Review Question - QID 211650

The patient is presenting with an aseptic hypertrophic nonunion that is amenable to a reamed exchange nail.

Femoral shaft fractures typically occur after a high-energy mechanism. Reamed, locked intramedullary nailing has a high reported union rate (>95%). Nonunion is defined as the failure to heal 9 months from the index operation or no healing progression in 3 months of follow-up radiographs. Evaluation of nonunions requires evaluation for infectious or metabolic etiologies including WBC count, ESR, CRP, vitamin D, calcium, thyroid hormones, parathyroid hormone, and sex hormones. Intraoperative cultures may be of further use for detecting occult septic nonunions. Treatment options include reamed exchange nailing, compression plating with bone graft, and nail retention with plate augmentation. In this case, with a hypertrophic nonunion with an undersized nail, a reamed exchange nailing procedure could be recommended. Reaming is thought to stimulate the fracture site and provide localized bone grafting and angiogenesis - reaming also allows for placement of a larger nail that can improve the relative stability of the construct. Compression plating and bone grafting or augmentative plating are options if reamed exchange nailing is unsuccessful.

Tsang et al. retrospectively studied 40 patients treated with exchange-nailing of femoral shaft nonunions. They reported union was achieved in 91.9% of cases and the need for additional fixation was associated with infected nonunions and cigarette smokers. The authors concluded exchange-nailing is an effective means to address aseptic femoral shaft nonunions with infected nonunions likely requiring additional fixation and procedures.

Crowley et al. reviewed the ideal treatment method for aseptic femoral shaft nonunions. They stated exchange nailing remains the gold standard with plating techniques reaching equivocal union rates. In cases where exchange nailing has failed the authors recommend the use of plates and external fixators as adjunctive fixation and bone grafting in secondary and tertiary procedures.

Ramoutar et al. performed a retrospective review of 96 patients treated with either Judet decortication and compression-plating with or without bone graft for long bone nonunions. Patients treated with bone grafting achieved a 95% union rate compared to 94.6% of patients treated with Judet decortication and compression-plating alone. They concluded the routine use of autologous bone grafts for the treatment of long bone nonunions is not necessary.

Figure A is a lateral radiograph of the left distal femur with hypertrophic nonunion.

Incorrect answers:
Answer 1: Continuing to observe this patient is unlikely to resolve his symptoms. He has a declared nonunion which should be addressed surgically to resolve his symptoms.
Answer 2: The patient does not have evidence of an infected nonunion. An antibiotic nail is not necessary.
Answer 3: Nail removal with the placement of an external fixator is a treatment option for septic nonunion. Stabilization with an external fixator alone is likely less mechanical stable than a reamed, locked nail and wouldn't sufficiently address the patient's cause of nonunion.
Answer 5: Nail removal followed by casting could be considered as a temporizing option in infected nonunions however this case has no evidence of infection in screening and casting of a mid shaft femur fracture is relatively morbid.