European Journal of Trauma and Emergency Surgery

https://doi.org/10.1007/s00068-020-01333-0

ORIGINAL ARTICLE

Augmentation plating leaving the nail in situ is an excellent option

for treating femoral shaft nonunion after IM nailing: a multicentre
study
Christiano Saliba Uliana1 · Fernando Bidolegui2 · Kodi Kojima3 · Vincenzo Giordano4,5

Received: 1 October 2019 / Accepted: 15 February 2020

© Springer-Verlag GmbH Germany, part of Springer Nature 2020

Abstract
Purpose In recent years, plate augmentation over a retained intramedullary (IM) nail has been shown to be an effective
option for managing femur fracture nonunions because it improves the biomechanical environment of the fracture site without
causing additional biological damage. In the current study, we present outcome data from 22 consecutive patients treated
with plate augmentation for femoral shaft nonunion leaving the nail in situ.
Patients and methods Between 2015 and 2018, 22 consecutive patients with femoral shaft aseptic nonunion after IM nailing
were treated with plate augmentation over a retained nail at four different institutions. Nonunion was categorized based on its
anatomical location and was classified according to the Weber and Cech classification. Cortical defects greater than 1.0 cm,
the type of nailing procedure, and the number of previous interventions were recorded. Patients were assessed clinically
and radiographically to measure the healing of nonunion sites. The time to fracture union and complications were recorded.
Descriptive statistics were used when applicable.
Results One site location was supra-isthmic, 12 were isthmic, and 9 were infra-isthmic. There were 10 cases of vascular
nonunion and 12 cases of avascular nonunion. A cortical defect greater than 1.0 cm was observed in three patients. Antegrade
nailing was performed in 11 patients, and retrograde nailing was performed in 11 patients. Reaming was performed in 12
patients. In eight patients, the fracture was openly reduced during the IM nailing index procedure. The average number of
previous interventions before augmentation plating was 1.6 (1–4). Bone union was achieved in 19 patients after augmenta-
tion plating with an average follow-up of 23.5 months (12–51 months). Excellent and good clinical results were observed in
all patients. There was no plate or screw breakage, and no patient developed infection.
Conclusion Augmentation plating leaving the nail in situ is an excellent option for treating femoral shaft nonunion after IM
nailing, with a high union rate and few complications. We believe the technique should gradually replace exchange nailing
as the standard of care for the majority of femoral shaft nonunions that occur after IM nailing.

Keywords Femoral nonunion · Augmentation plating · Adjunctive plating · Biological stimulation · Failed intramedullary
nailing

* Vincenzo Giordano Introduction

v_giordano@me.com
1
Departamento de Ortopedia e Traumatologia, Hospital Indirect closed reduction and intramedullary (IM) nailing
do Trabalhador, Curitiba, Brazil have represented the treatment of choice for most femoral
2
Hospital Sirio Libanes, Buenos Aires, Argentina shaft fractures. However, up to an 8% nonunion rate has been
3 reported after rigid IM fixation of femoral shaft fractures in
Faculdade de Medicina, Hospital das Clinicas HCFMUSP,
Universidade de Sao Paulo, Sao Paulo, Brazil adults [1]. Although many biological factors, such as the
4 severity of bone injury and soft tissue damage, can lead to
Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro,
Hospital Municipal Miguel Couto, Rua Mário Ribeiro 117, this complication, the major risk factors seem to be related
Rio de Janeiro, RJ 22430‑160, Brazil to biomechanical reasons, such as instability at the fracture
5
Clínica São Vicente, Rede D’or São Luiz, Rio de Janeiro, site and shear stress [1, 2].
Brazil

