Date: Tue, 9 Apr 2002 20:07:10 +0600

Subject: Femoral Shaft Nonunion

Hello All,

A female 48 y.o. admitted to us with femoral nonunion. She was plated elsewhere 2,5 yrs ago and Sep 2001 the plate was removed. Since that she has been trying to increase knee ROM and walked with cane. After Jan 2002 she marked "progress" in "knee motions" along with deformation above the knee. She demonstrates mobility at the nonunion site, mostly in sagittal plane. Lateral film presents maximal alignment, and about 30 degrees of more "flexion" is possible. Walks with cane. Knee seems conpletely frozen. No signs of infection reported since initial treatment.

We plan to perform closed intramedullary nailing. I feel lack of experience in this approach for the sort of patients so some questions arise.

Is acute axial alignment acceptable here? Or gradual axial correction by external fixator with hinges should be preferred? What sort of nailing is better here - closed or open with bone grafting? In case of closed procedure how to open medullary canal if the bone is solid above the site? Dynamic or static locking? Maybe it is worth to combine femoral stabilization with some kind of knee mobilization procedure? If yes what to do?

Any other aspects which should be kept in mind here?

Best regards,

Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia


Reply at: Orthopaedic Trauma Association forum

Date: Tue, 9 Apr 2002 22:12:50 +0530

From: DR T I GEORGE

Dear Dr Alexander,

I would vote for

i) Open reduction,
ii) Cancellous bone grafting and
iii) retrogrde nailing through open knee exposure.

I see one danger in antegrade nailing. The bone looks very porotic in the condylar and supracondylar region. With the added problem of stiff knee if you do antegrade nailing there is a chance of path fracture just distal to the nail unless condyles are locked.

The advantage of retrograde nailing are:

i) Arthrolysis of knee can be done.
ii) Condyles can be locked.
iii) Hence less worry when mobilising knee of having a new fracture.

Advantage of open reduction: Deformity can be corrected on the table. Cancellous graft can be laid around the fracture site there by increasing the chance for union in an already problematic situation.

Do keep the list informed on what you do.

Dr.T.I. George, Consultant Orthopaedic Surgeon,
Polytrauma, Microvascular Surgery And Hand Surgery Unit,
Metropolitan Hospital, Trichur, S.India.


Date: Tue, 9 Apr 2002 18:10:42 +0100

From: chris wilson

Appears to be a good case for a retrograde femoral nail, with open excision of fibrous tissue and use of autologous bone graft.A retrograde approach would allow dissection at the knee to enhance range of motion there. We use retrograde nails by Depuy and by Smith and Nephew-both quite good.

Chris Wilson
Conultant Orthopaedic and Trauma surgeon
University Hospital
Cardiff, UK


Date: Wed, 10 Apr 2002 00:16:58 +0600

From: Alexander Chelnokov

Hello chris,

cw> would allow dissection at the knee to enhance range of motion there.

Looks like the trouble is not limited by the articular area. Maybe myolysis of quadriceps and lengthening of its tendon is required.

Best regards,

Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia


Date: Tue, 09 Apr 2002 15:15:59 -0500

From: Steven Rabin

i'd do a closed reamed IM nailing, with the plan of coming back in 6-12 weeks to do a quadricepsplasty plus or minus bone graft then. I wouldn't do it together because i would not want to destroy the endosteal blood supply with my reaming and then destroy the periosteal blood supply with the soft tissue disection necessary for the quadriceps plasty. (She may also need lysis of intra-articular adhesions.) (If I am unable to do the rodding closed - as sometimes the medullary canal is walled off - then I would open it, and if I had to open it, then I would bone graft at the same time, probably with a quadricepsplasty as well. There are sharp awls that can be introduced from above through the medullary canal to open up a canal that is closed off, and these sometimes work, and sometimes they don't depending on how hard the bone is.) Static locking to control rotation, which could be dynamized later.


Date: Wed, 10 Apr 2002 12:55:03 -0400

From: James Carr

I agree with the retrograde votes. Arthrolysis/ quad release will help take the stress off the repair, and is important. Bone graft is good idea. Be prepared to use a Kuntschner nonunion chisel (?source) to make a medullary canal. Drive it up using a-p, lat fluoro, them pass the bulb tip. I am not a fan of lengthing in the face of nonunion. I find nearly all are so happy to get their leg healed, they never want to see an ortho surgeon again. Lengthing complicates the whole matter, but I know some experts are good at it.

James B. Carr, MD
Palmetto Health Orthopedics


Date: Tue, 09 Apr 2002 10:25:27 -0600

From: Thomas A. DeCoster

I concur with the suggestion for retrograde nail and lysis of adhesions.

Peri-articular nonunions typically involve joint stiffness and if you don't mobilize the joint your new fixation is at great risk because the long lever arm and the stiff joint puts lots of stress on the nonunion. Thus your comment about "improved knee flexion".

Although "quadricepsplasty" is the term most orthopedists think of when faced with a stiff knee it is not usually actually shortening of the quadriceps but rather scar formation that includes (in order of importance IMHO):

Rather than cutting and lengthening quad tendon as primary focus (with some loss of strength etc) a focus on releasing and stretching scar/adhesions/contractures is more effective at obtaining and maintaining motion. You could consider a lateral parapatellar approach for nail insertion and obtaining knee flexion(releases) and getting the reamer guide across the nonunion.

Re-establishing a medullary canal requires breaking through the sealing callus at the fragment ends. Sometimes easy sometimes hard. Ball tipped guide occasionally works, Kuntscher long thin spade tipped guide for more difficult cases and for the other 50% Smith & Nephew makes a "pseudarthrosis chisel" (Catalog # 115128 5.6 mm) 6 mm diameter very sharp tip with a heavy handle for hammering; long enough for tibia or retrograde femur here. Alternative for difficult cases is to open the fracture and drill out the medullary canal but you really have to mobilize the ends which is much more extensive than a fresh fracture situation. The amount of angulatory deformity in this case would be amenable to acute correction. You might have to remove the broken screw part to ream the medullary canal. Check for indolent infection.

