I have faced with situations where despite a good looking interlocking femoral nail, the fracture fails to unite and there is rotational instability at the # site. What are the best options for such a clinical scenario?
If there is rotational instability, the nail is only pseudo-good looking. Probably, you have to explore this osteosynthesis. Depending on the findings (stability ? infection ?), you have to change the nail adding bone grafts or remove it proceeding to plating and bone grafting again. I do not see much sense in leaving the nail in situ, if it does not provide stability.
Thanks. I do agree with your approach. But there are publications suggesting good results with retention of nail and plate augmentation in non infected cases.
Leaving the nail and putting a plate you will make it even worse. The nail already compromises endostal blood supply, with the plate you cut also periostal supply.
Exchange the nail, eventually with additional bone grafting
8We retained the femoral nail and did over the top plate augmentations with bone grafting and BMP. Let's hope for the best
I agree with u .it is good decision for augmentation the ILN with plating plus grafting .it will do better and will unite.
Comments from internal medicine/osteology:
Consider Vitamin D-deficiency as a part of delayed fracture healing seen in some patients !!! And stop smoking if applicable (the patient, not necessarily the surgeon ;-)).
Due to high costs, maybe BMP-2 or BMP-7 given locally may not be available. I hope, future medical developments of Anti-Sclerostin-Antibodies (AMG 785 = romosuzumab, phase II studies performed, but not published to my knowledge) can support the surgeons, but it is not easy to perfom good prospective randomised trials in the small cohort of non-union fractures (e.g. complex frature history, blood supply etc. affects proper randomisation; when best to use the drug?, how to place it - systemically or locally...).
In hypertrophic non-union the plate augmentation will be the treatment of choice, in normotrophic or atrophic non-unions it can be used to, but you must use some other helps to enhance the biologic reaction of the bone, like the ones you mentioned bone grafting and BMP.
The vitamin D is very important to and it deficiency is highly prevalence in a lot of populations.
Other Treatments options you can use are Teriparatide or strontium ranelate in the pharmacology department and in therapy, Low-intensity pulsed ultrasound is a very good option or pulsing electromagnetic stimulation, a Cheaper option is Transcutaneus electrical stimulation(but this have a low level of evidence).
Either way, non-unions are always an interesting case to discus, please let us know the end of the story, Hope the information is of help. If want the references let me know.
There is no need for using BMP etc.There is no problem with bone biology... This is a viable fracture non-union, the reason for failure is instability (nail loosening distally). The LFN is malrotated in the canal (should be turned 90° towards lateral). I would go for exchange reamed nailing and use a compression nail with at least 3x interlocking distally. in my opinion no need to open the fracture site.
I think that it is a valid option. But with 2 times prior failure it is risky to assume that it is still a viable fracture non-union.
@ Dr. Vaishya
Do You have already follow-up X-rays from Your patient? It`4 months since last procedure, maybe we see some success?
i think plate augmentation with bone grafting is good option with high rate of union. plate augmentation will prevent rotational instability.
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