Results of Indirect Reduction and Plating of Femoral Shaft Nonunions After Intramedullary Nailing

OBJECTIVETo observe and report the clinical results of indirect plating techniques in the treatment of femoral shaft nonunions originally treated with intramedullary nailing. DESIGNProspective consecutive. SETTINGRegional trauma center. PATIENTSA consecutive series of twenty-three patients with nonunion of femoral shaft fractures previously treated with intramedullary nailing. INTERVENTIONSurgical treatment with indirect plating techniques using the AO 95-degree condylar blade plate in nonunions of the distal and proximal one thirds and broad large-fragment dynamic compression plating in nonunions of the middle one third, with selective autologous cancellous bone grafting. Emphasis was placed on preoperative planning, intraoperative attention to soft tissue sparing and selection of the appropriately applied implant to correct deformity and obtain union. MAIN OUTCOME MEASUREMENTSHealing rate and time, operative blood loss and time, and incidence of complications, including hardware failure, loss of fixation, infection, and postoperative malalignment. RESULTSTwenty-one of the twenty-three nonunions healed without further intervention at an average of twelve weeks (range 10 to 16 weeks) postoperatively. The two remaining patients (9 percent) had early breakage of their hardware, requiring repeat plating. Union in both of these cases occurred within sixteen weeks of the revision (12 and 16 weeks). Including the two patients requiring reoperation, all twenty-three nonunions healed at an average of seventeen weeks (range 10 to 24 weeks) from the initial plating procedure. There were no intraoperative complications. Average operative time was 164 minutes (range 120 to 240 minutes), and blood loss was 340 milliliters (range 200 to 700 milliliters). There were no cases of significant postoperative axial or rotational malalignment (more than 5 degrees), limb length discrepancy (more than 1 centimeter), or deep infections. CONCLUSIONSModern plating techniques are effective in the treatment of femoral shaft nonunions after intramedullary fracture fixation. The authors consider this method particularly valuable in the presence of deformity. Union occurred reliably with few complications.