Osteoperiosteal decortication and bone grafting combined with wave plating for femoral shaft aseptic atrophic nonunion after intramedullary nailing

Abstract

Objective

Femoral shaft nonunion after intramedullary nailing fixation remains a challenge for orthopedic surgeons. This study evaluated osteoperiosteal decortication and iliac bone grafting combined with wave plating as a treatment for aseptic atrophic nonunion of the femoral shaft after intramedullary nailing.

Methods

The study included 22 patients (two female, 20 male; mean age 40.8 years [range, 19–61]) with aseptic atrophic nonunion of the femoral shaft who underwent osteoperiosteal decortication and iliac bone grafting combined with wave plating between January 2016 and January 2020. Cases with infected nonunion, hypertrophic nonunion, and nonunion after plate osteosynthesis were excluded. Clinical outcomes were assessed retrospectively using the Samantha X-ray and Paley scale scores.

Results

The mean follow-up period was 18.8 months (range, 12–35). Bone union was achieved in all patients. The average clinical healing time was 5.7 months (range, 3–14). The mean Samantha X-ray score was 5.7 ± 0.45 and the Paley scores indicated excellent or good clinical results in all cases. One patient developed sterile wound leakage that resolved after a dressing change.

Conclusions

Osteoperiosteal decortication and bone grafting combined with wave plating is an excellent treatment for aseptic atrophic nonunion of the femoral shaft after intramedullary nailing.

Introduction

Femoral shaft fractures are a common high-energy traumatic injury, accounting for 6% of all fractures.¹ Intramedullary nailing (IMN) is the gold standard treatment for these fractures. In recent years, with continuous refinement of the IMN technique and the expanding clinical indications, the incidence of bone nonunion after IMN of femoral shaft fractures has been reported to be 10%.² This has become a key issue in terms of the prognosis. However, controversy persists regarding the management of nonunion after IMN of femoral shaft fractures, including surgical and non-surgical treatment. Exchange nailing has been considered the gold standard for both aseptic hypertrophic and atrophic nonunion femoral shaft fractures, with a reported success rate of 70% to 100%.^3,4 With the continuing research on nonunion, there has been an increasing number of clinical reports describing the failure rate of the above treatment methods, especially in cases of aseptic atrophic nonunion.^5,6 Furthermore, intramedullary nails come in different styles, which make it impossible to remove them, and some patients cannot afford to replace them for financial reasons.

In recent years, plate augmentation with IMN retention has become an effective option for femoral shaft nonunion. Plate augmentation can improve the biomechanical environment at the site of nonunion without causing more biological damage and achieves union rates of 88.5% to 99.8%.^7,8 Judet and Patel⁹ were the first to report that osteoperiosteal decortication was effective in the management of femoral shaft nonunion. Cho et al.¹⁰ also found that osteoperiosteal decortication was an effective treatment for oligotrophic and atrophic femoral shaft nonunion. However, these conclusions were based on cases that sometimes included plate fixation.

Here we report the results of IMN in patients with aseptic atrophic nonunion of femoral shaft fractures after treatment with Judet’s osteoperiosteal decortication technique and autogenous iliac bone grafting combined with wave plate augmentation for IMN retention.

Patients and methods

This retrospective study included 22 patients who underwent revision surgery at our center for aseptic atrophic nonunion after IMN of a femoral shaft fracture between January 2016 and January 2020. The reporting of this study conforms to the STROBE guidelines.¹¹ The inclusion criteria were as follows: diagnosis of aseptic atrophic nonunion after IMN for management of a femoral shaft fracture; undergone revision surgery (Figure 1a,b); and postoperative follow-up ≥12 months. The following exclusion criteria were applied: subclinical septic nonunion; pathological fracture; refusal to complete follow-up; and lack of complete clinical data before and/or after surgery.

Figure 1.

A 53-year-old man in whom a fracture of the right femoral shaft caused by a fall was internally fixed with a femoral intramedullary nail (open reduction) at a local hospital. At 1 year postoperatively, the fracture had not healed and was treated with augmentation plating leaving the nail in situ. Four years after the second operation, the fracture still had not healed (a, b). After osteoperiosteal decortication (c) and an iliac bone graft combined with wave plating, anteroposterior (d) and lateral (e) radiographs showed adequate bone grafting. Anteroposterior (f) and lateral (g) radiographs obtained 1 year postoperatively showed full fracture healing. Photographs obtained at the same times as radiographs during follow-up showing the patient’s general functional status (h, i).

