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Double plating nonunion femur
1. DOUBLE PLATING WITH
BONE GRAFTING IN ASEPTIC
NONUNION OF DIAPHYSEAL
FRACTURES OF FEMUR
Dr. SAJEEV. P.S
Prof. Cherian M. Thomas
SP Fort Hospital , Trivandrum
2. AIM
To assess the efficacy of
Double Plating with bone
grafting in achieving union of
aseptic ununited fractures of
femoral diaphysis
3. Introduction
10 % of fractures require SECOND
procedure for fracture healing
Nonunion after ILN is 1 %
Higher incidence of nonunion in open
reduction techniques
5. Exchange Nailing
Ideal in hypertrophic nonunion
Previous Closed Nailing
Wide medullary canal
Weresh et al (2000 )
47 % failure of Exchange Nailing
Routine Exchange Nailing may
require reevaluation
6. Exchange nail - unsuitable
Narrow medullary canals
Broken implants
Nonavailability of bigger size nails
Rotational mal alignment
Gap nonunion
Previous open reduction
7. Plate osteosynthesis
Implant failure is more in plating with a
single Plate
Double Plating is an established procedure
in metaphyseal fractures of femur
Construct of Double plate is 235 times
stronger than the single plate on
compression side
8. In the literature Large series of
DOUBLE PLATING
in diaphyseal femoral fractures
is not reported
10. Observations
16 male and 4 female
Average age 44 yrs (24 to 68 )
Primary Procedure
ORIF IL Nail 12
ORIF K nail 5
ORIF DCS 2
ORIF DCP 1
11. Duration of nonunion - 6 months
to 5 years ( Average 16 months )
Earlier bone grafting in 5 cases
5 cases of Broken nails
9 cases had 2 surgeries before
12. Procedure
Bone Graft From Iliac crest
Previous implants removed
Exposure through previous incision
Fracture ends were freshened
Intervening fibrous tissue sent for C & S
13. Compression Plating with 4.5 broad DCP
on lateral aspect with minimum 8 cortices
purchase on either side
Interfragmentary compression whenever
possible
14. Smaller 4.5 narrow DCP on anterior
aspect as second plate at right angle to
the broad DCP
Ends of plates should not be at the same
level
15. Petalling (shingling ) one inch on
either side
Bone graft laid more on medial
aspect
Suction drain for 1 day
Knee stiffness manipulated before
the procedure
16. Post op
Parenteral antibiotic for 3 days
Non weight bearing crutch walking
Xray at 6 weeks
10 weeks
14 weeks
then at 6 weeks interval
18. RESULTS
19 cases (95 % )united without additional
procedures
Average time for union was 5.5 months (3
to 9 months )
1 case required further bone grafting
All cases united eventually
1 case of Superficial infection
Average further shortening of 1 cm
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33. DISCUSSION
Treatment of Nonunion of Diaphyseal
fractures of Femur by Plate Osteosynthesis
has almost been condemned
due to increased risk of infection
necessity of opening the nonunion site which
may further damage the blood supply
due to frequent implant failure
34. INFECTION
The review of literature shows that there is
little difference in the reported incidence of
infection which is between 5 to 10 %
irrespective of the type of implant or
technique used
In the present study also there was only
one case of superficial infection ( 5% )
even though all 20 cases had previous
open reductions
35. Avascularity
Rand et.al compared the effects of
compression plating and open nailing after
reaming at the fracture site in tibia of dogs
No decreased vascularity of the cortex after
plate fixation
Higher values of blood flow at the fracture
site after reaming and rod fixation due to
some compensatory mechanism
Rate of union and maturation of fracture
was slower with rod fixation
36. IMPLANT BREAKAGE
Breakage of plate is another reason for
its condemnation.
As the construct of double plate is far
stronger than a single plate, there is
less chance of failure.
In our study there was no breakage of
implant.
37. BONE GRAFTING
Powered reaming in an already reamed
medullary canal produces necrotic debris
and micro sequestrae along with some
osteogenic material
Cancellous bone has superior osteogenic
properties and helps to achieve union in
less time and is advocated for atrophic
nonunions
In our study bone grafting was done in all cases
43. Advantages
Compression at fracture site
More stable construct
Minimum learning curve
No need of C – arm
Not technically demanding
No sophisticated instruments
44. Sound Principles of internal
fixation with highly stable
construct and provision of
an environment conducive
to bone healing has a
significant value in many
cases of difficult aseptic
nonunion of femur
45. CONCLUSION
Double Plating with Bone grafting
is an effective and easy option
in treatment of nonunion of
femoral shaft in which the
fracture site was opened in an
earlier procedure