13
Vol.:(0123456789)

The current surgical treatment of choice for delayed union
and nonunion after femoral shaft nailing is reamed exchange
nailing [1, 3]. However, exchange nailing procedures can
sometimes be extremely challenging, as broken intraosseous
screws, broken nails, and heterotopic ossification over the
tip of the implant can make the procedure difficult or even
avoid bone extraction. In addition, technical issues, such as
those associated with the implant characteristics and surgical
techniques, are often ignored when patients are referred from
other institutions. Finally, the mechanical requirement of
reaming the medullary canal to allow for the use of thicker
nails can potentially damage endosteal blood vessels, ulti-
mately affecting the biological healing response.
In recent years, plate augmentation over a retained
intramedullary nail has been shown to be an effective option
for managing femur fracture nonunions because it improves
the biomechanical environment of the fracture site without
causing more biological damage [4–7]. In a recent system-
atic review of 21 papers, plate augmentation was found to
provide a better union rate with fewer complications com-
pared to exchange nailing [3]. The union rate and complica-
tion rate with plate augmentation were found to be 99.8%
and 4.0% compared to 74% and 20%, respectively, with
exchange nailing.
In the current study, we present outcome data from 22
consecutive patients treated with plate augmentation for
femoral shaft nonunion leaving the nail in situ.
Methods
Patient information
From January 2015 to January 2018, all patients present-
ing with femoral shaft fracture nonunion who were treated
with plate augmentation over a retained intramedullary nail
in four different institutions (one in Argentina and three in
Brazil) were retrospectively reviewed. All patients were
operated on primarily in authors’ institutions. All fractures
were adequately reduced with no gaps during the first pro-
cedure (IM nailing) and the nails were locked with at least
two screws proximally and two screws distally. The choice
between antegrade and retrograde nailing was based on sur-
geons’ preference. Twelve nails were reamed normally one
and half millimeters over the diameter of the nail. We regu-
larly use the concept of ‘ream to fit’, avoiding over-ream-
ing. Ten nails were unreamed due to one of the surgeon’s
preference.
The inclusion criteria of this study were as follows: (1)
skeletally mature patients; (2) patients with complete clini-
cal and radiologic documentation of the whole treatment;
and (3) patients with at least a 1-year follow-up. The exclu-
sion criteria were as follows: (1) patients with septic femoral
13
C. S. Uliana et al.
shaft nonunion; (2) patients with pathological fractures; and
(3) patients who had an incomplete history of the index pro-
cedure (femoral nailing).
Surgical site infection was defined either preoperatively
or intraoperatively according to four confirmatory criteria:
(1) presence of fistula, sinus, or wound breakdown, (2) puru-
lent drainage from the wound or presence of pus during sur-
gery, (3) pathogens identification by culture from at least two
separate deep tissue/implant specimens, and (4) presence
of microorganisms in deep tissue taken during an operative
intervention, as confirmed by histopathological examina-
tion [8]. After the exclusion of patients who did not satisfy
the inclusion criteria, a total of 22 patients (18 males and 4
females) were eligible for this study. The average age at the
time of treatment was 32.3 years (range 20–46 years). The
average time between the initial fixation with an intramed-
ullary nail and augmentation plating was 21 months (range
6–72 months).
Nonunion was defined both clinically as persistent pain at
the fracture site during the stance phase and frank instability
and radiographically as the presence of a radiolucent line at
the fracture site with no evidence of union after 6 months or
more from the time of the index procedure. Nonunion was
categorized based on its anatomical location (proximal to the
isthmus, at the level of the isthmus, and distal to the isthmus)
and was classified according to the Weber and Cech clas-
sification (vascular and avascular) [1]. When present, any
cortical defect greater than 1.0 cm was registered. The type
of nailing procedure (antegrade vs. retrograde, reamed vs.
unreamed) and the number of previous interventions were
recorded.
Surgery information
Patients were placed on a radiolucent table in either the
supine or lateral position depending on the surgeon’s pref-
erence. A fracture table was not used. Through a lateral
approach to the thigh, the vastus lateralis was raised to
expose the nonunion site. Autogenous bone graft from the
ipsilateral anterior iliac crest was harvested and placed at
the original fracture site in almost all cases depending on
the surgeon’s preference. Either a small fragment dynamic
compression plate (sf DCP) or locked compression plate
(sf LCP) or a large fragment dynamic compression plate (lf
DCP) or locked compression plate (lf LCP) were applied to
the lateral surface of the femur. Plates were molded when-
ever necessary to adapt to the periosteal callus on the sys
cortical. Dynamic compression was achieved at the nonun-
ion site with either one or two lag screws or in the form of
axial compression through the plate.
Postoperatively, patients were stimulated to bear weight
with crutches as tolerated and to start functional knee exer-
cises. Progressive weight-bearing was allowed, and full
Augmentation plating leaving the nail in situ is an excellent option for treating femoral shaft…

