Effectiveness of tunnel osteogenesis technique in treatment of aseptic non-hypertrophic nonunion of femoral shaft_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

YE Haobo ¹ , SUN Liang ² , XUE Hanzhong ² , LI Zhong ² ,  ZHANG Kun ²

1. Xi’an Medical University, Xi’an Shaanxi, 710068, P. R. China;
2. Department of Orthopaedics and Trauma, Honghui Hospital Affiliated to Medical College of Xi’an Jiaotong University, Xi’an Shaanxi, 710054, P. R. China;

Corresponding author：

ZHANG Kun, Email: hhyyzk@126.com

Keywords：

Femoral shaft; locking plate; bone nonunion; tunnel osteogenesis technique

DOI：

10.7507/1002-1892.202203083

Video：

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Objective To investigate the effectiveness of tunnel osteogenesis technique combined with locking plate in the treatment of aseptic non-hypertrophic nonunion of femoral shaft. Methods The clinical data of 23 cases of aseptic non-hypertrophic nonunion of femoral shaft treated with tunnel osteogenesis technique combined with locking plate between January 2017 and December 2020 were retrospectively analysed. There were 17 males and 6 females with an average age of 41.4 years (range, 22-72 years). There were 22 cases of closed fracture and 1 case of open fracture. The types of internal fixation at admission included intramedullary nail in 14 cases and steel plate in 9 cases. The number of nonunion operations received in the past was 0 to 1; the duration of nonunion was 6-60 months, with an average of 20.1 months. Among them, there were 17 cases of aseptic atrophic nonunion of the femoral shaft and 6 cases of dystrophic nonunion. Twenty-two cases were fixed with 90° double plates and 1 case with lateral single plate. The operation time, theoretical blood loss, hospitalization stay, nonunion healing, and postoperative complications were recorded. Harris hip function score, Lysholm knee function score, lower extremity function scale (LEFS), and short-form 36 health survey scale (SF-36) were used at last follow-up to evaluate hip and knee functions. Visual analogue scale (VAS) score was used to evaluate the relief of pain at 1 day after operation and at last follow-up. Results The average operation time was 190.4 minutes, the average theoretical blood loss was 1 458.4 mL, and the average hospitalization stay was 8.2 days. All the 23 patients were followed up 9-26 months, with an average of 18.2 months. The healing time of nonunion in 22 patients was 3-12 months, with an average of 5.6 months. There were 8 cases of limb pain, 8 cases of claudication, 6 cases of limitation of knee joint movement, and 2 cases of limitation of hip joint movement. At last follow-up, the imaging of 1 patient showed that the nonunion did not heal, accompanied by pain of the affected limb, lameness, and limitation of knee joint movement. At 1 day after operation, the VAS score of 23 patients was 6.5±1.8, the pain degree was good in 7 cases, moderate in 12 cases, and poor in 4 cases; at last follow-up, the VAS score was 0.9±1.3, the pain degree was excellent in 21 cases and good in 2 cases, which were significantly better than those at 1 day after operation (t=12.234, P<0.001; Z=–5.802, P<0.001). At last follow-up, the average Harris hip function score of 22 patients with nonunion healing was 94.8, and the good rate was 100%; Lysholm knee function score averaged 94.0, and the excellent and good rate was 90.9%; LEFS score averaged 74.6; SF-36 physical functioning score averaged 85.0 and the mental health score averaged 83.6. Conclusion Tunnel osteogenesis technique combined with locking plate in the treatment of aseptic non-hypertrophic nonunion of femoral shaft has a high healing rate and fewer complications, which can effectively relieve pain and improve lower limb function and quality of patients’ life.

