Volume 9, Issue 10, October – 2024 International Journal of Innovative Science and Research Technology

ISSN No:-2456-2165 https://doi.org/10.38124/ijisrt/IJISRT24OCT396

Novel Method of Tackling Fracture Non-Union

Dr. Vinay V Sherlekar

Abstract:- Keywords: Proximal Femoral Nails (PFN), Locking

Compression Plates (LCP), Closed Reduction And Internal
 Aim: Fixation (CRIF), Diabetes Mellitus (DM), Hypertension
To evaluate the novel methods in revision surgery to (HTN), And Chronic Kidney Disease (CKD)
tackle non-union fractures of different cases of patients.
I. INTRODUCTION
 Background:
Non-union of bone is the body's inability to heal a The femur, or thigh bone, is the longest and strongest
fracture. The most agreed-upon standard definition of bone in the human body. It extends from the hip joint at the
non -union made by the FDA is a fracture that persists for pelvis to the knee joint. It plays a vital role in weight bearing
a minimum of nine months without signs of healing for in the lower extremities. Because of its strength, fracturing
three months. Non-union fractures of femur pose the femur typically requires a big force, as that from a fall or
significant challenges in orthopaedic surgery, often an automobile accident. Femur fractures are classified based
requiring revision procedures to achieve successful bone on the location and pattern of the break, they are; Proximal
healing. In cases where the initial implant has failed, femur fracture, Femoral shaft fracture and Distal femur
innovative solutions are necessary to promote bone union fracture.
and functional recovery.
Femoral shaft fractures, also known as broken
 Case Description: thighbone fractures, can occur in the proximal femur and can
The case report presented with four different be classified as spiral or transverse. The proximal segment of
geriatric patients had previously undergone implants the femur is often pulled into flexion and external rotation by
surgery, which subsequently failed to promote bone the psoas muscle and abduction by the abductors. Spiral or
healing. The patients were reoperated using a proximal transverse are the most common types of femoral shaft
femur nail (PFN) and augmented with a locking fractures. Femoral shaft fractures can be caused by trauma,
compressed plate (LCP) to address the non-union. The such as a direct hit to the thigh or an indirect force transmitted
combination of the PFN and LCP along with bone graft through the knee. Orthopaedic physicians treat femur shaft
successfully provided stability to the fracture site, fractures more frequently than any other type of injury. These
promoting bone union, and enabling functional recovery. fractures are potentially fatal and frequently accompany
Radiographic evidence and clinical assessment polytrauma[1]. They frequently arise from high-energy
demonstrated excellent healing progress. events like auto accidents, and if left untreated, can cause
limb shortening and abnormalities. The yearly incidence of
 Conclusion: femur shaft fractures ranges from 10 to 37 per 100,000
This case study emphasizes the significance of individuals, peaking in young males at age 27 and older
customized care for non-union femur shaft fractures, women at age 80 [2].
particularly in cases where implant failure has occurred
in the past. When treating difficult non-union fractures, The AO-Müller/Orthopaedic Trauma Association
35mm locking plate and bone graft coupled can be a (AO/OTA) system is widely used to classify femur shaft
useful tool for stabilizing the fracture and promoting fractures. It encompasses the classification of diaphyseal
effective bone healing. femur shafts as well as all long bone fractures. The fracture
patterns are primarily classified into three categories: simple,
 Clinical Significances: wedge, and complex fractures[3]. When it comes to treating
This case report exemplifies the need for innovative femur shaft fractures, intramedullary nailing (IMN) is the
and individualized approaches in the management of preferred method due to its low complication rates (4.9%) and
challenging non-union femur fractures. Locking high union rates (72% to 100%) for aseptic non-unions of
compression plates along with PFN and bone graft noncomminuted femoral shaft fractures[4],[5].Nevertheless,
present a viable method, but further investigation and because of the need for repeated surgeries, extended hospital
clinical data are needed to confirm the efficacy and long- stays, and the incapacity to resume regular activities, non-
term results of this strategy. Even with such complex union continues to provide difficulties for orthopaedic
orthopedic settings, successful outcomes can be attained surgeons as well as significant economical difficulties for
via meticulous planning and a patient-centered approach. patients. Non-union of femur shaft fracture has been linked to
Moreover, to prevent revision, the initial treatment must several risk factors, including open fractures, smoking,
be the best. delayed weight bearing, comminution of the fracture site,
instability of fracture reduction, nonsteroidal anti-

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Volume 9, Issue 10, October – 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165 https://doi.org/10.38124/ijisrt/IJISRT24OCT396

inflammatory drugs that may interfere with fracture healing, are common indicators of a non-union. There may be
and inadequate nail diameter selection [6]. According to underlying rotational instability or malalignment due to
Weresh et al., the nail locking technique and age were found inadequate fixation or biological healing failure. Clinical
to be highly correlated with the likelihood of healing[7]. examination and radiographic imaging (X-ray or CT scan)
Because this will result in favourable clinical results and an confirmed non-union and mal alignment.
early return to work, it is imperative to comprehend fracture
union in middle-aged patients.

