Arch Orthop Trauma Surg (2012) 132:937–940

DOI 10.1007/s00402-012-1497-4

ORTHOPAEDIC SURGERY

Augmentative locking compression plate Wxation for the management of long bone nonunion afterintramedullary nailing

Jianping Ye · Qiang Zheng

Received: 2 December 2011 / Published online: 7 March 2012© Springer-Verlag 2012

AbstractObjective Intramedullary nailing is widely used in thetreatment of long bone fractures. But some patients suVerfrom nonunion after receiving intramedullary nailing. Thispaper investigates the methods and eVects of locking com-pression plate (LCP) in the treatment of long bone non-union after intramedullary nailing.Methods A total of 6 patients (4 males, 2 females) withlong bone nonunion were enrolled. All these patients hadpreviously undergone intramedullary nailing for fracturesof long bones (4 femurs, 2 tibiae). The average time frominjury to LCP treatment was 12.2 months. The lockingcompression plate was applied over the intramedullary nail,and unicortical purchase achieved with locking head screwsdue to underlying nails. Autologous bone grafting was donein all cases.Results Six patients were followed up for 12–20 months(mean 14.2 months). X-ray imaging showed bone callus atthe broken ends of the fracture at 3–7 (mean 4.5) monthsafter surgery. All patients did not have any complicationssuch as infection, breaking or loosening of the LCPs.Conclusion LCP can be used for the treatment of longbone nonunion after intramedullary nailing for its conve-nience, minimal invasion and curative eVect.

Keywords Locking compression plate · Intramedullary nailing · Long bone fracture · Bone nonunion

Introduction

Intramedullary nailing is popular for treating long bone frac-tures for many years. Although most long bone fractures arecured by intramedullary Wxation, nonunion sometimesoccurs. Currently, there are several options in the treatmentof nonunion after intramedullary nailing: exchanging anunlocked nail with a locked nail [1, 2], reamed exchangenailing [1, 3], dynamizing a locked nail [2], and nailremoval followed by plating [4], or external Wxation [5]. Anautogenous bone grafting is usually required in an atrophicnonunion or in a signiWcant bone defect to enhance bonehealing [6, 7].

Instability is believed to be a cause of nonunion [2, 8, 9].Increasing stability is necessary in these nonunions [9].This paper demonstrates our recent experience in treatinglong bone nonunions subsequent to intramedullary Wxationwith augmentative locking compression plate Wxation.

Materials and methods

From 2008 to 2010, six patients with tibial or femur non-unions after intramedullary nail Wxation were treated withthe augmentation plating procedure. There were four menand two women. Average age at the time of injury was 47(range 23–46) years. Plate augmentation and bone graftingwere done at an average of 12.2 (range 7–20) months afterthe primary procedure.

A nonunion was deWned as persistent pain at the fracturesite combined with the absence of progressive healing onthree consecutive radiographs taken at 1-month intervals orfailure to unite at 6 months after surgery. All the cases wereclosed fractures and there were three atrophic nonunionsand three hypertrophic nonunions (Table 1). A hypertrophic

J. Ye · Q. Zheng (&)Department of Orthopaedic Surgery, Second AYliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Chinae-mail: dlameng1986@126.com

J. Yee-mail: yejianping1986@gmail.com

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nonunion was deWned radiographically by demonstratingabundant fracture callus with inadequate stability and per-sistent fracture lines, whereas an atrophic nonunion wasdeWned by no evidence of callus formation with failure tobridge the fracture gap.

The nonunion site was exposed through a lateralapproach. The rotational instability of the nonunion sitewas veriWed by a direct view of a rotational movementbetween the two fracture ends. This was present in allcases. The retained nail maintained alignment of thefracture, a locking compression plate was applied to thelateral aspect of the bone and unicortical purchaseachieved with locking head screws due to underlyingnail. The plating did not require excessive devascularisa-tion of the bone or the soft tissue envelope. Autologousbone graft harvested from iliac crest was added to thefracture site to enhance the biology. Although therewas visible motion at the fracture site in all cases beforeplate Wxation, the movement disappeared after plateaugmentation.

After the operation, patients were allowed knee-jointexercise and partial or full weight bearing with the aid ofcrutches without external supports or devices. They werefollowed up regularly at the outpatient clinic until the frac-ture had healed.

Results

The time of operation was an average of 105 (range 90–120)min, mean blood loss was 155 (range 30–400) ml, andthere were no complications during the procedures.Mean follow-up period after plate augmentation andbone grafting was 14.2 (range 12–20) months. Bonyunion was achieved in all six cases. The average time toradiologic union was 4.5 (range 3–7) months (Table 1).In one case the hardware had been removed at 14 monthsafter plating. During a 12- to 20-month follow-up periodthere was no complication of infection or implant failure(Fig. 1).

Discussion

Intramedullary nailing has been popularly used in mostlong bone fractures for many years. Although most frac-tures were cured by intramedullary Wxation, nonunions dosometimes occur. There is no standard guideline for thetreatment of femoral and tibial nonunions after intramedul-lary Wxation.