Citation： YE Haobo, SUN Liang, XUE Hanzhong, LI Zhong, ZHANG Kun. Effectiveness of tunnel osteogenesis technique in treatment of aseptic non-hypertrophic nonunion of femoral shaft. Chinese Journal of Reparative and Reconstructive Surgery, 2022, 36(8): 976-982. doi: 10.7507/1002-1892.202203083 Copy

1.	Hak DJ, Fitzpatrick D, Bishop JA, et al. Delayed union and nonunions: epidemiology, clinical issues, and financial aspects. Injury, 2014, 45 Suppl 2: S3-S7.
2.	Riemer BL, Butterfield SL, Burke CJ, et al. Immediate plate fixation of highly comminuted femoral diaphyseal fractures in blunt polytrauma patients. Orthopedics, 1992, 15(8): 907-916.
3.	Panteli M, Vun JSH, Pountos I, et al. Biological and molecular profile of fracture non-union tissue: A systematic review and an update on current insights. J Cell Mol Med, 2022, 26(3): 601-623.
4.	Wiss DA, Garlich J, Hashmi S, et al. Risk factors for development of a recalcitrant femoral nonunion: A single surgeon experience in 122 patients. J Orthop Trauma, 2021, 35(12): 619-625.
5.	Zura R, Xiong Z, Einhorn T, et al. Epidemiology of fracture nonunion in 18 human bones. JAMA Surg, 2016, 151(11): e162775. doi: 10.1001/jamasurg.2016.2775.
6.	Palaniappan P, Baalann KP. Fracture nonunion. Pan Afr Med J, 2021, 40: 93. doi: 10.11604/pamj.2021.40.93.28184.
7.	Yang KH, Kim JR, Park J. Nonisthmal femoral shaft nonunion as a risk factor for exchange nailing failure. J Trauma Acute Care Surg, 2012, 72(2): E60-E64.
8.	Mittal KK, Gupta H, Kaushik N. Reunion of post nail aseptic non-union of diaphyseal femoral fractures by augmentation plating, decortication and bone grafting—Replacement for exchange nailing. Injury, 2021, 52(6): 1529-1533.
9.	马腾, 许毅博, 任程, 等. 皮质骨剥离及附加钢板植骨治疗髓内钉固定后股骨干非肥大型骨不连的临床疗效. 中国骨与关节杂志, 2021, 10(9): 661-664.
10.	Zhang W, Hao M, Chang Z, et al. Comparison of a multidimensional cross locking plate versus a locking compression plate for the treatment of femoral shaft nonunion: Finite element analysis. Med Eng Phys, 2020, 83: 106-111.
11.	Peng Y, Ji X, Zhang L, et al. Double locking plate fixation for femoral shaft nonunion. Eur J Orthop Surg Traumatol, 2016, 26(5): 501-507.
12.	Xing W, Pan Z, Sun L, et al. Sliding bone graft combined with double locking plate fixation for the treatment of femoral shaft nonunion. J Int Med Res, 2019, 47(5): 2034-2044.
13.	Maimaitiyiming A, Amat A, Rehei A, et al. Treatment of the femoral shaft nonunion with double plate fixation and bone grafting: A case series of 14 patients. Injury, 2015, 46(6): 1102-1107.
14.	王兴义, 王伟, 王公奇, 等. 感染性骨不连. 北京: 人民军医出版社, 2016: 22-25.
15.	宋文奇, 陆晟迪, 徐铮宇, 等. 低毒性感染性骨不连术前诊断标准的建立. 中华创伤骨科杂志, 2020, 22(5): 390-393.
