Nonunion of femoral shaft fracture

As people age, their bones will gradually age, their body functions will deteriorate, and their body flexibility will begin to decline. Coupled with excessive fatigue and lack of rest, bone pain is very likely to occur. Some people have femoral shaft injuries and fractures. The femur is our thigh bone. If the fracture does not heal during treatment, what should we do?

Different methods should be used to treat nonunion according to the cause and type of its formation. In general, the fracture needs to be well reduced, and the appropriate internal or external fixation materials should be used to stabilize the fracture. The need for bone grafting should be determined based on the condition of the fracture ends: for vascularized nonunion, as long as there is stable fixation, a connection can be achieved without bone grafting; while for ischemic nonunion, the sclerotic bone at the fracture ends needs to be removed, the medullary cavity needs to be opened, and bone grafting should be performed. Bone grafting is the most common and effective method for treating nonunion. There are many sources of bone, including autologous bone, allogeneic bone, and synthetic bone substitutes, among which autologous bone is the best bone grafting material.

The treatment of segmental bone defects, a special type of nonunion, is more difficult. Depending on the specific situation, vascularized bone transplantation (such as free fibula transplantation, etc.), cortical osteotomy and bone migration can achieve good results. Of course, this requires high professional knowledge and skills of doctors.

Actively improving the patient's metabolic and nutritional status before surgery, encouraging the patient to quit smoking, using the limbs as much as possible and performing adjacent joint functional exercises, and controlling infection can help improve the efficacy. In addition, low-intensity ultrasound, electrical and electromagnetic stimulation methods can be used to treat some patients with bone nonunion.

Although the technical level in the field of trauma treatment is improving, with very complete nursing measures, advanced surgical techniques, newer internal fixation implants, and new auxiliary measures to promote fracture healing, nonunion of fractures still occurs frequently in trauma patients, especially those with high-energy injuries. Nonunion of femoral shaft fracture is a serious socioeconomic problem for patients. Long-term nonunion can lead to walking impairment, inability to work, reoperation and serious psychosocial problems. At the same time, the treatment of femoral shaft fracture nonunion is a huge challenge for trauma orthopedic surgeons. In treating this type of disease, many factors need to be considered, such as the initial treatment plan for the fracture, correction of deformity, control of infection, rapid recovery after surgery, etc.

The Winquist–Hansen femoral shaft fracture classification system takes the degree of fracture comminution into account when classifying and assesses whether the fracture requires locking and nailing to determine the postoperative weight-bearing regimen for the injured limb and to prevent nonunion of femoral shaft fractures. Inappropriate mechanical and dynamic environment during fracture (such as insufficient fracture stability), insufficient blood supply, loss of fracture fragments, or the presence of infection are the main causes of fracture nonunion. In some cases, unexplained nonunion may occur despite appropriate treatment. There are also some special cases, such as patients with femoral shaft fractures and acute spinal cord injury. The non-union rate of femoral shaft fractures in these patients after conservative treatment is as high as 31%.

There are many methods for treating nonunion of femoral shaft fractures, including intramedullary nail dynamization, bone plates, external fixation, plate replacement, and auxiliary treatment measures such as electrical or ultrasonic stimulation, autologous or allogeneic bone grafting, and BMP. In patients with segmental bone defects, vascularized bone grafting may be an option.

Many authors recommend closed reamed intramedullary nailing alone or in combination with open bone grafting for the management of femoral shaft nonunion. The nonunion rate of femoral shaft fractures treated with intramedullary nailing varies from 1% to 20%, depending on the type of fracture and treatment technique. Repeated treatment of femoral shaft fractures will reduce the success rate of fracture nonunion, mainly because repeated treatment will damage the blood supply and periosteal membrane of local tissues and reduce the nutritional supply to the fracture site. Other methods for treating nonunion of fractures, such as replacement of intramedullary nails, dynamization of intramedullary nails, external fixation, and bone plates, have varying success rates, reported at 47%-100%.