weight-bearing was allowed after the fracture was clini- Results

cally and radiographically healed. Patients were checked
at regular outpatient visits until there was radiographic Based on the anatomical location of nonunion, one was
evidence of bone healing and yearly thereafter until the supra-isthmic, 12 were isthmic, and nine were infra-
last follow-up evaluation. isthmic. According to the Weber and Cech classification,
there were ten cases of vascular nonunion and 12 cases of
avascular nonunion. A cortical defect greater than 1.0 cm
Outcome assessment was observed in three sites: one isthmic and two infra-
isthmic nonunion sites. Antegrade nailing was performed
Patients were assessed both clinically and radiographi- in 11 patients, and retrograde nailing was performed in
cally to measure the healing of nonunion sites. The fol- 11 patients. Intramedullary reaming was performed in 12
lowing clinical parameters were adapted from Wu [11]: patients. In eight patients, the fracture was openly reduced
(1) pain and tenderness at the nonunion site, (2) range of during the intramedullary nailing index procedure. The
motion of the knee, (3) ability to walk independently, and average number of previous interventions before augmen-
(4) residual deformity [9]. The total score was 50 points, tation plating was 1.6 (range 1–4): mainly decortication
with 50 points indicating excellent, 45–30 points indicat- and nail dynamization. Table 2 summarizes the patient
ing good, 20–15 points indicating fair, and less than 15 data.
points indicating poor results. The radiographic criteria An sf DCP was used in five patients, an sf anatomical
were (1) bridging of the nonunion site seen at three corti- LCP for the proximal lateral tibia was used in one patient,
ces and (2) obliteration of the initial fracture line. Table 1 an lf DCP was used in five patients, an lf LCP was used
summarizes the clinical parameters adapted from Wu [11]. in seven patients, and an lf anatomical LCP for the distal
The time to fracture union after plate augmentation femur was used in four patients. Autogenous bone grafts
was recorded. Complications, if any, were also recorded. were used in 18 patients; there were nine cases of avascu-
Descriptive statistics were used when applicable. lar nonunion and nine cases of vascular nonunion. Figure 1
illustrates the case of one patient managed with an lf LCP
for a vascular isthmic nonunion.
The average follow-up was 23.5 months (range
Table 1  Clinical parameters adapted from Wu 12–51 months). At the last follow-up, union was achieved
in 19 (86.0%) patients after augmentation plating. The
Criteria Level Score (points)
average time to fracture union after plate augmentation was
1. Pain No 10 11.7 months (range 2–16 months). Three (13.6%) patients
Moderate 5 experienced failure of the fracture to unite: one refused fur-
Intense 0 ther intervention, and the others were treated with exchange
2. Range of motion Complete 10 plating and repeated bone grafting. At the last follow-up
Limited 5 at 25 months, the patient who refused new surgery had a
Severely reduced (stiff 0 5.0 cm bone defect at the nonunion site and walked without
joint) crutches. All are still being followed-up with no healing.
3. Independence to walk No restriction 10 Clinically, eight patients had excellent scores, and 14
Crutches 5 patients had good scores including the three patients with
Unable to walk 0 unhealed nonunion sites in the last follow-up. All patients
4. Residual deformity No 10 were able to walk independently with full weight bear and
Mild (angulation < 10°, 5 no crutches. There was no plate or screw breakage, and
rotation < 10°, or short- no patient developed infection. Table 3 summarizes the
ening < 2 cm)
surgical data.
Severe (angulation > 10°, 0
rotation > 10°, or short-
ening > 2 cm)
5. Bone healing Bridged fragments in two 10
planes Discussion
Bridged fragments in one 5
plane In this study, augmentation plating for treating femoral
Nonunion 0 shaft nonunion leaving the nail in situ allowed for excel-
Interpretation: 50 points—excellent; 30–45 points—good; 15–20 lent and good clinical outcomes in all patients, with
points—fair; < 15 points—poor