When evaluating patients for studies or treatments

involving femur fracture non-union, particularly in geriatric
patients, it is important to establish clear inclusion and
exclusion criteria to ensure the population is suitable for the
objectives of the study or treatment. Inclusion criteria have
certain characteristics such as age, fracture diagnosis, surgical
history, osteoporosis, rotational instability, consent, and
compliance [8]. Similarly, exclusion criteria have certain
characteristics that would disqualify the patient from
treatment protocol. It includes active infection, pathologic
fractures, severe comorbidities, and past treatment for non-
union fracture.

Minimally invasive surgical techniques offer several Fig 1: X-Ray Showing the Pelvic and Femur Regions with
advantages, particularly for elderly patients with femur PFN Implant
fractures. However, to achieve successful union, addressing
the factors contributing to non-union, such as deforming The management of patient by optimizing healing can
muscle forces, osteoporosis, comorbidities, mobilization be done through glycemic control and careful evaluation by a
status, and nutrition, is vital. A holistic, multidisciplinary cardiologist to ensure the patient is fit for any further surgical
approach is necessary to overcome these challenges and intervention. Since the patient is struggling from non-union is
promote optimal outcomes for geriatric patients. confirmed then potential replacement of failed PFN by
revision surgery and a combination of a Proximal Femoral
II. CASE DESCRIPTION Nail (PFN) with an additional plate of 35mm locking
compression plate (LCP) is considered to enhance fixation
A. Case 1 and address rotational or axial instability. In addition, bone
The case report describes a 72-year-old female graft is done to stimulate the biological healing for bone loss
presented with right hip pain and antalgic gait using a walker or non-union.
for ambulation. The patient also having comorbidities such as
Diabetes mellitus (DM), Hypertension (HTN) and ischemic Post operation monitoring of fracture through radiology
heart disease (IHD). Here is an in-depth detail based on the is conducted on 6 weeks and after 12 months to evaluate the
assessment, clinical findings, and imaging studies. intensity healing and callus formation. The pharmacological
support can be given to the patient based on their age and
The patient had a medical history of proximal femur bone density Bisphosphonates or Denosumab along with
fracture sustained about 8 months ago by treated with a calcium and vitamin D supplemented to support bone health
Proximal Femoral Nail (PFN) in a local hospital. Persistent or treat osteoporosis.
pain, abnormal gait, and delayed or absent healing on X-rays

Fig 2: X Ray Images Showing the Follow Up after Surgery at 6 Weeks (a) and 12 Months(b), (c)

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Volume 9, Issue 10, October – 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165 https://doi.org/10.38124/ijisrt/IJISRT24OCT396

Post-operative early mobilization and physiotherapy

will be key to regaining mobility and preventing
complications such as further muscle atrophy or joint
stiffness. Regular monitoring of fracture healing via X-rays
and close attention to blood sugar levels, cardiovascular
status, and physical function.

B. Case 2
This case report describes 67-year-old male who was
treated for an upper-third femur shaft fracture and lost follow-
up for about 9 months after surgery due to the COVID-19
pandemic. The patient presented with complaints of pain in
the right hip and limb shortening. The patient has
hypertension (HTN) and is an alcoholic, both of which are
important factors to manage the current condition. Here is an
outline of the key concerns and potential next steps based on
the provided details:

The possibility of non-union can be resulted from Fig 4: Radiological Examination after 9 Months of Surgery
delayed follow up which leads to limb shortening and pain. Indicating Implant Failure
Other potential complications due to delayed follow up are
hardware failure and avascular necrosis. Although the X-ray Further investigation through X-rays confirmed the non-
shows the internal fixation hardware (an intramedullary nail union femur shaft fracture and the patient was planned to
and screws), the pain and limb shortening could suggest remove the implant and managed with combination of long
possible failure of the hardware. Over time, stress on the PFN with locking compression plate of 3.5mm plates along
hardware could lead to issues, especially if the fracture did with bone graft to stabilize the bone and regenerate fracture
not heal correctly. Whereas pain in the hip after a long period site to heal effectively. After augmentation of LCP with PFN,
of immobility could also point to avascular necrosis, a the patient underwent follow up at 6weeks, 6 months showed
condition where blood flow to the femoral head is intact implants and signs of fracture healing. Final follow-up
compromised, leading to bone death. This is more common at 12 months yielded excellent range of motion in operated
in older individuals and those with a history of alcohol abuse. limb.to evaluate the healing and callus formation.