This study was reviewed and approved by the Ethics Committee of Honghui Hospital, Xi’an Jiaotong University (approval number: 202210004). All participating patients provided written informed consent. All patient details have been de-identified.

Several accepted nonunion criteria were used to standardize the data. First, nonunion was defined as “A fracture that has failed to unite completely. Nonunion is usually established when a minimum of 9 months has elapsed since the injury and the fracture site has shown no, or minimal, progressive signs of healing for a minimum of 3 months.”¹² Second, atrophic nonunion was defined as no demonstrable callus on radiographic examination when a fracture line persists and absorption at the ends of the fragments extends beyond the 9 months expected for union.¹³ Third, the criteria for septic nonunion was consistent with that used in previous studies.⁶ The diagnosis of infective nonunion was based on intraoperative tissue biopsy of specimens obtained from the nonunion site in the femoral stem. The C-reactive protein, erythrocyte sedimentation rate, and procalcitonin values were reviewed to exclude chronic low-grade infection before surgery. Tissue was collected intraoperatively from all patients for pathological examination. During the procedure, three tissue biopsies were taken from each nonunion site; if all results were negative for bacterial growth, the patient was included in the study.⁶

The previous IMN was left in place. A new incision was made over the nonunion site. The skin, subcutaneous, and broad fascia of the nonunion site were incised layer by layer. The cortical surface of the nonunion site was decorticated using Judet’s osteoperiosteal decortication technique. An osteotome was used to elevate the cortex of the bone together with the attached periosteum and soft tissues (Figure 1c). Care was taken to protect the periosteum and surrounding soft tissues, thereby avoiding excessive disruption of blood flow to the nonunion site. Autologous bone was harvested from the iliac crest. Next, the autologous iliac bone was bitten into a slender strip using an occlusal forceps, while the cortical strip of iliac bone was placed on the surface of the cancellous bone to protect it. An avoidance technique was used to fix the plate so that the fixation screws avoided the IMN. Staggered fixation was performed on the contralateral side. We drilled the holes with a Kirschner wire. No breaks occurred when the Kirschner wire touched the IMN. The screw was then applied. Finally, the stripped bone cortex, periosteum, and scar tissue around the nonunion site were sutured and wrapped around the bone graft. The soft tissue was adequately isolated from the nonunion site. The bone graft and internal fixation were assessed on radiographs (Figure 1d,e).

The patient demographic and clinical characteristics, including age, sex, side of injury, duration of follow-up, clinical healing time, and complications, were analyzed. All cases were contacted at a minimum of 12 months later for clinical and radiographic follow-up to check that bone union was achieved. The quality of union was evaluated using the Samantha X-ray scale^14,15 (Table 1) and clinical outcomes, including joint function and bone results, using the Paley scale.¹⁶ The differences between the preoperative and final follow-up data were subjected to statistical analysis.

Table 1.

Radiographic grading scale for degree of healing.

Description	Grade
* No changes from the appearance immediately after surgery	0
* A slight increase in radiodensity distinguishable from the graft	1
* Recognizable increase in radiodensity, bridging of one cortex with new bone formation at the graft	2
* Bridging of at least one cortex with material of nonuniform radiodensity, early incorporation of the graft suggested by obscuring of graft borders	3
* Defect bridged on both the medial and lateral sides with bone of uniform radiodensity, cut ends of the cortex still visible, and graft and new bone not easy to differentiate	4
* Same as grade 3, with at least one of four cortices obscured by new bone	5
* Defect bridged by new uniform bone, cut ends of cortex no longer distinguishable, and graft no longer visible	6

Statistical analysis

The Shapiro–Wilk test was used to determine whether the data were normally distributed. The data are summarized as the mean ± standard deviation (or range).

Results

Twenty-two patients (two female, 20 male; mean age 40.8 years [range, 19–61]) were identified to have aseptic atrophic nonunion of the femoral shaft during the study period. The mechanism of injury was a simple fall in four patients, a traffic accident in 11, a fall from height in six, and being hit by an object in one. The patients’ baseline data are shown in Table 2.

Table 2.

Summary of the patient characteristics and outcomes of femoral shaft non-union.

