What do you mean by "fracture of unknown reason" - was there a trauma or not? Can you provide how long ago the first ORIF was done, and at what time the revision and iliac bone graft was done? Was infection of the non-union ruled out? What was the reason to go for plate instead of intramedullary nailing?

From the Xray, the non-Union Looks like an atrophic one. Partial load bearing to provide some mechanical stimulus might be beneficial. Full load bearing cannot be resumed until callus is seen in the gap.

Dear Thomas Randau,

I mean to say "Nonunion of an unknown reason" not "fracture of unknown reason".

1st ORIF was done 19 months ago in another hospital and the Revision surgery with Iliac bone graft was done 2 days ago in our hospital.

Infection as a cause of Nonunion was ruled out. Any other significant cause was not found so we called it an unknown cause.

Thank You.

I agree looks like an atrofic non-union, if infection is ruled out, maybe the problem is distration at the fracture site where you would rather have compression. Because you have a very rigid osteosynthesis with the big angle stable plate with 8 cortices on both sites in young,strong bone maybe this is your problem. Adding biology with your bone grafting could work, I would definitly go for partial weightbaring to bring in some mechanical stimulus.

Personally I would have gone for a reamed intramedullary osteosyntheses with a large diameter nail to make it stable and weightbaring. If you use the Synthes RIA (Reamer/irrigator/aspirator) system, you can collect all the bone marrow you ream en get a large amount of high quality bonemarrow for your autografting, you could have had compression over your fracture and biology with the reamed autograft with a static locking and if even this didn't work you could have dynamised the nail by simply removing one of the locking screws.

Would have also saved him potential pain at the iliac crest.

Good luck and looking forward to your result...

So i stand with my above recommendation. With the plate already in place, I would allow 20 kg of load on the leg while walking and half of body weight in axial load (standing). If you see callus in 6 weeks, increase load by 10 kg per week until full load, pause if the patient should have increase in pain.

We have also made some good experience with application of low intensity pulsed ultrasound (like e.g. Exogen(R) by S&N) in such cases. Daily Stimulation with US was shwon to be beneficial to bone healing in many studies with good evidence. It might be helpful in this case as well.

Dear P.J. & Thomas, Thank You.

I also agree with the above sugestions. I think in atrophic pseudarthrosis like above. First it is important adding bonegraft but also is very important to apply some compression in the fracture site. One another option beside Bone graft is adding bmp.

Early Rehabilitation Following Surgical Fixation of a Femoral Shaft Fracture

http://ptjournal.apta.org/content/86/4/558.long

I have some different opinion regarding this fracture. This is atrophic nounion, biomechanically it has got high bending strees overthere, fracture pattern is transverse that is not suitable for plating in lower limb so I guess it can go in to fatigue failure of the plate, if you start weight bearing now. I prefer to wait weight bearing till callus seen if you have put bone graft recently. This fracture is ideal for revision IM nailing.

l would choose an IMN as first choice especially in a midshaft femoral fracture with a transverse pattern. I would try for now using bone growing stimulation such as MELMAK and if there is no improvement I would go to IMN with a dynamic distal lock.

If you wait for callus to form before even partial weight bearing is allowed, you might end up waiting a very lomg time... I would have done nailing as one, as i already enquired in my first answer why it was not done in this case. However now it is plated and that is it. MELMAK seems to be the same as Exogen, i think..

A 19 month old non-union following a diaphyseal femur fracture originally managed with plate osteosynthesis in my opinion should be revised, more so since it appears to be atrophic in nature. I generally favour load sharing implants to load bearing implants and implants that are placed closer to the mechanical axis of the bone. This ensures lower rates of implant failure and some element of dynamization of the fracture. Augment this with cancellous bone graft and the fracture should go on to union.

in my hospital do this:

the movement of the hip and knee off the weight should be given immediately. Useful for magnetic cycles in the first 40 days. The weight on the limb would be useful to start it after 40 days. the load starts with 15/20 kg assisted by physical therapist, then gradually increased.

It seems to be a nounion of Trans fracture shat of femur.

I would prefer to go down, remove the implant & go head with Nailing, Interlocking & Bone grafting. May be perform Dynamic locking proximally & allow early weigh bearing after 4-6 weeks.

Respected Seniors and my Colleagues, Thank You.

Dear Ashok, there is still a good periosteal reaction, it´s not atrophic.