Fig 3: X Ray Image Showing Post Surgery of Femur Shaft Fig 5: X Ray Image Showing Replacement with Long PFN
Fracture with 3.5mm LCP

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Volume 9, Issue 10, October – 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165 https://doi.org/10.38124/ijisrt/IJISRT24OCT396

Fig 6: Post Operative Follow Up at 6 Weeks (a,b), 6 Months(c,d) and One Year(e,f)

If avascular necrosis is present, additional interventions The medical examination of the patient indicates spiral
such as core decompression or even hip replacement surgery femur shaft fracture occurs due to a twisting force, often
may be necessary. A structured rehabilitation plan to help causing a helical or coiled pattern along the length of the
regain mobility and strength, with focus on managing limb bone. This type of fracture typically requires rigid internal
length discrepancy. Optimization of blood pressure control fixation to maintain alignment during healing. The long PFN
and addressing alcohol dependence are essential for used in the surgical repair is a common choice for these types
improving surgical outcomes and overall health. Limb of fractures, offering good biomechanical stability and
shortening after a femur fracture can be addressed in several facilitating early mobilization.
ways, if shortening is significant and causing functional
issues, limb-lengthening procedures can be considered by
surgical correction. Orthotic Devices such as custom shoe
inserts or orthotics can help balance the leg length
discrepancy for smaller differences.

C. Case 3
This case report describes a 67-year-old female patient
with a right lower third spiral femur shaft fracture, who
underwent closed reduction and internal fixation (CRIF) with
a long proximal femoral nail (PFN) in January 2022. The
patient has comorbidities, including diabetes mellitus (DM),
hypertension (HTN), and chronic kidney disease (CKD),
which are important factors to consider in her management
and recovery.
Fig 7: Radiograph Shows the CRIF with PFN in Jan 2022

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Volume 9, Issue 10, October – 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165 https://doi.org/10.38124/ijisrt/IJISRT24OCT396

The regular monitoring through X-rays provided the

healing progress of the fracture and showed signs of non-
union and required re-evaluation of the treatment strategy.
Physical examination also helped to assess for signs of
hardware loosening (pain, instability) or complications like
deep vein thrombosis (DVT) or infection. The patient decides
to remove the implant as well as fibrous tissues thereby
enhance the freshening of bone margin. The fracture site is
augmented with locking compression plate of 3.5mm plates
along with bone graft to stabilize the lower femur region and
regenerate fracture site to heal effectively.

Fig 8: Post Operative X Ray Image Showing Implantation of

LCP with Bone Graft

The post operative radiological examination of patient

was followed at 6 weeks and 12 month to evaluate the healing
reported the intact implant and ideal sign for callus formation.

Fig 9: Post Operative Follow Up at Sixth Week (a) and 12 Months(b)

Spiral fractures can sometimes heal slowly, especially The patient persist pain after 8 months suggests
in patients with comorbidities like diabetes and CKD. Since potential complications such as non-union, delayed union,
the patient is having diabetes, will face higher risk for malunion, or hardware failure. These are common issues in
postoperative infections. Regular examination of signs of fractures, especially in the lower third of the femur, where
deep or superficial infections (fever, wound drainage, healing can be slower due to decreased blood supply.
localized pain/swelling) were necessary. Customized Diabetes mellitus (DM) increases the risk of delayed or non-
physiotherapy to strengthen the quadriceps, hamstrings, and union due to impaired bone healing, poor vascularization, and
hip abductors, focusing on improving the range of motion, a higher risk of infection. Hypertension (HTN) needs to be
muscle strength, and gait pattern. As the patient is older and well-controlled perioperatively, especially if revision surgery
likely at risk of falls due to reduced mobility and underlying is required. Osteoarthritis (OA) of the Knee could be
conditions, fall prevention strategies such as home safety contributing to the patient's antalgic gait and pain,
assessments and assistive devices (e.g., walkers) should be complicating the assessment of whether the pain is from the
considered. fracture site, knee arthritis, or both.

D. Case 4 On thorough radiographic evaluation discovered the

A 65-year-old female presented with pain at the fracture current state of fracture, non-union and assessed the condition
site and an antalgic gait with a history of distal femur shaft of hardware. Due to mechanical instability at the fracture site
fracture in the lower third, which operated with closed and persistent stress on an inadequately healing fracture
reduction and internal fixation (CRIF) using an antegrade nail results in screw loosening or nail migration. Concomitant
8 months back. The patient also has known comorbidities, knee osteoarthritis experienced by the patient due to the pain
including diabetes mellitus (DM), hypertension (HTN), and in knee joint and at the fracture site complicated gait and lead
osteoarthritis (OA) of the knee. to difficulty in fully assessing the fracture-related pain.