Patient	Age	Sex	Side	Mechanism of injury	Number of previous surgeries	Graft material	Time to union	Follow-up	SamanthaX-ray score	Paley scale score		Complications
no.	(years)	(M/F)	(L/R)				(months)	(months)		Bone	Function
1	37	M	R	Simple fall	1	Iliac bone	6	12	6	Excellent	Excellent	None
2	53	M	R	Simple fall	2	Iliac bone	12	12	5	Excellent	Excellent	Delayed union
3	47	F	R	Traffic accident	2	Iliac bone	14	18	5	Excellent	Good	Delayed union
4	28	M	L	Traffic accident	1	Iliac bone	5	13	5	Excellent	Excellent	None
5	19	M	R	Fall from height	1	Iliac bone	3	18	6	Excellent	Excellent	None
6	52	M	L	Traffic accident	1	Iliac bone	6	21	6	Excellent	Excellent	None
7	29	M	L	Traffic accident	2	Iliac bone	3	32	6	Excellent	Excellent	None
8	51	M	L	Traffic accident	3	Iliac bone	6	16	5	Excellent	Excellent	None
9	61	M	L	Fall from height	1	Iliac bone	4	24	6	Excellent	Excellent	None
10	48	M	L	Hit by an object	1	Iliac bone	5	18	6	Excellent	Excellent	None
11	33	M	R	Fall from height	1	Iliac bone	4	35	6	Excellent	Good	None
12	42	F	L	Traffic accident	1	Iliac bone	4	12	6	Excellent	Excellent	None
13	45	M	L	Traffic accident	1	Iliac bone	7	12	6	Excellent	Excellent	None
14	51	M	R	Fall from height	1	Iliac bone	6	24	6	Excellent	Excellent	None
15	53	M	L	Simple fall	3	Iliac bone	4	30	6	Excellent	Excellent	Sterile wound leakage
16	38	M	R	Traffic accident	1	Iliac bone	6	20	6	Excellent	Excellent	None
17	43	M	L	Traffic accident	1	Iliac bone	4	18	6	Excellent	Excellent	None
18	32	M	R	Simple fall	1	Iliac bone	6	12	5	Excellent	Excellent	None
19	27	M	R	Traffic accident	1	Iliac bone	3	16	6	Excellent	Excellent	None
20	23	M	R	Fall from height	1	Iliac bone	6	15	6	Excellent	Excellent	None
21	30	M	L	Fall from height	1	Iliac bone	4	24	5	Excellent	Good	None
22	55	M	L	Traffic accident	1	Iliac bone	4	12	6	Excellent	Excellent	None

The mean follow-up duration was 18.8 months (range, 12–35). All patients had clinical and radiographic evidence of union (Figure 1f,g), which was slightly delayed in two patients (united at 14 months in one and 10 months in the other). The average union time for a nonunion was 5.7 months (range, 3–14). The mean Samantha X-ray score was 5.7 ± 0.45. The functional results were excellent in 19 cases and good in three (Figure 1h,i). The bone evaluation outcomes were excellent in all 22 patients, none of whom suffered a nerve or vascular injury. One patient showed sterile wound leakage that resolved after a dressing change (Table 2).

Discussion

Exchange nailing with reamed larger-diameter nails is suitable for treating cases of aseptic atrophic nonunion after IMN of a femoral shaft fracture.¹⁷ However, there are conflicting reports regarding its success. Swanson et al.¹⁸ investigated 50 patients with aseptic femoral nonunion who underwent exchange nailing at a mean of 25 months and reported a 100% healing rate. Oh et al.¹⁹ used exchange nailing to treat cases of aseptic femoral nonunion with a success rate of 93%. However, a meta-analysis of five randomized controlled trials (256 patients) indicated a union rate of 78.9%.²⁰ Plate fixation is also a preferred treatment method. The success rate of plate augmentation with bone grafting in the treatment of nonunion is reportedly 100%.²¹ Schulz et al.²² used wave plating to treat cases of aseptic femoral nonunion and reported a success rate of 85.3% and a mean time to union of 7.3 months (range, 3–19).