Remove the plate, ream the canal, thick nail, immediate full-weght bearing.

The healing time will be longer than you would expect...

Reaming is very important, not only because you can fit a thicker tighter IM nail, but also because the process itself "lays" autograft in the fracture site as you go up and down with the reamer. Plus, all the previous comments on the advantages of an IM nail on this type of fracture.

Dear Yongshen Chen,

Thank You for your opinions.

Yes, I agree, IM Nailing could have been a better option.

For your curiosity, during the Revision surgery enough curettage was done and there was presence of healthy bone bleeding at the fracture site. Since there was no any evidence of infection Culture was not done.

Dear Carlo,

Thank You very much.

Dear Alexander,

Million thanks for your opinions.

You have mentioned that it isn't Atrophic Non-union in contrary to all of above colleagues. Since there is absence of Exuberant Callus formation, it doesn't look like Hypertrophic Non-union as well.

With due Respect, Can it be called Normotrophic Non-union, which shares characteristics of both ???

Thank You.

In my humble opinion the plate has to be removed and a nail to be placed. The reamings of the preparation for the nail are good enough bone graft in the area. The nail has to be strong and locked only distally to control the rotation but not proximally. Let the patient to fully weight bear. As the nail is not locked there is the benefit of full dynamization.

Dear Ashok,

to answer your second question it would be most helpful to see the X-rays after the initial surgery. I suppose that initially the fracture was not reduced anatomically and a small gap was still present. The uploaded picture shows a transverse diaphyseal fracture fixed with a very stiff osteosynthesis (rigid plate with four screws on each site, which are pretty close to the fracture site). All bending forces acting on this rigid construct will be concentrated at the fracture site and the risk for a plate crack is high. There is no way for the fracture to heal and the small gap is a kind of a critical diaphyseal defect which cannot be bridged in this situation. Of course it´s not atrophic, in particular, it´s not avascular. Using the terms "atrophic" or "hypertrophic" the contributors in this blog supposingly refer to the classification of Weber and Cech (1976) where the causes for different morphological types are illustrated. The use of the both terms is somewhat misleading. If you look at this classic paper you will realize that "your" fracture can be classified as normotrophic or hypotrophic, which are both vascular non-union types. However, the morphological appearance of different avascular and vascular types may be very similar.

In your case, however, there is no problem with the "biology", in my eyes it´s only a biomechanical problem of the osteosynthesis. If you are interested in this topic, please send me an e-mail ([email protected]), I will answer and send you a ppt summarizing the current experimental/clinical evidence on this topic. Kindest regards.

Alex

Dear Alexander,

Many many thanks for your concern and the e-mail.

Yes, I am really interested in this topic. I would be very obliged if you could send me anything interesting.

Regards.

Dear Wietse,

I agree. Thank you very much.

Dear ashok

in my humble view, options are

1. Continue with plate, non weight bearing till hint of early callus then gradually protected weight bearing till union but my fear is that plating in this case is unlikely to achieve union and is more likely to fail.

2. My preferred option in this case will be to remove the plate, ream the canal, insert a thicker dynamically locked intramedullary nail and start early weiht bearing. Your findings of healthy bleeding bone are encouraging but will send samples to rule out any low grade infection.

I think it will be prudent to discuss the options with patient.

hope this is helpful .

Dear Muhammad Fazal,

I agree with your option to remove the plate, ream the canal, fix with the dynamic locked IM Nail and start early weight bearing.

Here in this case, since the same plate was considered with auto-grafting, I was just curious to know when should the weight bearing be started. Should it be started when we see an early callus formation radiologically or should it be delayed ???

Thank You.

Dear ashok

as mentioned, in my view

to start weight bearing when there is hint of callus

regards

ali

This picture shows a fracture, delayed union or non-union of a transversal diaphyseal fracture managed with a rigid plate. We do not receive enough information about the time elapsed after the injury or any data about this " unknown cause". Anyway, in this status weight bearing is not recommended because a priori plating of long bones is not suitable for weight bearing before reliable callus formation. Here I do not see any callus. I would proceed as follows: the plate should be removed, locked intramedullary nailing should be used for a stable fixation, autografts should be added to fill the gap and weight bearing should be started immediately.

