double plating nonunion femur

DOUBLE PLATING DOUBLE PLATING WITH WITH BONE GRAFTING IN ASEPTIC BONE GRAFTING IN ASEPTIC NONUNION OF DIAPHYSEAL NONUNION OF DIAPHYSEAL

FRACTURES OF FEMURFRACTURES OF FEMUR

Dr. SAJEEV. P.SDr. SAJEEV. P.SProf. Cherian M. ThomasProf. Cherian M. ThomasSP Fort Hospital , TrivandrumSP Fort Hospital , Trivandrum

AIMAIM

To assess the efficacy of To assess the efficacy of Double PlatingDouble Plating with bone with bone

grafting in achieving union of grafting in achieving union of aseptic ununited fractures of aseptic ununited fractures of

femoral diaphysisfemoral diaphysis

IntroductionIntroduction

10 % of fractures require SECOND 10 % of fractures require SECOND procedure for fracture healingprocedure for fracture healing

Nonunion after ILN is 1 %Nonunion after ILN is 1 %

Higher incidence of nonunion in open Higher incidence of nonunion in open reduction techniquesreduction techniques

Exchange NailingExchange Nailing (commonest ) (commonest )

Ext.fixatorsExt.fixators

DynamisationDynamisation

Plate OsteosynthesisPlate Osteosynthesis

OptionsOptions

Exchange NailingExchange Nailing

Ideal in hypertrophic nonunionIdeal in hypertrophic nonunion

Previous Closed NailingPrevious Closed Nailing

Wide medullary canalWide medullary canal

Weresh et alWeresh et al (2000 ) (2000 )

47 % failure of Exchange Nailing47 % failure of Exchange Nailing

Routine Exchange Nailing may Routine Exchange Nailing may require reevaluationrequire reevaluation

Exchange nail - unsuitableExchange nail - unsuitable

Narrow medullary canalsNarrow medullary canals

Broken implantsBroken implants

Nonavailability of bigger size nailsNonavailability of bigger size nails

Rotational mal alignmentRotational mal alignment

Gap nonunionGap nonunion

Previous open reductionPrevious open reduction

Plate osteosynthesisPlate osteosynthesis

Implant failure is more in plating with a Implant failure is more in plating with a single Platesingle Plate

Double Plating is an established procedure Double Plating is an established procedure in metaphyseal fractures of femurin metaphyseal fractures of femur

Construct of Double plate is Construct of Double plate is 235235 times times stronger than the single plate on stronger than the single plate on compression sidecompression side

In the literature Large series of In the literature Large series of DOUBLE PLATINGDOUBLE PLATING in diaphyseal femoral fractures in diaphyseal femoral fractures

is not reportedis not reported

Materials and MethodsMaterials and Methods

Prospective studyProspective study

Jan 2005 to May 2007 Jan 2005 to May 2007

20 cases20 cases

Follow up 6 to 35 months ( average 24)Follow up 6 to 35 months ( average 24)

ObservationsObservations

16 male and 4 female16 male and 4 female

Average age 44 yrs (24 to 68 )Average age 44 yrs (24 to 68 )

Primary ProcedurePrimary Procedure

ORIF ORIF IL NailIL Nail 1212

ORIF ORIF K nailK nail 55

ORIF ORIF DCSDCS 22

ORIF ORIF DCPDCP 11

Duration of nonunion - 6 months Duration of nonunion - 6 months to 5 years ( Average 16 months )to 5 years ( Average 16 months )

Earlier bone grafting in 5 casesEarlier bone grafting in 5 cases

5 cases of Broken nails5 cases of Broken nails

9 cases had 2 surgeries before9 cases had 2 surgeries before

ProcedureProcedure

Bone Graft From Iliac crestBone Graft From Iliac crest

Previous implants removedPrevious implants removed

Exposure through previous incisionExposure through previous incision

Fracture ends were freshenedFracture ends were freshened

Intervening fibrous tissue sent for C & SIntervening fibrous tissue sent for C & S

Compression Plating with 4.5 Compression Plating with 4.5 broad DCPbroad DCP on lateral aspect with minimum 8 cortices on lateral aspect with minimum 8 cortices purchase on either sidepurchase on either side

Interfragmentary compression whenever Interfragmentary compression whenever possiblepossible

Smaller 4.5 Smaller 4.5 narrow DCPnarrow DCP on anterior on anterior aspect as second plate at right angle to aspect as second plate at right angle to the broad DCPthe broad DCP

Ends of plates should Ends of plates should notnot be at the same be at the same levellevel

Petalling (shingling ) one inch on either Petalling (shingling ) one inch on either sideside

