Femoral shaft non-union post closed non-comminuted fracture fixed using a locked intra-medullary nail
If the fracture is still not healed after 9 months we can certainly declare it as a non-union. There are many different classification in use, but 9 months of non-healing is in my opinion reasonable to define not healing bone.
There was no progress to union in time with certain level of biological activity present at the level of the fracture (new bone formation). In my opinion next reasonable step is to exchange the nail before it fails, realign the fragments and compress the non-union. It would be reasonable to exchange the nail through the same approach but because the fracture was below the femoral isthmus, I decided to replace existing nail with a retrograde femoral nail, as the retrograde nail gives us better control of the distal fragment but does affect the knee joint.
There was no major problem to remove the existing nail and replace it with the new, retrograde femoral nail. Femoral canal was then reamed up to 14.5 mm for 13 mm nail. Nail was than proximally locked, non-union compressed by backing out the nail using slotted hammer (slightly bent proximal locking screw) and locked distally. Initial plan included poller screw in the distal fragment but was abandoned during the procedure due to the excellent position of the nail inside the fragment.
Slideshow below describes the procedure as it goes on. There is one trick how to improve (achieve) perfect entry point if the initial wire is sub-optimally placed, and another trick how to remove bits of broken screws engaged in the medullary canal.
We intentionally ignored two broken screws securely locked in the medial cortex. Usually it is not difficult to remove them using a punch from the lateral side, but medial exposure is usually extensive and we decided to leave them in as they are not interfering with our fixation.
06 October 2015
Patient walks with a frame. Ideally should convert to crutches ASAP. All wounds healed, no clinical sign of infection. No major concern. Still pain in the latter side of the knee due to the meniscal tear. Muscle power improved. We decided today to wait for another two months before further action on meniscal tear.
X-rays show surprisingly improved callus and new bone formation, certainly more than expected for 6 weeks.
04 December 2015
The patient walked into the examination room unaided, but was still limping. All wounds were dry.
X-ray shows significant improvement in non-union healing.
Torn lateral meniscus is causing pain and we agreed to list him for knee arthroscopy and lateral meniscus repair.
02 February 2016
Progressing as expected. walking un-aided. Awaiting arthroscopy at the end of this month. No metal failure on the X-ray. Further progress on callus formation.
31 March 2016
Significant improvement post arthroscopy and lateral meniscus repair 6 weeks ago. Pain in the knee is almost completely gone. There is also minimal if any pain in the thigh, but some pain in the groin which started after recent arthroscopy. I do not have a good explanation for it.
On the X-rays I looked for broken screws or any other sign of instability. At the moment the construct looks stable to me. Further improvement in callus formation but union has yet to happen.
As there is no sign of instability I strongly believe that the non-union will heal in time without any further intervention.
Mr Matija Krkovic, MD, PhD
I am Consultant Orthopaedic Trauma Surgeon with special interest in Limb reconstructions and bone infections.