Retrograde nailing allows:

1) better distal fixation than antegrade nailing in this case
2) concomitant release of scar allowing knee flexion
3) easier intramedullary passage than antegrade (whether open or closed).

TD


Date: Wed, 10 Apr 2002 14:02:19 -0500

From: Adam Starr

I agree with what Tom said, especially the "check for indolent infection" part. It wouldn't change my fixation method - I'd still nail it. But if your intra-op cultures grew out staph, at least you'd know to treat the patient with antibiotics while the fracture was healing.

Adam Starr
Dallas


Date: Mon, 15 Apr 2002 20:52:01 +0600

From: Alexander Chelnokov

Hello All,

THX for your valuable comments. We still decided not to try knee mobilization procedure in one step. As a less invasive procedure an external fixator was applied. The attached image demonstrates maximal correction reached under manual pressure and traction of posterior sides of the rings. I plan to align the femur in 7-10 days then perform antegrade nailing. The bloodless transformation must be much less traumatic than acute correction. Comments are welcome.

Best regards,

Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str. Bankovsky, 7. Ekaterinburg 620014 Russia


Date: Mon, 15 Apr 2002 13:28:11 -0400

From: David Goetz

We have had two open femoral fractures nailed through the knee that developed late knee sepsis along with their delayed presentation of femoral osteomyelitis [4-6 months post op]. Is there hesitancy to nail a femoral nonunion [and therefore possibly a septic nonunion] through the knee?

David R. Goetz MD
Medical Director, Orthopaedic Trauma


Date: Mon, 15 Apr 2002 12:37:19 -0500

From: Adam Starr

We haven't had that problem down here. But it's something to worry about, I agree.

Maybe Tom's idea of doing a lateral approach to free the quadriceps from the femur would decrease that risk some. I suppose you could also mobilize the nonunion site through that same lateral exposure...but a retrograde nail would still leave you with a hole in the femur and a conduit for the bugs to swim into the knee joint.

Antegrade nailing works fine. Maybe an antegrade nail would be the best choice, if you were concerned about pus after you'd seen the fracture site.

Adam Starr
Dallas


Date: Mon, 15 Apr 2002 14:42:01 -0500

From: Steven Rabin

I presented a poster at the OTA 2 years ago where we reported both acute and late presentations of knee infection after retrograde nailing of open fractures. Our paper did not have enough of a sample size to draw any firm conclusions, but I think it is a concern. I have continued to treat some open fractures with retrograde roddings when the indications are strong, but I do think there should be a high index of suspicion when a previously open fracture of the femur goes on to nonunion.

steve rabin
loyola

Date: Mon, 15 Apr 2002 18:19:21 -0400

From: bruce meinhard

In the past I have handled this in the following way: ESR,CRP,CBC and diff. If any of these is questionable, or if I have a bad feel about the case (prior open fx post op wound problems, etc.) then I will stage it by first obtaining a craig needle biopsy for culture. If results are negative then I will proceed with Retro Nailing.

BPM


Date: Tue, 16 Apr 2002 04:38:43 -0600

From: Thomas A. DeCoster

I don't follow your logic in this case. You mention "gradual correction of deformity" but there really wasn't much deformity on the initial radiographs. There was nonunion with motion at the fracture site but knee joint stiffness. The alignment was ok on the earlier radiographs. Are you going to use the fixator to get knee joint motion somehow?

Tom DeCoster


Date: Thu, 18 Apr 2002 08:40:16 +0600

From: Alexander Chelnokov

Hello Thomas,

TAD> I don't follow your logic in this case. You mention "gradual correction of deformity" but there really wasn't much deformity on the initial radiographs.

Stiff/hypertrophic pseudarthroses are routinely treated here by gradual distraction. It results with improvement of vascularization of bone ends and filling the gap by regenerate. I think that more high healing potential is useful even if ex-fix is exchanged with the nail. Also the approach is used to make correction minimally invasive. And maybe my fears about neurovascular lesion were not too dramatic - she marked foot numbness at 4-5 days of distraction.

TAD> There was nonunion with motion at the fracture site but knee joint stiffness. The alignment was ok on the earlier radiographs.

Not exactly. I found her films made in Nov. 1999 - looks like the angle was set at the initial surgery.

TAD> Are you going to use the fixator to get knee joint motion somehow?

At least not at this stage. At all, she is not highly motivated to restore knee motion. Looks like she got accustomed being with stiff knee for some years.

Best regards,

Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia


Date: Sun, 21 Apr 2002 17:56:38 +0600

From: Alexander Chelnokov

Hello All,

After 8 days of gradual angular correction alignment was reached and antegrade femoral nailing was performed with UFN 11 mm. Long flat awls were used to open canal in both fragments. The nail is locked statically. I plan to dynamize it after 2 months. Comments are welcome.

Best regards,

Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia


Date: Sun, 21 Apr 2002 14:32:52 -0400

From: bruce meinhard

Very nice Job. But you may not have to dynamize it.

BPM


Date: Mon, 22 Apr 2002 09:49:10 -0400

From: James Carr

Looks Great

JBC


Date: Mon, 22 Apr 2002 10:18:40 -0400

From: Andrea Salvi

Dear colleague,

I think it is a good idea to dynamize the nail after 2 months.

Best regards

Andrea Salvi, MD - Traumatologist
Spedali Civili Brescia
2 Divisione Ortopedia-Traumatologia
ITALY