Exchange nailing has been the procedure of choice fortreatment of nonunions of long bones speciWcally in thelower limbs [1, 3]. Recent reports have, however, ques-tioned the procedure in every long bone nonunion. Wereshet al. in 2000 showed results of exchange nailing in 19 fem-oral nonunions. Only 10 of 19 (55%) had osseous union,whereas the rest did not unite [10]. Failures of exchangenailing has speciWcally been noted in long bone nonunionsassociated with extensive comminution at fracture site, largesegmental defects, humeral nonunions and metaphyseal–diaphyseal junctional fractures [11]. Also exchanging thenail with nail of larger diameter cannot be done if the nailalready inserted is of largest diameter as marketed by themanufacturer.

Problems of ununited fractures may be due to proximalor distal location of the fractures in the respective bones,undersized nail, extensive comminution or broken implants[11]. All these factors lead to rotational instability at thefracture site even though axial and translational alignmentshave been suitably restored. Thereby it becomes paramountto control rotational instability at nonunion site by addi-tional stabilizing mechanism [12].

Augmentative plate Wxation for the management of longbone nonunions after intramedullary nailing has been suc-cessfully attempted by few workers. Ueng et al. in his studyof 17 femoral nonunions showed union of all fractures at 7(range 6–10) months by using augmentation plates. Bonegrafting was performed in seven patients based on oligo-trophic nature of nonunions [9]. The same authors latershowed good results of this procedure in management oftibial nonunions after intramedullary nailing. They treated12 tibial nonunions with intramedullary nails in situ with

Table 1 Summary of patients

WH Winquist–Hansan classiWcation, Noun duration of nonunion, Op time operation time, Bl loss blood loss, Rad union radiologic union,FU followed up available till latest review

No. Age/sex Bone Site Injury type (WH)

Type of nonunion

Noun (months)

Op time (min)

BI loss (ml)

Rad union(months)

FU(months)

1 45/M Femur Middle I Atrophic 20 120 100 6 20

2 34/F Tibia Middle I Atrophic 7 90 30 4 12

3 67/M Femur Proximal I Atrophic 14 120 400 7 14

4 54/M Tibia Proximal 3rd III Hypertrophic 12 90 100 3 15

5 59/M Femur Distal 3rd II Hypertrophic 12 120 200 3 12

6 23/F Femur Proximal 3rd I Hypertrophic 8 90 100 4 12

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augmentation plates. All of them united within an averageof 5.5 (range 4–8) months. Bone grafting was performed inone patient who had oligotrophic nonunion. They used adynamic compression plate in their series [13].

Support for this technique was reinforced later. Ring andJupiter showed their results of treating nonunions ofhumerus leaving the intramedullary nail in site and applica-tion of locking compression plates. Locking plates provided

Fig. 1 a A 59-year-old man with nonunion fracture of distal thirdfemur with intramedullary nail in situ. b Immediate postoperativeX-ray after application of locking compression plate along with bone

grafting. c Three months after surgery, X-ray imaging showed bonecallus at the broken ends of the fracture

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eVective solution in all six cases that they operated withoutremoving the intramedullary nail [14]. Choi and Kimshowed radiologic union in 15 patients with femoral non-unions when treated with AO plates. Radiological bonyunion was achieved in all patients in 7.2 (range 5–11)months. Bone grafting was performed in all patients [15].Nadkarni et al. showed their good results of treating 11long bone nonunions (seven femurs, two humeri, twotibiae) without removing intramedullary nail and applica-tion of locking compression plates. Cortico cancellousautologous bone grafting was performed in every patient toenhance the biology. All the fractures showed radiologicunion at 6.2 (range 5–8) months [12].

Our series contained 6 patients nonunions in femur (4),tibia (2). None of these patients had any broken implants.None of these patients were infected nonunions. The nailwas static in all the cases. All these patients had rotationalinstability on the fracture site. Application of locking com-pression plates in such situations restored rotational stabil-ity in these fractures. We did not use any compressiondevice, we chose LCP for its convenience and minimalinvasion. Locking compression plates by virtue of theirangular stability gives a superior hold over conventionalnonlocking plates, and when applying a plate over an intra-medullary nail, unicortical locking screws can be insertedwhen it is not possible to drill a bicortical screw [12, 14].The plating did not require excessive devascularisation ofthe bone or the soft tissue envelope. Bone grafting wasperformed in every patient to improve the biology at thefracture site. The technique is minimally invasive and doesnot require any special instrument. All our six cases of non-union were successfully managed with the augmentativeplate Wxation without a complication of infection or implantfailure.

Although this study is limited by the lack of controlgroup and small cohort of patients, we believe that augmen-tation plates in the form of locking compression plates andbone grafting leaving the nail in situ can be an eVectivesolution in case of long bone nonunion after interlockingintramedullary nailing.

ConXict of interest This project did not have any Wnancial supportand the authors have received nothing of value.

References

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