| Abstract|| |
Background: Treatment of tibial diaphyseal nonunions are rather difficult. Plate-screw, intramedullary nailing and external fixation are the methods used for treatment. The aim of this study is to evaluate the treatment results of aseptic diaphyseal nonunions following tibia fractures by intramedullary compressive tibia nailing (IMCN) with or without bone graft. Materials and Methods: Twenty eight patients who had aseptic tibial nonunion without bone defects operated between 2005 and 2015 were included in the study. The mean age of our patients was 36.4 years (range 20–56 years). There were 22 males and 6 females. Fifteen of the patients exhibited hypertrophic nonunion and thirteen exhibited atrophic nonunion. The average time between fracture occurrence and presentation to our department was 1.6 years (range 1–20 years). All patients underwent fibular osteotomy by removal of a 2 cm bone block from the middle one-third of the fibulas. In all cases, IMCN was applied following the reaming procedure, then maximum bone contacts were achieved manually between proximal and distal bone fragments afterward, and dynamic compressive fixation with 1 mm of compression was performed by a single rotation of the compression screw at the top of the nail. Direct X-ray images were assessed according to the Rust criteria, and functional outcomes were assessed according to the Johner–Wrush criteria. Finite-element analysis was performed for 1 mm of compression. For statistical analysis, Fisher's exact test, Pearson's Chi-square test, and Mann–Whitney U-test were used. Results: Union was achieved in all patients. Radiological union was obtained at an average of 15.5 ± 1.86 weeks. Functional results were found to be good or excellent in 25 (89.2%) patients and average or poor in 3 (10.8%) patients. One patient developed skin necrosis at the wound site, which was treated with rotational flap and skin graft. None of the patients developed implant failure, thromboembolism, deep-vein thrombosis, or infection. Conclusions: The use of compressive intramedullary nailing with or without bone graft is an effective method for the treatment of tibial nonunion.
Keywords: Autologous bone grafting, intramedullary compressive tibial nail, nonunion
|How to cite this article:|
Aldemir C, Duygun F. Outcome of locked compressive nailing in aseptic tibial diaphyseal nonunions without bone defect. Indian J Orthop 2019;53:251-6
|How to cite this URL:|
Aldemir C, Duygun F. Outcome of locked compressive nailing in aseptic tibial diaphyseal nonunions without bone defect. Indian J Orthop [serial online] 2019 [cited 2019 Sep 18];53:251-6. Available from: http://www.ijoonline.com/text.asp?2019/53/2/251/252674
| Introduction|| |
Fracture healing is a progressive and dynamic process. In diaphyseal fractures of the tibia, the lack of radiological healing 3–5 months after the injury is identified as delayed union. The nonunion was described for those fractures that had not healed after 9 months.,
There are various reasons for fracture nonunion, and different nonunion types can develop due to different causes.,, These should be accounted for when treatment is being planned. Systemic causes such as nutritional disorder, smoking, osteoporosis, diabetes mellitus, anticonvulsive and nonsteroidal anti-inflammatory medications, opioids, benzodiazepines, vitamin D deficiency, and alcoholism, along with local causes such as infection, circulatory insufficiency, inadequate reduction, biomechanical imbalance, force of trauma, and open fracture, may cause nonunion.,,
Conservative treatment of nonunion cases rarely results in full recovery. However, methods such as functional cast bracing, electromagnetic stimulation, and low-frequency ultrasound may be used in select cases.,,,
The type of nonunion must be taken into consideration when planning surgical therapy. Hypertrophic nonunions present with extensive callus formation and have a high chance for recovery. Application of a stable osteosynthesis is the best treatment course in this type of nonunion. Atrophic nonunions are characterized with a low amount of callus formation, circulatory insufficiency of the bone, and low chance for recovery. This type of nonunion requires debridement of the necrotic tissue and additional biological stimulation. Various methods such as bone grafts – especially autografts, decalcified bone allograft, bone marrow injections, and/or the application of bone morphogenic protein among other osteoinductive agents are used as biological stimulants.,,
The surgical treatment of nonunions includes augmentative plating, compression plate, intramedullary nail (static/dynamic), exchange nailing, and external fixator application.