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Volume 9, Issue 10, October – 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165 https://doi.org/10.38124/ijisrt/IJISRT24OCT396

The patient was planned to remove antegrade nail and weight-bearing protocol initiated at 6 week of post operation.
replaced by retrograde nailing approach where retrograde Partial or full weight bearing should do after the confirmed
intramedullary nail is inserted from the knee into the femoral radiographic evidence of healing or after completed callus
canal, providing better stabilization for lower third fractures. formation and it should be under supervision. Followed 1 year
Locking Compression Plates (LCP) can offer angular stability of post operation with the radiological examination which
and may be combined with bone grafting. If there is evidence showed intact implants and signs of fracture healing.
of poor healing, autologous bone grafting or synthetic bone
grafts may be used to stimulate bone healing.

Fig 12: Follow up after One Year Shows Healing Across the
Fig 10: Preoperative X-Rays Showing CRIF using Fracture Line and Alignment
Antegrade Nail in Distal Femur Fracture Leads to Non-
Union III. DISCUSSION

Over time, significant advancements have been made in

the management of non-union femur fractures. Numerous
methods have been reported for the treatment of these
fractures. For the most part, these fractures were treated
conservatively in the early 1900s. The concepts of the newly
formed Arbeitsgemeinschaft fur Osteosynthesefragen (AO)
were not used to treat these fractures until 1970 [9,10]. But
these fractures still present a problem and are challenging to
treat, even with the range of available treatment options.
Although locking plates and retrograde intramedullary nails
are the two most often used fixation techniques for fractured
femurs, neither technique has been shown to be better than
the other[11,12]. Jankowsky et al. found that there are
similarities in the union rates of retrograde intramedullary
nails and locking plates in their meta-analysis[13]. Surgeons
needed a rigid construct for non-union management in cases
of non-unions of the distal femur, which is why the more
Fig 11: Post Operative X-Ray Showing Removal of recent method of combining nail and plate was first described.
Antegrade Nails by Retro Grade Intramedullary Nails and In a clinical context, the use of an intramedullary nail to treat
Augmentation Plating with LCP. long bone non-union is not entirely novel. In a series of 38
femoral and tibial non-unions treated primarily with IM nails,
Postoperatively the patient was administered with Inj. Birjandinejad et al.'s 2009 study demonstrated the treatment's
teriparatide and calcium for three months daily to improve effectiveness. After adding a 4.5 mm compression plate
bone formation and healing. Focused rehabilitation exercises construct with a nail in place, they found that 36 fractures,
to improve strength and mobility of the quadriceps, including all femoral fractures, healed in their series [14]. A
hamstrings, and hip muscles. A structured program to retrospective study for non-union of the distal femur using a
improve her gait, address any compensatory movement nail plate combination was carried out by Attum et al. [15];
patterns, and restore normal walking mechanics. Targeted they also concluded that all the patients in their study
physiotherapy interventions for pain relief, possibly in eventually underwent union. Quinzi and colleagues
conjunction with medication, should be tailored to manage conducted a meta-analysis and found that while there were
both the knee osteoarthritis and any pain related to the differences in the complication profiles, there were no
fracture site. Depending on the stability of the fracture, non- statistically significant differences in the frequency of major

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Volume 9, Issue 10, October – 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165 https://doi.org/10.38124/ijisrt/IJISRT24OCT396

complications or re-operations in fractures treated with showed excellent healing and bone union, highlighting the
locking plates, retrograde intramedullary nails, or distal effectiveness of this method. While the results are positive,
femoral replacement[16]. Weight bearing was started in the further investigation is necessary to confirm the long-term
post-operative period for all 15 patients, 6 of whom were efficacy and broader applicability of this novel approach in
native and 9 of whom were periprosthetic. Liporace and Yoon orthopaedic surgery.
reported favorable short-term outcomes in all of their patients
and discovered that none of them experienced hardware V. CLINICAL SIGNIFICANCE
failures, non-union, or infections during the healing process
[17]. By combining the advantages of plating and nailing, the This case report exemplifies the need for innovative and
technique confers increased biomechanical stability by individualized approaches in the management of challenging
shifting the weight-bearing axis more medially along the non-union femur fractures. The use of a proximal femoral
anatomic axis, increasing points of fixation, and creating a nail, intramedullary nail and locking plate ( dual plating ) with
fixed-angle construct. This nail plate combination is crucial bone graft offers a potential solution, but the field requires
for early mobilization following fractures in the elderly, more extensive research and clinical evidence to firmly
osteopenic, and/or obese. It aids in the patients' early establish the reliability and long-term outcomes of this
rehabilitation, reducing the risk of pressure ulcers, DVT, and approach. Despite the complexities involved, with careful
other injury-related complications. Additionally, they are planning, and a patient-centred approach, it is possible to
crucial in inter- and peri-prosthetic fracture cases [18,19] as achieve favorable results in addressing these intricate
well as complex fractures involving significant orthopaedic scenarios. Furthermore, the first treatment should
communication or segmental defects [15]. be optimal to avoid revision.

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