13
 C. S. Uliana et al.

Table 2  Patient data Patient Sex Age Location W&C Cortical Type of nail Reaming Direct Number of
defect procedure reduc- previous
(cm) tion surgeries

1 M 35 I V < 1.0 Antegrade No No 2

2 M 29 I V < 1.0 Retrograde Yes No 1
3 M 22 II V < 1.0 Retrograde Yes No 1
4 M 32 II A 5.0 Retrograde No No 1
5 M 40 II A < 1.0 Antegrade No Yes 3
6 M 33 I V < 1.0 Antegrade No No 2
7 F 45 I A < 1.0 Retrograde No No 2
8 F 27 I A 2.0 Antegrade No Yes 1
9 M 43 I A < 1.0 Antegrade No No 2
10 M 23 SI A < 1.0 Antegrade Yes No 1
11 F 20 II A 2.0 Antegrade Yes No 4
12 M 36 II A < 1.0 Retrograde Yes No 1
13 F 39 I A < 1.0 Antegrade No Yes 4
14 M 43 I A 1.0 Retrograde Yes Yes 3
15 M 28 I A < 1.0 Retrograde Yes Yes 1
16 M 24 I V < 1.0 Antegrade Yes Yes 1
17 M 46 I V < 1.0 Antegrade Yes No 1
18 M 23 II V < 1.0 Retrograde Yes No 1
19 M 30 II A < 1.0 Retrograde Yes Yes 2
20 M 25 II V < 1.0 Retrograde Yes No 1
21 M 30 II V < 1.0 Retrograde No No 1
22 M 38 II V < 1.0 Antegrade No Yes 1

W&C Weber and Cech, M male, F female, I isthmic, II infra-isthmic, SI supra-isthmic, A avascular, V vas-
cular

Fig. 1  Case 6—a Pre-operative AP and lateral X-rays of the left
femur demonstrating a vascular isthmic nonunion after an antegrade
femoral nail. There is no sign of mechanical failure of the implant;
b Immediate post-operative AP and lateral X-rays show interfrag-
mentary compression with two cortical lag-screws and an lf LCP. No
bone graft was used. Observe the oblique positioning of the implant
to allow adequate purchase of the screws with bicortical fixation, thus
avoiding interference with the nail; c Follow-up AP and lateral X-rays
at 7 months demonstrate uneventful fracture healing. Patient was con-
sidered to have good final result at last follow-up at 18 months

13
Augmentation plating leaving the nail in situ is an excellent option for treating femoral shaft…

Table 3  Surgical data

Patient Type of plate Number of screws Bone graft Last F-U Fracture union Time to union Clinical score
(proximally/distally) (months) (months)

1 lf LCP 3/2 Yes 36 Yes 12 Excellent

2 lf LCP 2/2 Yes 34 Yes 14 Excellent
3 lf LCP 2/2 Yes 18 Yes 9 Good
4 lf LCP 2/2 Yes 20 No N/A Good
5 lf LCP 4/4 Yes 22 Yes 5 Excellent
6 lf LCP 3/3 No 18 Yes 7 Good
7 lf anat LCP DF 4/8 No 28 Yes 8 Good
8 lf anat LCP DF 4/5 Yes 13 Yes 9 Excellent
9 lf anat LCP DF 5/5 No 20 Yes 11 Good
10 sf anat LCP PT 4/5 Yes 12 Yes 5 Good
11 lf anat LCP DF 7/7 No 48 Yes 6 Excellent
12 lf LCP 2/2 Yes 29 No N/A Good
13 lf DCP 3/3 Yes 12 Yes 8 Good
14 sf DCP 2/2 Yes 12 Yes 7 Good
15 sf DCP 3/3 Yes 12 No N/A Good
16 lf DCP 2/2 Yes 15 Yes 3 Excellent
17 lf DCP 2/2 Yes 17 Yes 14 Good
18 sf DCP 2/2 Yes 30 Yes 5 Good
19 sf DCP 2/2 Yes 42 Yes 16 Good
20 sf DCP 2/2 Yes 26 Yes 8 Excellent
21 lf DCP 2/2 Yes 51 Yes 10 Good
22 lf DCP 5/3 Yes 49 Yes 2 Excellent