The aim of the present study is to evaluate the treatment results of aseptic diaphyseal atrophic and hypertrophic nonunions following tibia fractures by intramedullary compressive tibia nailing (IMCN) with or without bone graft.
| Materials and Methods|| |
Twenty eight patients who were diagnosed with aseptic tibial nonunion without bone defect, between 2005 and 2015, were included in the study. Infected nonunions, lower extremity compartment syndrome cases, those who had history of malignancy, and those under 2 years of followup were excluded from the study. The mean age of the patients was 36.4 years (range 20–56 years). A total of 22 patients were male while 6 were females. Fifteen patients had presented with hypertrophic nonunion and thirteen had presented with atrophic nonunion. Patient characteristics are shown in [Table 1]. The average time between fracture occurrence and presentation to our department for surgery was 1.6 years (range 1–20 years). The initial treatments of patients were external fixation for fractures in four, expandable intramedullary nail in two, plate-screw fixation in sixteen, and conservative in the remaining six patients. Due to nonunion during followup, compressive intramedullary tibial nail was utilized in all cases. The fractures were closed in all cases, except for the four patients who had Gustilo–Anderson type 2 open fractures. First, fibula osteotomy was performed in all patients by the removal of a 2 cm bone block. Dynamic compressive fixation was performed with reaming and compressive intramedullary nail (C75 IMCN, Hipokrat, İzmir, Turkey) in 15 hypertrophic nonunion cases. On the other hand, the 13 patients who had atrophic nonunion were treated with dynamic compressive fixation by reaming and compressive intramedullary nail, along with the implementation of autogenic bone graft from the iliac crest. Among our patients, 12 were smokers, 2 of these also had diabetes mellitus and were using insulin, another patient was an alcohol abuser along with being a smoker, and 1 patient had osteoporosis due to surgical oophorectomy. A 48-h treatment regimen of 1 g of cefazolin sodium four times a day was started on all patients 1 h before surgery. After surgery, all patients received low-molecular-weight heparin for 21 days. X-ray images were ordered, and clinical evaluations were performed for all patients during post surgery followup. Weight bearing was not allowed until the callus was seen on plain X-ray. Followup period was 3.2 year (2–6 years). Direct X-ray images were assessed according to the Rust criteria, and functional outcomes were assessed according to the Johner–Wrush criteria. Finite-element (FE) analysis was performed for 1 mm of compression.
Descriptive statistics were presented as “mean ± standard deviation,” “median (min-max),” and “n (%)” values, where appropriate. Fisher's exact test and Pearson's Chi-square analysis were performed for categorical variables. Mann–Whitney U-test was used for comparison of quantitative variables with non normal distribution. Statistical analysis was made using the computer software Statistical Package for Social Sciences (IBM SPSS Statistics for Windows, version 21.0. released 2012, IBM Corp., Armonk, New York, USA). P < 0.05 was considered statistically significant.
Two types of material were used in the analysis. The first is the cortical bone material which was identified according to bone data. The mechanical properties of the bone material were determined as follows: elasticity module 20 GPa, Poisson ratio 0.15, and density 1650 kg/m 3. The material of the nails and screws was titanium. The mechanical properties of titanium were determined as follows: elasticity module 96 GPa, Poisson ratio 0.36, and density 4620 kg/m 3.
FE modeling and analysis were performed using ANSYS® 16.2 (NASDAQ: ANSS). The FE model was constructed with the bone, intramedullary compressive nail, and screws.
