IMN is the gold standard method for managing adult femoral shaft fractures. In recent years, with the continuous development of IMN techniques and the expanding clinical indications, the incidence of nonunion after IMN of femoral shaft fractures is reportedly 10%. When encountered, it represents serious economical, functional, and psychological burdens on patients.
Exchange nailing with reamed larger-diameter nails is suitable for treating cases of aseptic atrophic nonunion after IMN for femoral shaft fractures. However, there are conflicting reports of its success. Swanson investigated 50 patients with aseptic femoral nonunion who underwent exchange nailing at a mean 25 months and found a 100% healing rate. Oh used exchange nailing to treat cases of aseptic femoral nonunion, and the success rate was 93%. However, a meta-analysis of five randomized controlled trials (256 patients) indicated a union rate of 78.9%. Plate fixation is also a preferred treatment method. The success rate of augmentative plating with bone grafting in the treatment of nonunion is reportedly 100%. Schulz 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 months).
Christiano reported that augmentation plating for the treatment of femoral aseptic shaft nonunion leaving the IMN in situ featured excellent and good clinical outcomes in all patients. The healing rate of the nonunion site was 86%. The mean time to union was 11.7 months (range, 2–16 months). A recent meta-analysis demonstrated that the femoral shaft nonunion rate was 98.7% (225/228) in the augmentative plating group and 78.9% (202/256) in the exchange nailing group, while the mean union time was 9.0 months in the augmentative plating group and 10.9 months in the exchange nailing group.
Judet first reported that osteoperiosteal decortication was an effective and simple technique for managing femoral shaft nonunion, but 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, augmentative plating has featured a significantly higher union rate for femoral shaft atrophic nonunion cases. Ramoutar reported that 96 cases of nonunion were treated with Judet’s decortication and an additional plate with or without bone grafting with union rates of 94.6% without a bone graft and 95% with a bone graft. Autogenous bone grafting is still recommended to enhance healing in most cases of atrophic nonunion.
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) is lower than that reported by another study[15, 18, 23]. 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 22 patients. There were two cases of delayed union, but union was achieved eventually in both. One patient showed sterile wound leakage that was cured after a dressing change.
Plate augmentation with retention of the IMN in situ for nonunion of femoral shaft fracture has many advantages, such as 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. For the additional plates, there are various types of plates and fixation methods, such as large fragment plates (4.5 mm) or small fragment plates (3.5 mm), a dynamic compression plate or locked compression plate, non-locking or locking screws, and bicortical or unicortical screws.
According to a biomechanical study, Ma compared different screw types and several auxiliary plates for the treatment of nonunion of femoral shaft fracture after IMN. The authors found that the use of three screws on each side allowed additional rotational stability than the use of two screws on each side. There was no significant difference between single cortical locking screw fixation and bicortical screw fixation with identical screw numbers. They recommended three single cortical locking or bicortical screws on each side. However, they had a greater tendency to adopt bicortical screw fixation in patients with a history of osteoporosis, especially elderly patients. Gautier found that single-cortical locking screw fixation must have sufficient cortical thickness to provide mechanical stability, especially in patients with osteoporosis. Due to the limited residual space after IMN fixation to the femoral shaft, it is difficult to achieve double cortical fixation using 4.5-mm system screws. In addition, the locking plate and screw system cannot adjust the screw angle due to its own intrinsic characteristics. As such, we recommend dual cortical fixation using a 3.5-mm plate system and cortical screws.
There are some limitations to the current study. First, it was a retrospective single-center study with a small sample size. 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, this study confirmed the safety and feasibility of femoral shaft nonunion treated with Judet’s decortication and autogenous bone grafting combined with wave plate augmentation. However, a study with a longer follow-up period is required to ensure a comprehensive evaluation.