same sur-
gical exposure. We do not have suffi-
cient experience with this technique
to support or refute the evidence pre-
sented; however, the advantage of al-
lowing earlier weight bearing com-
bined with the benefits attributed to
compression plate osteosynthesis
make this technique an attractive al-
ternative inthe appropriate situation.
Plate osteosynthesis for the man-
agement of femoral nonunion fol-
lowing nailing results in a high rate
of union. The authors primary indi-
cation for plate osteosynthesis is
metaphyseal and metadiaphyseal
femoral nonunions associated with
Figure 5
Anteroposterior (A) and lateral (B) radiographs of a 32-year-old man with a femoral diaphyseal nonunion 10 months following
treatment with a reamed retrograde statically locked medullary nail. Anteroposterior (C) and lateral (D) radiographs
demonstrating a healed femoral diaphyseal nonunion 4 months following nail removal, open dbridement, autogenous bone
grafting, and plate osteosynthesis.
Femoral Nonunion: Risk Factors and Treatment Options
94 Journal of the American Academy of Orthopaedic Surgeons
significant malalignment. In situa-
tions requiring open dbridement of
infected tissue or in nonunions re-
quiring bone grafting, plate osteo-
synthesis through the same surgical
exposure is a logical and successful
form of nonunion stabilization. De-
spite the high reported union rates,
plate osteosynthesis requires large
surgical exposures and may be asso-
ciated with increased perioperative
morbidity. Important considerations
for successful plate osteosynthesis
include meticulous surgical dissec-
tion, limited soft-tissue stripping,
and, when possible, compression of
the nonunion site.
External Fixation
External fixation has been re-
ported for the treatment of femoral
nonunion. The Ilizarov technique
has been described in small case se-
ries, with good results in aseptic
nonunions.
42,43
The small patient
numbers indicate that these tech-
niques are used less frequently than
dynamization, exchange nailing, and
plate osteosynthesis. Compression
and distraction using half-pin and
tensioned-wire external fixators has
been described as being capable of
providing a mechanical stimulus
that facilitates union.
44
However,
pain necessitating strong analgesic
agents and pin-related complications
(eg, osteomyelitis, septic arthritis,
pin failure) continue to be significant
limitations. The complexity and as-
sociated economic costs suggest that
these techniques should be limited
to tertiary care centers with experi-
enced surgeons.
43
External fixation
may be most useful for managing in-
fected femoral nonunion.
Adjuvant Treatment
Alternatives
Additional treatments have been
used either in isolation or, more
commonly, as adjuvants to one of
the skeletal stabilization methods
previously described. These include
electrical stimulation, bone grafting
and bone graft substitutes, and the
application of newer biologics such
as BMPs.
The principal advantage of electri-
cal stimulation as an adjuvant treat-
ment is its minimal risk. For this
reason, many surgeons choose to use
it for difficult femoral nonunions in
conjunction with medullary nailing
or plate fixation. Electrical stimula-
tion as a stand-alone procedure for
the ununited tibia has produced
higher rates of healing than casting
alone, but there are few data con-
cerning the femur.
45,46
We rarely use
it in isolation. The numerous con-
traindications to the use of electrical
stimulation include the presence of
a gap at the nonunion site, synovial
pseudarthrosis, and significant os-
seous devascularization.
Autogenous bone, allograft bone,
bone marrow aspirate, BMPs, and
combinations thereof may be added
to the nonunion site as isolated pro-
cedures. The results of aseptic fem-
oral nonunions treated with bone
grafting as an isolated and open pro-
cedure have not demonstrated great-
er efficacy than exchange nailing
alone, and we rarely choose this
technique.
47
Most commonly, they
are used as adjuvants along with ex-
change nailing and plate osteosyn-
thesis techniques. We choose one of
these adjuvants for patients requir-
ing repeat exchange nailing, or when
plate osteosynthesis is used and ad-
equate compression across the frac-
ture site cannot be obtained.
BMP has been studied extensively
in animal models as well as in pro-
spective randomized clinical trials in
humans. It is effective as a treatment
alternative for recalcitrant nonunion
in the tibial diaphysis.
10,11
In one
study,
11
patients with tibial non-
union were randomized to either re-
combinant human BMP-7 (rhBMP-7)
or autogenous bone grafting as an ad-
junct to medullary nailing. Efficacy
of rhBMP-7 was similar to autoge-
nous bone grafting in this study
(81% union with rhBMP-7 versus
85% with graft; P = 0.524). The FDA
issued a humanitarian device exemp-
tion for the application of rhBMP-7
as an alternative to autograft in re-
calcitrant long bone nonunion in
which the use of autograft is not fea-
sible and alternative treatments have
failed. However, the efficacy of this
adjunctive treatment has not been
specifically reported with femoral
nonunion. Also, the robust bone for-
mation and healing potential demon-
strated in animal models has not, as
yet, been as impressive in clinical se-
ries evaluating ununited fractures of
long bones in humans.
10,11
Summary
Management of acute femoral diaphy-
seal fracture with a medullary device
has one of the most predictable out-
comes in orthopaedic surgery, with
unionrates ranging between90%and
100%in most series. However, when
a femoral shaft fracture fails to unite,
it becomes a difficult problemfor the
surgeonand presents significant func-
tional and economic challenges for
the patient. Careful history, physical
examination, and radiographic eval-
uation can confirm the diagnosis of
nonunion and are essential in formu-
lating an appropriate treatment plan.
Consideration should be given to the
optimization of modifiable risk fac-
tors such as nutritional status, nico-
tine, NSAIDuse, and medical comor-
bidities. Treatment options should be
individualized based on patient and
fracture characteristics to achieve os-
seous union, correct malalignment,
eradicate infection, and optimize
muscle strength and rehabilitation.
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Volume 16, Number 2, February 2008 95
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Joseph R. Lynch, MD, et al
Volume 16, Number 2, February 2008 97