As a result of the FE analysis for the tibia screw that we used, the strain distribution shown in [Figure 1] was obtained. The 1 mm displacement value applied by the nail screw appears to be the result of moment and axial force. The average stress is around 34 MPa.
|Figure 1: The surface stress of the bone when the screw was pressured for 1 mm. To see the stress distribution at the fracture site, the lower part of the bone was hidden after analysis and the von Mises stress values are given as MPa|
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All patients were in the supine position when the fracture line was accessed. Necrotic tissue was removed. Osteotomy was performed from the middle one-third of the fibulas with a lateral incision, and 2 cm of bone was excised. A midline incision on the anterior aspect of the knee was used as entrance. Reaming was performed through superior access from the proximal tibia. The appropriate length and diameter of the nail were determined, and then nailing was performed in all cases. Having achieved maximum bone contacts manually between proximal and distal bone fragments, two locking screws were used to obtain distal locking, and one screw was used for locking through the proximal dynamic hole. 1 mm compression was performed by a single rotation of the compression screw at the top of the nail., Locking was achieved without fluoroscopy in a short time, using one or more combining techniques described in our previous article. With these techniques, the surgeon was protected from radiation exposure. Grafts obtained during reaming were placed in the site of nonunion. In patients who had atrophic nonunion, autogenic grafts acquired from the iliac crest and fibula segment were used as bone grafts.
| Results|| |
Union was achieved in all patients [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d and [Figure 3]a, [Figure 3]b, [Figure 3]c, [Figure 3]d. Radiological evaluations were done according to the Rust criteria, and we found that average union time was 15.5 ± 1.86 weeks. There was no statistically significant difference in union time between males and females (P = 0.712). However, union time was found to be significantly different in regard to fracture type; open fracture union times were significantly longer (P = 0.007). Smokers' union time was found to be significantly longer than those who did not smoke (P < 0.001). We also found that union time was longer in patients who had atrophic nonunion compared to hypertrophic nonunion (P < 0.001) [Table 2] and [Figure 4].
|Figure 2: (a-d) Presurgery and 20-week postsurgery images from AP and lateral viewpoints of a 47-year-old patient who was conservatively treated after a traffic accident 20 years ago|
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|Figure 3: (a-d) Presurgery and 20-week postsurgery images from AP and lateral viewpoints of a 35-year-old female patient who received plate and screw osteosynthesis|
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|Table 2: Union time in regard to gender, fracture type, smoking status, and nonunion type|
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Clinical and functional outcomes were assessed according to the Johner–Wrush scale. Functional results were determined as good or excellent in 25 (89.2%) patients and fair or poor in 3 (10.8%) patients. At final followup, in good and excellent group, mean shortening in the limb was 8.36 mm (range 5 mm–10 mm) and in the fair and poor group it was20 mm (range 18 mm–22 mm). Skin necrosis around the wound site was seen in one patient, which was treated with rotational flap and skin graft. None of the patients developed implant failure, thromboembolism, deep-vein thrombosis, or infection.
| Discussion|| |
Many systemic and local factors have been proposed to cause tibial nonunion. Twelve of our patients were smokers, two of these had diabetes, one was alcoholic, and one was diagnosed with osteoporosis. Four patients were treated with external fixator due to open fractures. The patients who had open fractures, smoked, abused alcohol, and had diabetes or osteoporosis were found to have the longer union times reported in our series. This finding is in parallel with the systemic and local factors listed in the literature.,,
The intramedullary nailing method is widely used in aseptic tibial nonunions without bone defect. Two of our patients had developed nonunion following treatment with expandable nails for their tibia shaft fractures. Steinberg et al. report that they obtained satisfactory results with expandable nailing in tibia nonunions; however, Smith et al. do not recommend expandable nailing even in acute tibia shaft fractures. We did not use expandable nails in either acute or nonunion cases.
Varying values for the duration and rate of union are reported in the literature. Niedźwiedzki  utilized intramedullary nailing in tibial nonunion cases and reported the rate of union as 94% and time until union as 9.2 months. On the other hand, Faisham et al. used static intramedullary nailing and found union rate to be 100% within 4 months.
In a study focused on cases which developed tibia nonunion after intramedullary nailing, Hsiao et al. achieved 100% union rate within 4.7 months when they replaced the nail with dynamic locked nails.
Swanson et al. replaced the nail and performed overreaming by 1 mm or more in their cases. They reported a 98% rate of union achieved in 4.8 months.
In a study based on literature review by Brinker and O'Connor, aseptic tibial nonunion cases (without segmental defect) treated with intramedullary nailing were evaluated. They found that, when replacement was done with augmentative plate and bone graft or reamerized nail, a high rate of union was achieved. They also report that aseptic nonunion cases which were previously treated with plates showed highsuccess rates with revision plate-screw fixation and bone graft or other biological implants. We didn't study the difference in union rate depending on primary fixation.
