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Re: The patient with non-union of the distal femur
Peter Trafton 08 Май 2007, 00:03
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Meta-diaphyseal atrophic nonunions generally respond better to absolute than relative stability. I presume your "freshening up" would involve taking this nonunion down to obtain an anatomical reduction, after which absolute stability might best be achieved with interfragmentary compression using a blade-plate, or, as others have suggested and I would prefer, if it were available, a locking distal femoral plate. If appropriate bone contact could be achieved, fixation might be enhanced significantly by using the external tension device to compress the fracture. I'd add bone graft.
The following reference, which describes the short "GSH" retrograde femoral nail, seems to offer relevant evidence:
J Orthop Trauma. 1995;9(4):285-91.
Distal femoral nonunion: treatment with a retrograde inserted locked intramedullary nail. Koval KJ, Seligson D, Rosen H, Fee K.
Between March 1989 and August 1993, 16 distal femoral nonunions (16 patients)
were treated using the supracondylar intramedullary nail. The time between the
initial event and retrograde nailing averaged 33 months. The nonunion level was
infraisthmal in four patients and supracondylar in 12. Operative technique involved retrograde insertion of a reamed supracondylar intramedullary nail through the intercondylar notch. Follow-up was available on all patients and averaged 20 months (range 9-46). Four nonunions (25%) united with a single surgery at an average of 17 months. A fifth nonunion united at 21 months after
nail dynamization and subsequent nail breakage. The nonunions of two additional patients united after exchange of a broken retrograde nail. Additional surgical procedures were performed in six of the remaining nine patients in an attempt to gain union. At an average follow-up of 16 months (range 9-23), none of the nine
had united. Nine nails fractured at an average of 11 months, all through a screw hole near the nonunion. Based on these results, we cannot recommend use of the supracondylar intramedullary nail in its present form for the treatment of distal femoral nonunions.
Best wishes,
pg trafton
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