Session IX - Femur Fractures

The Failure of Reamed Intramedullary Exchange Nailing for Aseptic Ununited Femoral Shaft Fractures

Matthew J. Weresh, MD, Robyn Hakanson, MD, Michael Stover, MD, Stephen H. Sims, MD, James F. Kellam, MD, Michael J. Bosse, MD

Carolinas Medical Center, Charlotte, North Carolina, USA

Purpose: To determine the effectiveness of reamed exchange nailing for treatment of aseptic femoral delayed unions and nonunions in patients whose index procedure was performed with a contemporary locked nail.

Methods: Nineteen patients were managed for aseptic femoral delayed union or nonunion at our institution from 1990 to 1996. Criteria for inclusion of patients in the study were radiographic evidence of failure of progression of the fracture for three months, clinical symptoms of nonunion, i.e., pain at the fracture site, and six months postoperative follow-up from the initial procedure. All patients were initially managed with reamed exchange nailing. The success of the secondary procedure was determined by radiographic and clinical evidence of union of the fracture or necessity for additional procedures.

Results: In 53% of the patients (10 of 19, average patient age, 38) the secondary procedure of reamed exchange nailing resulted in fracture union. In 47% of the patients (9 of 19, average patient age, 47), one or more additional procedures was required to achieve fracture union. Eight of the nine fractures that did not unite with exchange nailing united after a third procedure. Two of these underwent bone grafting; in three patients another exchange nailing was performed with simultaneous bone grafting; in two patients compression plating was performed with simultaneous bone grafting; and nail dynamization was used in one patient. One patient has undergone three additional procedures (two bone grafts and an additional exchange nailing) since her initial exchange nailing, and her fracture has not yet united. No change in rotational alignment or length of any femur was reported since the time of the exchange nailing. Neither the type of nonunion (atrophic [5], oligotrophic [11] or hypertrophic [3]), the location of the shaft fracture, the use of static vs. dynamic crosslocking, nor the use of tobacco products was statistically predictive of the need for additional procedures. An open bone graft was performed on four patients at the time of the initial exchange nailing, and three of these required an additional procedure.

Discussion: Exchange femoral nailing is the accepted practice for the treatment of delayed or ununited femoral fractures. Three reviews of results of this infrequent occurrence have been published, and all were completed prior to the advent of crosslocking nails. A success rate of 96-100% was reported for treatment of femoral nonunions in these series. Our experience does not reflect this positive result and, to the contrary, suggests that a significant percentage of ununited femoral shaft fractures will require additional operative intervention to achieve union of the fracture. In our experience, the use of contemporary techniques and nail designs on our population of femoral delayed unions or nonunions is not as demonstratively successful as was reported previously.

Conclusion: It behooves the surgeon to evaluate the fracture, the type of fixation used, and the biology of the injury prior to intervention. Simply solving the problem of femoral delayed unions and nonunions by use of exchange nailing should be replaced by more meticulous surgical planning and consideration of the use of crosslocking, dynamization, bone grafts, or compression plating. A significant number of patients, 47% in our series, who undergo reamed exchange nailing for treatment of aseptic femoral delayed union or nonunion will require additional procedures to achieve fracture healing. Routine exchange nailing may require reevaluation as the recommended treatment of choice for this problem.