Uliana et al.⁸ reported excellent or good clinical outcomes in all patients with aseptic femoral shaft nonunion after plate augmentation and leaving the IMN in situ. The healing rate at the nonunion site was 86%. The mean time to union was 11.7 months (range, 2–16). A recent meta-analysis demonstrated that the femoral shaft nonunion healing rate was 98.7% (225/228) in the plate augmentation group and 78.9% (202/256) in the exchange nailing group, with respective mean union times of 9.0 months and 10.9 months.²⁰

Although Judet and Patel⁹ were the first to report that osteoperiosteal decortication was an effective and simple technique for managing femoral shaft nonunion, this claim was based on cases treated after plate fixation. There were no clinical studies of osteoperiosteal decortication that developed nonunion following IMN of femoral shaft fractures. In recent years, with the application of biomechanics in orthopedics, plate augmentation has achieved a significantly higher union rate in cases of atrophic nonunion of a femoral shaft fracture.⁶ Autogenous bone grafting is still recommended for enhancement of healing in most cases of atrophic nonunion.²³

In our study, we performed Judet’s decortication and wave plate augmentation of the IMN combined with bone grafting in all cases and obtained a 100% union rate. The mean time to union (5.7 months) was lower than that in other reports.^17,20,24 The results were evaluated using the Paley bone and functional scores. The functional results were excellent in 19 cases and good in three. The bone evaluation outcomes were excellent in all 22 patients. There were two cases of delayed union, but union was achieved eventually in both. One patient showed sterile wound leakage that resolved after a dressing change.

Plate augmentation with retention of the IMN in situ for nonunion of a femoral shaft fracture has many advantages, including providing additional rotational stability, the nail left in situ preventing bending load on the plate, minimal incisions, no need for an extensive approach, less blood loss, and early rehabilitation.²⁵ For the additional plates, there are various types of plates and fixation methods, such as large (4.5-mm) or small (3.5-mm) fragment plates, a dynamic or locked compression plate, non-locking or locking screws, and bicortical or unicortical screws. The question arises as to when a wave plate or a straight plate should be used. After bone grafting, the grafted area is not higher than the cylinder of bone. Therefore, a straight plate should be used. Our previous study also supports this choice.²⁶ However, if the bone graft is beyond the cylinder of bone, a wave plate is a suitable choice (Supplementary Figure 1). The wave plate does not exert pressure on the graft and is beneficial for bone reconstruction.

Ma et al.²⁷ performed a biomechanics study in which they compared different types of screws and several auxiliary plates for the treatment of nonunion of a femoral shaft fracture after IMN. They found that rotational stability was improved when three screws rather than two screws were placed on each side. There was no significant difference between single cortical locking screw fixation and bicortical screw fixation with identical numbers of screws. They recommended three single cortical locking or bicortical screws on each side. However, they tended to use bicortical screw fixation more often in patients with a history of osteoporosis, especially elderly patients. Gautier and Sommer²⁸ found that single-cortical locking screw fixation required sufficient cortical thickness to provide mechanical stability, especially in patients with osteoporosis. It is difficult to achieve double cortical fixation using 4.5-mm system screws because of the limited residual space after fixation of the intramedullary nail to the femoral shaft. Furthermore, the locking plate and screw system cannot adjust the screw angle because of its intrinsic characteristics. Therefore, we recommend dual cortical fixation using a 3.5-mm plate system and cortical screws.

This study had some limitations. First, it had a retrospective single-center design with a small sample size and did not include a control group. Therefore, a large-scale prospective randomized case-control study is required to evaluate the effectiveness of Judet’s decortication, autogenous bone grafting, wave plate augmentation, and IMN retention. Second, although the study confirmed the safety and feasibility of Judet’s decortication and autogenous bone grafting combined with wave plate augmentation as a treatment for femoral shaft nonunion, a study with a longer follow-up period is required for more comprehensive evaluation.

Conclusion

In this study we obtained bony union using osteoperiosteal decortication and autogenous iliac bone graft combined with wave plate augmentation in all of 22 patients with femoral shaft nonunion after IMN with no cases of implant failure or significant complications. Our results suggest this treatment strategy is effective in patients with femoral shaft nonunion after IMN.

Availability of data and materials

The datasets used and/or analyzed in this study are available from the corresponding author on reasonable request.

Declaration of conflicting interests

The authors declare that there is no conflict of interest.

ORCID iDs

Yibo Xu https://orcid.org/0000-0003-4923-4820

Teng Ma https://orcid.org/0000-0003-3864-6600

Supplemental material

Supplemental material for this article is available online.