In contrast with these authors, in our study, we used the dynamic compressive implementation of locked compressive nailing in all our cases, and fibula osteotomy was performed on all patients. None of our patients needed revision or augmentative plates. In atrophic nonunions, autogenic grafts obtained from the iliac bone and fibula osteotomy and spongious tissue obtained during reaming were used as grafts, whereas only the spongious tissue was used in hypertrophic nonunions. A rate of 100% union was obtained in 15.5 ± 1.86 weeks on an average.
In addition to being a lockable nail, the nail we use is an intramedullary nail which makes compression possible through its proximal dynamic screw. Baki et al. in their experimental study on rabbits have shown the effect of compression and its amount on union. In this study, they evaluated the stress put upon the fracture site with 0.5 mm and 1 mm compression. They report that 0.5 mm of compression results in a stress value of 34.5 MPa and 1 mm of compression results in 88 MPa. They also found that union was histologically better and was obtained sooner in the 34.5 MPa group. In our study, through FE analysis, we found 1 mm of compression yielded 34 MPa of stress on average [Figure 1]. This result concurs with the 34.5 MPa stress distribution value proposed by Baki et al. This feature of our study may explain the relatively shorter union time reported by us in comparison to other studies. In the literature, Gupta presented a study on active compression through intramedullary compression nailing, which is applied for treating nonunions. He concluded that this may prove greatly advantageous to the fracture union through increased stability and the osteogenic potential.
Compressive intramedullary nailing with or without bone graft in the treatment of aseptic tibial diaphyseal nonunion without bone defect is an effective method offering significantly shorter union times and outstanding clinical and functional results
The low number of patients, the lack of different compression values, and the retrospective nature are limitations of our study. However, to the best of our knowledge, this is the first study where compression and surface stress values in the treatment of tibial nonunion are evaluated in conjunct. Although application of a stable osteosynthesis is the best treatment course in the hypertrophic type of nonunion, 15 of 28 patients had hypertrophic nonunion in the present study. Even in these cases, stabilized osteosynthesis with dynamic compression was applied, and this could be considered as a limitation of the study.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Chapman MW, editors. Principles of treatment of nonunions and malunions. In: Chapman's Orthopaedic Surgery. 3rd
ed. Philadelphia: Lippincott Williams & Wilkins; 2001. p. 847-85.
Wiss DA, Stetson WB. Tibial nonunion: Treatment alternatives. J Am Acad Orthop Surg 1996;4:249-57.
Zura R, Xiong Z, Einhorn T, Watson JT, Ostrum RF, Prayson MJ, et al.
Epidemiology of fracture nonunion in 18 human bones. JAMA Surg 2016;151:e162775.
Mathavan N, Tägil M, Isaksson H. Do osteoporotic fractures constitute a greater recalcitrant challenge for skeletal regeneration? Investigating the efficacy of BMP-7 and zoledronate treatment of diaphyseal fractures in an open fracture osteoporotic rat model. Osteoporos Int 2017;28:697-707.
Zhan Q, Gui X, Wang F, Yu P, Zhao M, Wang J, et al.
Sialoglycoprotein isolated from the eggs of Gadusmorhua
enhances fracture healing in osteoporotic mice. Food Funct 2017;8:1094-104.
Sarmiento A, Burkhalter WE, Latta LL. Functional bracing in the treatment of delayed union and nonunion of the tibia. IntOrthop 2003;27:26-9.
Guerkov HH, Lohmann CH, Liu Y, Dean DD, Simon BJ, Heckman JD, et al.
Pulsed electromagnetic fields increase growth factor release by nonunion cells. Clin Orthop Relat Res 2001;384:265-79.
Griffin XL, Warner F, Costa M. The role of electromagnetic stimulation in the management of established nonunion of long bone fractures: What is the evidence? Injury 2008;39:419-29.