F-U follow-up, sf DCP small fragment dynamic compression plate, sf anat LCP PT small fragment anatomical locking compression plate for the
tibial plateau, lf DCP large fragment dynamic compression plate, lf LCP large fragment locking compression plate, lf anat LCP DF large frag-
ment anatomical locking compression plate for the distal femur, N/A not applicable

radiographic healing of the nonunion site in 86% of
patients and no complications. Many surgeons have con-
firmed the efficacy of this technique in the management
of femur shaft aseptic nonunions [4, 5, 7, 9]. In a ret-
rospective review of 40 patients presenting with femoral
shaft nonunions or delayed unions after intramedullary
nailing, Jhunjhunwala and Dhawale reported a success
rate of 97.5% using plate augmentation [7]. In their series,
supplementary autogenous bone grafting was performed
in 24 patients with avascular nonunion. Exchange nail-
ing was performed in nine patients. However, they lacked
a description of which patients needed which surgery
(delayed union, avascular nonunion, or vascular nonun-
ion). In another study by Chiang et al., 30 patients were
treated with augmentation plating over a retained nail,
with uneventful union occurring in 29 patients [5]. Bio-
logic supplementation with autogenous bone grafting
(n = 17) and bone morphogenetic protein (BMP, n = 19)
was performed for selected patients with avascular or
oligotrophic vascular nonunions. However, there was no
clear indication why and when this was needed, as their
study included seven patients with avascular nonunion,
18 patients with oligotrophic vascular nonunion, and five
patients with hypertrophic vascular nonunion. Similar
results were reported by Vaishya et al. in a retrospective
study of 16 patients with femoral shaft nonunion, with
union occurring in all cases [9]. Autologous corticocancel-
lous bone grafts were used only in patients with avascular
nonunion, and no interfragmentary compression was per-
formed at the nonunion site to achieve bone healing.
While no specific recommendation exists in terms of the
most desirable augmentation plating technique for femoral
shaft nonunion after nailing, our results confirm that this
technique yields satisfactory outcomes. Nevertheless, key
treatment guidelines are still missing, mainly regarding
which plate should be used, whether associated dynamiza-
tion or exchange nailing is needed, and when bone grafting is
required. In our series, 16 (72.7%) of 22 patients had a large
fragment plate, with bicortical screw fixation. The length
of the plate varied from 4 to 14 holes. Although we did
not detect differences in bone union among the type (small
fragment vs. large fragment and non-locked vs. locked) and
length (short vs. long) of the plates used, we strongly recom-
mend that at least four cortices should be fixed proximally
and four cortices distally to the nonunion site. In addition,
dynamic compression at the nonunion site must be achieved