It is mentioned before that the metal work has to be removed and a nail has to be placed with grafting and I agree completely that thee weight bearing has to be immediate. The fracture is transverse and because of this stable and needs compression. The nail has to be placed in a way to achieve compression and if it will be locked on both sites has to be "loaded", meaning that after distal locking has to be "backtracked" and then to lock proximaly. On top of that weight bearing is achieving extra compression.

I agree entirely with Dr. Zafiropoulos. Eventually, in order to enhance bone healing the removal of the locking screws on the one side could be undertaken after 2 months. In this way a "dynamization" of the osteosynthesis could be achieved which stimulates fracture healing.

Dear Ashok,

I believe the simplest and most predictable option will be to remove the plate and convert to a reamed, dynamically locked intramedullary nail with weight bearing on postoperative day 1.

Dear Panayot,

I have mentioned in the above discussion that 1st ORIF was done 19 months ago in another hospital and the Revision surgery with Iliac bone graft was done 2 days ago in our hospital.

Thank you.

Dear Colleagues Thank You very much.

Dear Ashok

The surgical treatment was bridge plate. There are some problems: the work length is short and the density screw is high (rigid construction with less movement). I believe , in this moment, the diagnosis is avascular non union. I remove the plate and screws and fix with reamed intramedullary nail and the weight bearing should be started in second pos operative day.Best regards

Dear Nelson,

Thank You.

Interesting case of an atrophic femoral non-union. The current construct displays a short working distance and may be too stiff a construct to permit healing. This may be best managed by removal of the plate and implantation of a reamed, statically locked centromedullary nail. You can fully weight bare then. Good luck!

Dear Brian,

Thank You.

ls,

What i see on the x-ray is a hpotrofic pseudoartrosis. Weightbearing will lead to plate breakage. I am not sure but it seems that on both sides of the fracture there are locking screws used. Was this osteosynthesis ment to treta the fracture with relative stability?

In my opinion there are two options

1: remove the plate, Ream the canal and put a IM nail in with dynamic locking and immidiate weight bearing.

2: Nettoyage of the pseudortrosis and a bone block, then use the plate with compression. However, than the patient is at least 6-12 weeks non weight bearing

best Niels

Dear Ashok

All advises regarding replacement of plate to IM nail are theoretically right, but the advices do not respond to the question regarding just this postoperative situation. I have analysed only this one X-ray in obluque viev. Some callus is visible, and if You stated that after removal of previous plate the fracture was stable, so where was the graft placed? In the gap between main bone fragments or the fracture site was only "wraped" with graft? Please publish another X-ray in strictly a-p view. Kind regards

Since the re-operation with the bone graft is already done, I would not advice weight bearing until callus is visible in plain radiographs. I guess the real question is when this is going to happen, two operations equals more trauma against the local biology. Non-weight bearing is detrimental in regard of lost muscle mass, stiffness and eventually diminished bone quality (osteopenia), but at this point you should continue to encourage the patient to train active and passive ROM and isotonic-isometric training.

Sarmiento, Dehne, and Paul Brown promulgated the benefits of early weight bearing a generation ago. However, the bone must be allowed to shorten and compress, and the plate prevents that in your patient. If you want your patient to weightbear, which i obviously think would be beneficial, you must have some type of fixation that would allow the fracture site to compress.

my opinion is remove the plate, ream the canal, fix with the dynamic locked IM Nail and start early weight bearing.

This is a long lasting discussion. Probably it would be a good idea if Dr. Ashok Rai could upload new x-rays in 2 planes after the last operation (plate in situ, grafting). I think it is time for control radiographs. Then we could find the right answer,

IM and early weight bearing is the best choice

Dear Panayot,

Since this particular case was not mine, it wont be an easy task. I just found this case in an Operating Room, clicked this Picture and posted here.

But, I will try to upload new X-rays, if possible.

Thank you.

This fixation will fail. I also recommend plate removal and reamed nailing

This location of femoral fracture is not good indication for plate osteosynthesis.IM dynamic nail and imediate weight bearing is the best choice.

Observamos la placa cumpliendo los objetivos de fijacion.tornillos proximales y distales suficientes,dejando libre la parte de nounion;sin embargo persisten signos de hipotrofia a nivel del foco ,el espacio,esclesosis, bordes romos.A pesar de colocar injerto oseo esponjosa (,no refiere tiempo de evolucion desde la cirugia,)no evidencia signos de formacion callo por lo que el inicio de apoyo solicitaria la parte interna llevando a ruptura de la placa.