Khan Y, Laurencin CT. Fracture repair with ultrasound: Clinical and cell-based evaluation. J Bone Joint Surg Am 2008;90 Suppl 1:138-44.
Gómez-Barrena E, Rosset P, Lozano D, Stanovici J, Ermthaller C, Gerbhard F, et al.
Bone fracture healing: Cell therapy in delayed unions and nonunions. Bone 2015;70:93-101.
Sim R, Liang TS, Tay BK. Autologous marrow injection in the treatment of delayed and nonunion in long bones. Singapore Med J 1993;34:412-7.
Valdes MA, Thakur NA, Namdari S, Ciombor DM, Palumbo M. Recombinant bone morphogenic protein-2 in orthopaedic surgery: A review. Arch Orthop Trauma Surg 2009;129:1651-7.
Jain A, Kumar S, Aggarwal AN, Jajodia N. Augmentation of bone healing in delayed and atrophic nonunion of fractures of long bones by partially decalcified bone allograft (decal bone). Indian J Orthop 2015;49:637-42.
] [Full text]
Brinker MR, O'Connor DP. Management of aseptic tibial and femoral diaphysealnonunions without bony defects. OrthopClin North Am 2016;47:67-75.
Leow JM, Clement ND, Tawonsawatruk T, Simpson CJ, Simpson AH. The radiographic union scale in tibial (RUST) fractures: Reliability of the outcome measure at an independent centre. Bone Joint Res 2016;5:116-21.
Johner R, Wruhs O. Classification of tibial shaft fractures and correlation with results after rigid internal fixation. Clin Orthop Relat Res 1983;178:7-25.
Aldemir C, Doǧan A, İnci F, Sertkaya Ö, Duygun F. Distal locking techniques without fluoroscopy in intramedullar nailing. Eklem Hastalik Cerrahisi 2014;25:64-9.
Baki ME, Aldemir C, Duygun F, Doǧan A, Kerimoǧlu G. Comparison of non-compression and compression interlocking intramedullary nailing in rabbit femoral shaft osteotomy model. Eklem Hastalik Cerrahisi 2017;28:7-12.
Giannoudis P, Tzioupis C, Almalki T, Buckley R. Fracture healing in osteoporotic fractures: Is it really different? A basic science perspective. Injury 2007;38 Suppl 1:S90-9.
Haverstock BD, Mandracchia VJ. Cigarette smoking and bone healing: Implications in foot and ankle surgery. J Foot Ankle Surg 1998;37:69-74.
Steinberg EL, Keynan O, Sternheim A, Drexler M, Luger E. Treatment of diaphyseal nonunion of the femur and tibia using an expandable nailing system. Injury 2009;40:309-14.
Smith WR, Ziran B, Agudelo JF, Morgan SJ, Lahti Z, Vanderheiden T, et al.
Expandable intramedullary nailing for tibial and femoral fractures: A preliminary analysis of perioperative complications. J Orthop Trauma 2006;20:310-4.
Niedźwiedzki Ł. Use of reamed locked intramedullary nailing in the treatment of aseptic diaphysealtibial nonunion. Ortop Traumatol Rehabil 2007;9:384-96.
Faisham WI, Sulaiman AR, Sallehuddin AY, Zuhmi W. Early outcome of reamed interlocking nail for nonunion of tibia. Med J Malaysia 2006;61:339-42.
Hsiao CW, Wu CC, Su CY, Fan KF, Tseng IC, Lee PC, et al.
Exchange nailing for aseptic tibial shaft nonunion: Emphasis on the influence of a concomitant fibulotomy. Chang Gung Med J 2006;29:283-90.
Swanson EA, Garrard EC, O'Connor DP, Brinker MR. Results of a systematic approach to exchange nailing for the treatment of aseptic tibialnonunions. J Orthop Trauma 2015;29:28-35.
Gupta A. Dynamic compression nail: A preliminary report. BMC Musculoskelet Disord 2001;2:6.
Dr. Cengiz Aldemir
Department of Orthopaedics and Traumatology, SaglikBilimleri University, Antalya Education and Research Hospital, Varlik Avenue, KazimKarabekir Street, 07100 Antalya
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]