Bone graft laid more on medial aspectBone graft laid more on medial aspect

Suction drain for 1 daySuction drain for 1 day

Knee stiffness manipulated before the Knee stiffness manipulated before the procedureprocedure

Post opPost op

Parenteral antibiotic for 3 daysParenteral antibiotic for 3 days

Non weight bearing crutch walkingNon weight bearing crutch walking

Xray at 6 weeksXray at 6 weeks 10 weeks 10 weeks 14 weeks 14 weeks then at 6 weeks intervalthen at 6 weeks interval

Union assessedUnion assessed

Absence of pain on full weight bearing Absence of pain on full weight bearing

ClinicallyClinically

Radiologically Radiologically

RESULTSRESULTS

19 cases (19 cases (95 95 %% )united without additional )united without additional proceduresprocedures

Average time for union was Average time for union was 5.5 months5.5 months (3 (3 to 9 months )to 9 months )

1 case required further bone grafting1 case required further bone grafting

All cases united eventuallyAll cases united eventually

1 case of Superficial infection1 case of Superficial infection

Average further shortening of 1 cmAverage further shortening of 1 cm

DISCUSSIONDISCUSSION

Treatment of Nonunion of Diaphyseal Treatment of Nonunion of Diaphyseal fractures of Femur by Plate fractures of Femur by Plate

Osteosynthesis has almost been Osteosynthesis has almost been condemned condemned

due to increased risk of infectiondue to increased risk of infection

necessity of opening the nonunion site which necessity of opening the nonunion site which

may further damage the blood supply may further damage the blood supply

due to frequent implant failuredue to frequent implant failure

INFECTIONINFECTION

The review of literature shows that there is The review of literature shows that there is little difference in the reported incidence of little difference in the reported incidence of infection which is between 5 to 10 % infection which is between 5 to 10 % irrespective of the type of implant or irrespective of the type of implant or technique usedtechnique used

In the present study also there was only In the present study also there was only one case of superficial infection ( 5% ) one case of superficial infection ( 5% ) even though all 20 cases had previous even though all 20 cases had previous open reductionsopen reductions

AvascularityAvascularity

Rand et.al compared the effects of Rand et.al compared the effects of compression plating and open nailing after compression plating and open nailing after reaming at the fracture site in tibia of dogsreaming at the fracture site in tibia of dogs

No decreased vascularity of the cortex after No decreased vascularity of the cortex after plate fixationplate fixation

Higher values of blood flow at the fracture Higher values of blood flow at the fracture site after reaming and rod fixation due to site after reaming and rod fixation due to some compensatory mechanismsome compensatory mechanism

Rate of union and maturation of fracture Rate of union and maturation of fracture was slower with rod fixationwas slower with rod fixation

IMPLANT BREAKAGEIMPLANT BREAKAGE

Breakage of plate is another reason for Breakage of plate is another reason for its condemnation. its condemnation.

As the construct of double plate is far As the construct of double plate is far stronger than a single plate, there is stronger than a single plate, there is less chance of failure.less chance of failure.

In our study there was no breakage of In our study there was no breakage of implant. implant.

BONE GRAFTINGBONE GRAFTING Powered reaming in an already reamed Powered reaming in an already reamed medullary canal produces necrotic debris medullary canal produces necrotic debris and micro sequestrae along with some and micro sequestrae along with some osteogenic materialosteogenic material

Cancellous bone has superior osteogenic Cancellous bone has superior osteogenic properties and helps to achieve union in properties and helps to achieve union in less time and is advocated for atrophic less time and is advocated for atrophic nonunionsnonunions

In our study bone grafting was done in all casesIn our study bone grafting was done in all cases

AdvantagesAdvantages

Compression at fracture siteCompression at fracture site



More stable constructMore stable construct




Minimum learning curveMinimum learning curve





No need of C – armNo need of C – arm






Not technically demandingNot technically demanding






Not technically demandingNot technically demanding

No sophisticated instrumentsNo sophisticated instruments

Sound Principles of internal Sound Principles of internal fixation with highly stable fixation with highly stable

construct and provision of construct and provision of an environment conducive an environment conducive

to bone healing has a to bone healing has a significant value in many significant value in many cases of difficult aseptic cases of difficult aseptic

nonunion of femurnonunion of femur

CONCLUSIONCONCLUSION

Double PlatingDouble Plating with Bone grafting with Bone grafting is an effective and easy option is an effective and easy option

in treatment of nonunion of in treatment of nonunion of femoral shaft in which the femoral shaft in which the

fracture site was opened in an fracture site was opened in an earlier procedureearlier procedure

THANK YOUTHANK YOU

double plating nonunion femur

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