Reunion of post nail aseptic non-union of diaphyseal femoral fractures by augmentation plating, decortication and bone grafting - Replacement for exchange nailing.

INTRODUCTION: The aim is to re-unite post nail aseptic non-union of diaphyseal femoral fractures in an economical and safe way with almost certainty, reducing dependence on others with early rehabilitation. The cascade of fracture healing is dependent on mechanical stability and uninterrupted cellular and bio-chemical responses (biology). Intra-medullary nailing in fresh diaphyseal femoral fractures is gold standard treatment with high success rate, still non-union of these fractures is reported, though the incidence has declined considerably.

METHOD: This prospective study conducted at level one trauma centre on twenty-one patients in four years starting from July 2015 to June 2019. Eighteen patients had non-union with intact implant and three had broken nail. Non-union site approached through lateral approach. Non-union site fixed by 4.5 broad combi-hole LCP or distal femoral locking compression plate (DF-LCP) depending on fracture site. Decortication, Bone grafting done retaining the previous nail in situ in eighteen patients and in three patients, broken nail was exchanged with same size of unreamed nail and then, similar procedure carried out.

RESULT: All non-unions in 21 patients reunited without any complications. All patients regained painless unsupported walk.

DISCUSSION: The most preferred treatment for this complex non-union is reamed exchanged nailing. Larger nail increases mechanical stability by better frictional contact with surrounding bone in isthumic fracture but fails in cases of fractures with comminution, spacious distal fragment and fracture with small distal fragment. Various studies reported success rate in reamed exchange nailing from 53-96% with an average 74%. The main cause of instability is rotational stress which is completely obliterated by augmentation plating and various studies report 100% success. Augmentation plate with retained nail increases stiffness and strength of construct. Concomitant decortication and cancellous bone graft stimulates osteogenesis.

CONCLUSION: It is a simple, safe and economical procedure, correcting and providing both mechanical and biological environments to convert non-union into osseous union. It will be a treatment of choice in times to come.