13

either with lag screws or axial compression with the plate.
Most investigators have used large fragment plates, either
non-locked or locked, with bicortical screws whenever pos-
sible [4–7, 9]. Removal of the locking screws is regularly
performed to achieve dynamic compression at the nonun-
ion site. In a recent systematic review, Medlock et al. found
that when applied in a compression mode, large fragment
plate and screw construction helped to limit excessive axial
displacement, observed, for example, when dynamization
only was used [3]. In addition, these authors stated that the
construction was stiff enough to resist the rotational instabil-
ity commonly observed at a femoral nonunion site, offering
a more favorable mechanical environment for bone healing
and immediate weight bearing. This was corroborated in
a recent biomechanical experiment using synthetic femora
with intra-articular distal femur fractures with metaphyseal
comminution (OTA/AO 33-C) demonstrated that baseline
stiffness significantly increases when an IM nail is added to
a synthetic femur with a lateral locked plate [10].
Autogenous bone grafts or bone substitutes are of utmost
importance for the success of augmentation plating tech-
niques for femoral shaft nonunion after nailing. In our series,
18 (81.8%) of 22 patients had autogenous bone grafting.
The need for biologic supplementation has been constantly
emphasized by previous authors, who considered it for all
avascular nonunions and for the majority of vascular non-
unions [5, 6]. The potential for early bone union seems to be
responsible for the trend towards biologic supplementation
in almost all cases and not only for avascular nonunions.
Most investigators have recommended autogenous iliac crest
corticocancellous bone grafts regardless of the bone defect
size [4–8]. Jhunjhunwala and Dhawale used chiseled bone
chips from the hypertrophic callus for vascular nonunions,
thus reducing potential complications related to the iliac
crest donor site [7]. In addition, they suggested an associated
exchange nailing method for cases in which there were thin
nails, short nails, and broken nails. In our opinion, associ-
ated exchange nailing should be considered only if there
is a fixed angular deformity precluding correction due to
the intramedullary device. In this particular situation, we
feel that other techniques must be considered. In the current
study, only four (18.2%) patients had no bone grafts, and
three of them had avascular nonunions. Nevertheless, all of
them had bone union with no complications, reinforcing the
importance of a favorable mechanical environment based
on anatomic alignment, interfragmentary compression, and
adequate stability [1, 3, 6].
We recognize that there are several limitations in the cur-
rent investigation. First, the retrospective nature of the study
and the fact that there is no control group for direct com-
parison are limitations. Nevertheless, there is a substantial
amount of evidence that plate augmentation provides a more
reliable union rate, better functional outcomes, and faster
13
C. S. Uliana et al.
patient recovery compared to exchange nailing for the man-
agement of femoral shaft nonunion after IM nailing [1–8].
Second, we analyzed a relatively small cohort of 22 patients.
Other authors have reported case series varying from 11 to
40 patients, demonstrating both a low nonunion rate after
IM nailing and a gradual change from previous techniques
to augmentation plating [4, 5, 7, 8]. In addition, we highlight
the multicentre nature of our study with uniform satisfactory
results, which demonstrates the efficacy and reproducibility
of the technique. Third, we operated on relatively young
patients, with ages up to 46 years old (average age at the
time of treatment was 32.3 years). Nowadays, in most coun-
tries the problem of femoral diaphyseal fractures is seen in
elderly patients, which potentially could interfere in terms
of bone healing both primarily and after plate augmentation.
However, this theoretical concern was not clinically dem-
onstrated by many authors, that observed good to excellent
results after additional compression plating leaving the nail
in situ in older patients [2, 5, 7, 8]. In those studies, autog-
enous bone grafting was routinely used. Park et al. hypoth-
esized that the additive effect of stable mechanical fixation
with a plate and autogenous bone graft are necessary for a
successful union rate in their patients [2]. Fourth, different
types of plating (locking and non-locking) and variations
in nailing method (antegrade and retrograde, and reamed
vs unreamed) were used, potentially biasing our findings.
Again, this reflected the multicenter nature of the study. The
decision between antegrade and retrograde nailing as well as
to ream or not was basically a surgeons’ decision. Neverthe-
less, literature has been shown no difference in terms of bone
healing between antegrade and retrograde nailing for femur
shaft fractures [13, 14]. In addition, we did not detect dif-
ferences in bone union among the type (small fragment vs.
large fragment and non-locked vs. locked) and length (short
vs. long) of the plates used. More relevant than that, surgeon
has to focus on offering a more favorable mechanical envi-
ronment for bone healing and immediate weight bearing,
with at least four cortices fixed proximally and four cortices
distally to the nonunion site. Finally, we performed descrip-
tive statistical analysis, with frequencies and percentages
for categorical data and means. Although we cannot statis-
tically infer results with descriptive statistics, this method
seems completely appropriate to the current research, where
the goal was to address whether plate augmentation over a
retained IM nail was an effective option for managing femur
fracture nonunions [10].
Conclusion
Augmentation plating leaving the nail in situ is an excellent
option for treating femoral shaft nonunion after IM nailing.
The main indication is a non-isthmic nonunion with good
Augmentation plating leaving the nail in situ is an excellent option for treating femoral shaft…
cortical bone, small (< 1.0 cm) or no fracture defects, and
adequate axial alignment. In this scenario, the addition of
a large fragment plate with interfragmentary compression
provides great stability, controlling the potential deleterious
rotational instability commonly noted after failed IM nail-
ing. Bone grafting should be used in almost all cases, even
vascular nonunions, as it was demonstrated to accelerate
bone union. We feel the technique should gradually replace
exchange nailing as the standard of care for the majority of
femoral shaft nonunions that occur after IM nailing.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical standards Ethical clearance has been taken from the institu-
tional ethical committee.
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