There were several methods, such as free single and folded fibulae autograft, composed tissue autograft, however, it is still very difficult to repair long segment bone defect. In December 1995, we used free juxtaposed bilateral fibulae autograft to repair an 8 cm of femoral bone defect in a 4 years old child in success. The key procedure is to strip a portion of the neighboring periosteal sleeve of juxtaposed fibulae to make bare of the opposite sides of the bone shafts, suture the opposite periosteal sleeves, keep the nutrient arteries, and reconstruct the blood circulation of both fibular by anastomosis of the distal ends of one fibular artery and vein to the proximal ends of the other fibular artery and vein, and anastomosis of the proximal ends of the fibular artery and vein to lateral circumflex artery and vein. After 22 months follow up, the two shafts of juxtaposed fibulae fused into one new bone shaft. The diameter of the new bone shaft was nearly the same as the diameter of the femur. There was only one medullary cavity, and it connected to the medullary cavity of femur. This method also cold be used to repair other long segment bone defect.
Objective To investigate short-term effectiveness of using expert adolescent lateral femoral nail (EALFN) in treating femoral shaft fractures in older children and adolescents. Methods A retrospective analysis was conducted on the clinical data of 17 patients with femoral shaft fractures who met the inclusion criteria and were admitted between July 2020 and June 2024. All fractures were fixed with EALFN after reduction. There were 11 males and 6 females, with a mean age of 13.3 years (range, 11-16 years). The average body weight was 51.2 kg (range, 40-84 kg), and the average height was 162.1 cm (range, 150-172 cm). The causes of injury included traffic accidents (n=9), falling from height (n=1), and simple falls (n=7). One patient had an open fracture treated with an external fixator and experienced delayed fracture healing. The remaining patients were closed fractures, with an average time from injury to operation of 5.8 days (range, 2-10 days). Operation time and postoperative hospital stay were documented. During follow-up, X-ray films were taken to observe the fracture healing, and the bilateral femoral length, femoral neck-shaft angle, widest femoral neck diameter (FND), and articular trochanteric distance (ATD) were measured at last follow-up. Hip function was assessed using the Harris score. The differences in the all indicators between the healthy and affected sides were compared. Results The operation time ranged from 65 to 130 minutes (mean, 94.1 minutes). Postoperative hospital stay ranged from 5 to 40 days (mean, 16.7 days). All patients were followed up 7-36 months (mean, 14.4 months). One patient exhibited delayed fracture healing during follow-up. The distal locking nail was removed at 6 months after operation, and partial weight-bearing was initiated following dynamic fracture stabilization. The fracture healing was achieved, and the intramedullary nail was removed at 24 months after operation. The other fractures healed with the healing time of 6-20 months (mean, 9.6 months), and the intramedullary nails were removed. During follow-up, no femoral fracture, abnormal development of the greater trochanter, or ischemic necrosis of the femoral head occurred. At last follow-up, there was no significant difference in femoral length, femoral neck-shaft angle, FND, ATD, or Harris score between the affected and healthy sides (P>0.05). Conclusion For older children and adolescents with femoral neck fractures, the application of EALFN fixation aligns more closely with the principles of intramedullary central fixation and rapid rehabilitation. This approach is associated with fewer complications and superior short-term effectiveness.
Objective To review the recent advances in treatment of aseptic femoral shaft nonunion. Methods The clinical studies about the treatments of aseptic femoral shaft nonunion in recent years were widely reviewed and analyzed. Results There are several surgical methods for aseptic femoral shaft nonunion. Due to uncertain clinical outcome, dynamization of nail should be carefully selected. The exchange nailing is suitable for the hypertrophic nonunion of the isthmal femoral shaft fracture. The exchange lateral plating is suitable for nonunion with obvious malformation. However, wave plate or dual plate should be chosen when the bone nonuinon is combined with the medial defect. The augmentation plating improves the success rate of nailing for femoral shaft nonunion, but it should be carefully selected for patients with obvious deformity or bone defect. Ilizarov technique is suitable for various bone nonunion, especially with complicated or large segmental bone defects. Induced membrane technique is also an important method for the treatment of bone nonunion with large bone defects. The clinical efficacy of the blocking screw remains to be supported by further evidence. Biological stimulants are mainly used for atrophic nonunion, and the clinical efficacy of them alone are still controversial. Conclusion Due to lack of comparative studies between different surgical methods, the orthopedist should choose the appropriate treatment according to the individual situations of the patient and the types of bone nonunion.