16.	Judet R, Judet J. Osteo-periosteal decortication. Principle, technic, indications and results. Mem Acad Chir (Paris), 1965, 91(15): 463-470.
17.	Gross JB. Estimating allowable blood loss: corrected for dilution. Anesthesiology, 1983, 58(3): 277-280.
18.	杨荣, 陈雁西. 四肢骨不连早期诊断的研究进展. 中华骨科杂志, 2018, 38(9): 563-569.
19.	Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg (Am), 1969, 51(4): 737-755.
20.	Briggs KK, Lysholm J, Tegner Y, et al. The reliability, validity, and responsiveness of the Lysholm score and Tegner activity scale for anterior cruciate ligament injuries of the knee: 25 years later. Am J Sports Med, 2009, 37(5): 890-897.
21.	Hidayat L, Triangga AFR, Cein CR, et al. Low profile external fixation using locking compression plate as treatment option for management of soft tissue problem in open tibia fracture grade ⅢA: A case series. Int J Surg Case Rep, 2022, 93: 106882. doi: 10.1016/j.ijscr.2022.106882.
22.	Scarabottolo CC, Tebar WR, Gobbo LA, et al. Analysis of different domains of physical activity with health-related quality of life in adults: 2-year cohort. Health Qual Life Outcomes, 2022, 20(1): 71. doi: 10.1186/s12955-022-01981-3.
23.	Lanier K, Johnson AM, Tapia X, et al. A retrospective study on the effects of kinesiology taping on edema of the lower limb in 14 patients following intramedullary nailing for femoral shaft fracture. Med Sci Monit, 2022, 28: e936619. doi: 10.12659/MSM.936619.
24.	Rupp M, Biehl C, Budak M, et al. Diaphyseal long bone nonunions-types, aetiology, economics, and treatment recommendations. Int Orthop, 2018, 42(2): 247-258.
25.	Bellabarba C, Ricci WM, Bolhofner BR. Results of indirect reduction and plating of femoral shaft nonunions after intramedullary nailing. J Orthop Trauma, 2001, 15(4): 254-263.
26.	Zhang H, Li J, Zhou J, et al. Finite element analysis of different double-plate angles in the treatment of the femoral shaft nonunion with no cortical support opposite the primary lateral plate. Biomed Res Int, 2018, 2018: 3267107. doi: 10.1155/2018/3267107.
27.	薛汉中, 孙亮, 李忠, 等. 断端成骨能力区域划分对锁定钢板桥接技术联合植骨治疗骨不连的临床意义. 中华创伤骨科杂志, 2014, 16(10): 829-833.
28.	Refai O, Khalifa AA. Single stage open reduction, intramedullary rod, bone grafting, and plate fixation for managing adolescent midshaft femoral fracture non-union, report of two cases. Trauma Case Rep, 2022, 38: 100616. doi: 10.1016/j.tcr.2022.100616.
29.	Chamseddine AH, Mouchantaf ME, Freiha KF, et al. Bridge plating with decortication, autologous bone graft, and tight closure: a “stepwise surgical diamond concept” for treatment of nonunion in a series of fifty five patients. Int Orthop, 2022, 46(6): 1241-1251.