Objective To evaluate the effectiveness of reamed versus nonreamed intramedullary nailing for femoral fractures. Methods Randomized controlled trials (RCTs) and clinical controlled trials (CCTs) were identified from MEDLINE (1966-2004.5), EMBASE (1966-2004.5), Cochrane Library (Issue 2, 2004), Cochrane Musculoskeletal Injuries Group Database (2004.5), and CBM disc (1979-2004.5). We handsearched Chinese Journal of Orthopaedy (from establishment to May 2004) and Orthopaedic Journal of China (from establishment to May 2004) . RCTs and CCTs were included. Data were extracted by two reviewers with designed extraction form. RevMan 4.2.3 software was used for data analysis. Results Five RCTs and two CCTs were included. The combined results of meta-analysis showed that reamed intramedullary nailing for femoral fractures can reduce the rate of nonunion (RR=0.38, 95%CI 0.17 to 0.83, P=0.01) and the rate of implant failure (RR=0.42, 95%CI 0.20 to 0.89, P=0.02). Conclusions Compared with nonreamed intramedullary nailing for femoral fractures, reamed intramedullary nailing can reduce the rates of nonunion and implant failure. However, the relation between reaming or pulmonary complications, the time of union, infection, malunion, operative time, and blood loss needs further study.
Objective To investigate the effectiveness of tunnel osteogenesis technique combined with locking plate in the treatment of aseptic non-hypertrophic nonunion of femoral shaft. MethodsThe clinical data of 23 cases of aseptic non-hypertrophic nonunion of femoral shaft treated with tunnel osteogenesis technique combined with locking plate between January 2017 and December 2020 were retrospectively analysed. There were 17 males and 6 females with an average age of 41.4 years (range, 22-72 years). There were 22 cases of closed fracture and 1 case of open fracture. The types of internal fixation at admission included intramedullary nail in 14 cases and steel plate in 9 cases. The number of nonunion operations received in the past was 0 to 1; the duration of nonunion was 6-60 months, with an average of 20.1 months. Among them, there were 17 cases of aseptic atrophic nonunion of the femoral shaft and 6 cases of dystrophic nonunion. Twenty-two cases were fixed with 90° double plates and 1 case with lateral single plate. The operation time, theoretical blood loss, hospitalization stay, nonunion healing, and postoperative complications were recorded. Harris hip function score, Lysholm knee function score, lower extremity function scale (LEFS), and short-form 36 health survey scale (SF-36) were used at last follow-up to evaluate hip and knee functions. Visual analogue scale (VAS) score was used to evaluate the relief of pain at 1 day after operation and at last follow-up. ResultsThe average operation time was 190.4 minutes, the average theoretical blood loss was 1 458.4 mL, and the average hospitalization stay was 8.2 days. All the 23 patients were followed up 9-26 months, with an average of 18.2 months. The healing time of nonunion in 22 patients was 3-12 months, with an average of 5.6 months. There were 8 cases of limb pain, 8 cases of claudication, 6 cases of limitation of knee joint movement, and 2 cases of limitation of hip joint movement. At last follow-up, the imaging of 1 patient showed that the nonunion did not heal, accompanied by pain of the affected limb, lameness, and limitation of knee joint movement. At 1 day after operation, the VAS score of 23 patients was 6.5±1.8, the pain degree was good in 7 cases, moderate in 12 cases, and poor in 4 cases; at last follow-up, the VAS score was 0.9±1.3, the pain degree was excellent in 21 cases and good in 2 cases, which were significantly better than those at 1 day after operation (t=12.234, P<0.001; Z=–5.802, P<0.001). At last follow-up, the average Harris hip function score of 22 patients with nonunion healing was 94.8, and the good rate was 100%; Lysholm knee function score averaged 94.0, and the excellent and good rate was 90.9%; LEFS score averaged 74.6; SF-36 physical functioning score averaged 85.0 and the mental health score averaged 83.6. ConclusionTunnel osteogenesis technique combined with locking plate in the treatment of aseptic non-hypertrophic nonunion of femoral shaft has a high healing rate and fewer complications, which can effectively relieve pain and improve lower limb function and quality of patients’ life.
Objective To compare the outcomes between intramedullary nail change and augmentation plating with a retained intramedullary nail for aseptic nonunion of femoral shaft fractures after femoral nailing, and to analyze the cause so as to guide the clinical application. Methods Between June 2001 and June 2011, 28 patients with aseptic nonunion of femoral shaft fractures after femoral nailing were treated with intramedullary nail change (11 patients, group A) and augmentation plating with a retained intramedullary nail (17 patients, group B), and the clinical data were analyzed retrospectively. There was no significant difference in age, gender, smoking, location of fracture, Association for the Study of Internal Fixation (AO/ASIF) classification, type of injury, associated injury, type of nonunion, and time of nonunion between 2 groups (P gt; 0.05). The patients were followed up by imaging and the clinical function at regular intervals to observe the callus growth and the recovery condition of the affected limb function, and clinical curative effectiveness was evaluated by Tohner-Wrnch standard. Results The operation time, intraoperative bleeding volume, and intraoperative erythrocyte-transported volume in group A were significantly higher than those in group B (P lt; 0.05). There was no significant difference in postoperative drainage volume and hospitalization days between 2 groups (P gt; 0.05). All the incisions healed by first intention, and no nerve and blood vessel injury occurred. All patients were followed up 18.6 months on average (range, 12-36 months). All cases obtained bone union, and time of clinical and radiological bone healing in group B was significantly shorter than those in group A (P lt; 0.05). During follow-up, no following complication occurred: deep incision infection, injuries of blood vessels and nerves, loosening and breakage of internal fixation, loss of reduction, angulated and rotational malunion. According to Tohner-Wrnch standard at last follow-up, the results were excellent in 6 cases, good in 3 cases, and poor in 2 cases, with an excellent and good rate of 81.8% in group A; the results were excellent in 12 cases, good in 5 cases, with an excellent and good rate of 100% in group B; and difference was significant between 2 groups (Z= — 2.623, P=0.021). Conclusion Augmentation plating with a retained intramedullary nail is an ideal treatment for aseptic nonunion of femoral shaft fractures after femoral nailing and can achieve satisfactory clinical outcomes because it has simpler operation, shorter operation time, less blood loss, and less trauma than intramedullary nail change.
Objective To explore the effectiveness of Ilizarov external fixation without bone graft in the treatment of atrophic femoral shaft nonunion. Methods The clinical data of 12 patients with atrophic femoral shaft nonunion admitted between October 2010 and January 2017 were retrospectively analyzed. There were 8 males and 4 females, aged from 24 to 61 years, with an average age of 41.7 years. The nonunion sites located in the middle and upper femur in 7 cases and in the distal femur or supracondylar in 5 cases. The disease duration ranged from 1 to 9 years, with an average of 3.7 years. Previous operations ranged from 1 to 9 times, with an average of 2.8 times. The original fixator was removed, the fracture end of nonunion was debrided, and Ilizarov external fixator was installed. In patients with the length of bone defect less than 4 cm, direct compression fixation was performed during operation; in patients with limb shortening more than 2.5 cm, proximal femoral osteotomy and bone lengthening components were required to prepare limb lengthening after operation; all patients did not receive bone graft. The wearing time of external fixator, clinical bone healing time of nonunion fracture end, and complications were recorded. The effectiveness was evaluated by Paley’s nonunion evaluation criteria. Results All patients were followed up 24-50 months, with an average of 30 months. Bony union was achieved in all 12 cases with a healing time of 6.0-23.5 months (mean, 11.5 months). The wearing time of external fixator ranged from 7 to 25 months, with an average of 13.5 months. At last follow-up, according to Paley’s nonunion evaluation criteria, the results were excellent in 6 cases, good in 4 cases, and fair in 2 cases, with an excellent and good rate of 83.3%. Sagittal angulation deformity of femur more than 7° occurred in 4 cases, with no significant effect on knee extension function, and no special treatment such as osteotomy was performed. Two patients had shorter limbs (>2.5 cm) after operation and were replaced by high shoes; 4 patients with trans-knee fixation lost knee joint mobility of 10-30° after operation; 10 cases of needle tract infection occurred, of which 4 cases with infection and loosening of fixed needle were replaced and re-fixed after needle extraction, the remaining 6 cases of infection without loosening of fixed needle were controlled by local dressing change, needle nursing, and oral cephalosporin anti-inflammatory drugs. No complications such as deep infection and vascular nerve injury occurred. Conclusion Ilizarov external fixation has a high healing rate for atrophic femoral shaft nonunion, which is relatively minimally invasive and can avoid bone grafting. Its preliminary effectiveness is exact, and it is also effective for patients who have experienced multiple failed operations. It is necessary to pay attention to the nursing and rehabilitation training after external fixation.
【Abstract】 Objective To discuss the techniques and advantages of closed reduction and intramedullary nail ing intreating femoral shaft fracture without cannulated femoral reamer. Methods From January 2006 to June 2007, 24 cases offemoral shaft fracture were treated with closed reduction and intramedullary nail ing. Among them, there were 14 males and 10 females, with the average age of 38.3 years (ranging from 18 years to 63 years), with 7 left legs and 17 right legs. The average course of the disease was 7.6 days (ranging from 3 days to 20 days). According to the AO typing, there were 5 cases of type A, 6 of type B, 7 of type C1, 2 of type C2 and 4 of type C3. Closed reduction was achieved with manipulation and reaming of femoral canal was instructed by fluoroscopy. Results The operation time lasted from 100 minutes to 170 minutes, with the average time of 128.3 minutes. One patient was given a transfusion of 400 mL, and others were not. Twenty cases were followed up with the average time of 13.1 months (ranging from 6 months to 24 months). A mild to large amount of bony callus was showed on X-ray films 6 to 12 weeks postoperatively. Walking without crutches began at the average week of 22.2 (ranging from 15 to 30) postoperatively. Range of motion of the knee was 0° to 145.5°. No infection or break of the internal fixator occurred. Myositis ossificans with pain and insufficient flexion of hip (120°) happened in 1 case and the pain disappeared after non-steroid anti-inflammatory drugs were taken. Nonsymptomatic myositis ossificans occurred in 2 cases and no treatment was needed. Conclusion Closed reductionand intramedullary nail ing can help to protect the blood supply of fracture fragments and provide central fixation. The operation process will be more compl icated if cannulated femoral reamer is not available.