1. Hak DJ, Fitzpatrick D, Bishop JA, et al. Delayed union and nonunions: epidemiology, clinical issues, and financial aspects. Injury, 2014, 45 Suppl 2: S3-S7.
2. Riemer BL, Butterfield SL, Burke CJ, et al. Immediate plate fixation of highly comminuted femoral diaphyseal fractures in blunt polytrauma patients. Orthopedics, 1992, 15(8): 907-916.
3. Panteli M, Vun JSH, Pountos I, et al. Biological and molecular profile of fracture non-union tissue: A systematic review and an update on current insights. J Cell Mol Med, 2022, 26(3): 601-623.
4. Wiss DA, Garlich J, Hashmi S, et al. Risk factors for development of a recalcitrant femoral nonunion: A single surgeon experience in 122 patients. J Orthop Trauma, 2021, 35(12): 619-625.
5. Zura R, Xiong Z, Einhorn T, et al. Epidemiology of fracture nonunion in 18 human bones. JAMA Surg, 2016, 151(11): e162775. doi: 10.1001/jamasurg.2016.2775.
6. Palaniappan P, Baalann KP. Fracture nonunion. Pan Afr Med J, 2021, 40: 93. doi: 10.11604/pamj.2021.40.93.28184.
7. Yang KH, Kim JR, Park J. Nonisthmal femoral shaft nonunion as a risk factor for exchange nailing failure. J Trauma Acute Care Surg, 2012, 72(2): E60-E64.
8. Mittal KK, Gupta H, Kaushik N. Reunion of post nail aseptic non-union of diaphyseal femoral fractures by augmentation plating, decortication and bone grafting—Replacement for exchange nailing. Injury, 2021, 52(6): 1529-1533.
9. 马腾, 许毅博, 任程, 等. 皮质骨剥离及附加钢板植骨治疗髓内钉固定后股骨干非肥大型骨不连的临床疗效. 中国骨与关节杂志, 2021, 10(9): 661-664.
10. Zhang W, Hao M, Chang Z, et al. Comparison of a multidimensional cross locking plate versus a locking compression plate for the treatment of femoral shaft nonunion: Finite element analysis. Med Eng Phys, 2020, 83: 106-111.
11. Peng Y, Ji X, Zhang L, et al. Double locking plate fixation for femoral shaft nonunion. Eur J Orthop Surg Traumatol, 2016, 26(5): 501-507.
12. Xing W, Pan Z, Sun L, et al. Sliding bone graft combined with double locking plate fixation for the treatment of femoral shaft nonunion. J Int Med Res, 2019, 47(5): 2034-2044.
13. Maimaitiyiming A, Amat A, Rehei A, et al. Treatment of the femoral shaft nonunion with double plate fixation and bone grafting: A case series of 14 patients. Injury, 2015, 46(6): 1102-1107.
14. 王兴义, 王伟, 王公奇, 等. 感染性骨不连. 北京: 人民军医出版社, 2016: 22-25.
15. 宋文奇, 陆晟迪, 徐铮宇, 等. 低毒性感染性骨不连术前诊断标准的建立. 中华创伤骨科杂志, 2020, 22(5): 390-393.
16. Judet R, Judet J. Osteo-periosteal decortication. Principle, technic, indications and results. Mem Acad Chir (Paris), 1965, 91(15): 463-470.
17. Gross JB. Estimating allowable blood loss: corrected for dilution. Anesthesiology, 1983, 58(3): 277-280.
18. 杨荣, 陈雁西. 四肢骨不连早期诊断的研究进展. 中华骨科杂志, 2018, 38(9): 563-569.
19. Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg (Am), 1969, 51(4): 737-755.
20. Briggs KK, Lysholm J, Tegner Y, et al. The reliability, validity, and responsiveness of the Lysholm score and Tegner activity scale for anterior cruciate ligament injuries of the knee: 25 years later. Am J Sports Med, 2009, 37(5): 890-897.
21. Hidayat L, Triangga AFR, Cein CR, et al. Low profile external fixation using locking compression plate as treatment option for management of soft tissue problem in open tibia fracture grade ⅢA: A case series. Int J Surg Case Rep, 2022, 93: 106882. doi: 10.1016/j.ijscr.2022.106882.
22. Scarabottolo CC, Tebar WR, Gobbo LA, et al. Analysis of different domains of physical activity with health-related quality of life in adults: 2-year cohort. Health Qual Life Outcomes, 2022, 20(1): 71. doi: 10.1186/s12955-022-01981-3.
23. Lanier K, Johnson AM, Tapia X, et al. A retrospective study on the effects of kinesiology taping on edema of the lower limb in 14 patients following intramedullary nailing for femoral shaft fracture. Med Sci Monit, 2022, 28: e936619. doi: 10.12659/MSM.936619.
24. Rupp M, Biehl C, Budak M, et al. Diaphyseal long bone nonunions-types, aetiology, economics, and treatment recommendations. Int Orthop, 2018, 42(2): 247-258.
25. Bellabarba C, Ricci WM, Bolhofner BR. Results of indirect reduction and plating of femoral shaft nonunions after intramedullary nailing. J Orthop Trauma, 2001, 15(4): 254-263.
26. Zhang H, Li J, Zhou J, et al. Finite element analysis of different double-plate angles in the treatment of the femoral shaft nonunion with no cortical support opposite the primary lateral plate. Biomed Res Int, 2018, 2018: 3267107. doi: 10.1155/2018/3267107.
27. 薛汉中, 孙亮, 李忠, 等. 断端成骨能力区域划分对锁定钢板桥接技术联合植骨治疗骨不连的临床意义. 中华创伤骨科杂志, 2014, 16(10): 829-833.
28. Refai O, Khalifa AA. Single stage open reduction, intramedullary rod, bone grafting, and plate fixation for managing adolescent midshaft femoral fracture non-union, report of two cases. Trauma Case Rep, 2022, 38: 100616. doi: 10.1016/j.tcr.2022.100616.
29. Chamseddine AH, Mouchantaf ME, Freiha KF, et al. Bridge plating with decortication, autologous bone graft, and tight closure: a “stepwise surgical diamond concept” for treatment of nonunion in a series of fifty five patients. Int Orthop, 2022, 46(6): 1241-1251.

Chinese Journal of Reparative and Reconstructive Surgery

Effectiveness of tunnel osteogenesis technique in treatment of aseptic non-hypertrophic nonunion of femoral shaft

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