Introduction
Nonunion definition
Materials and methods
Inclusion and exclusion criteria
Identification of studies
((“Femoral Fractures”[Mesh]) OR (femur AND fracture*) OR (femoral AND fracture*)) AND (midshaft OR shaft OR diaphyseal) AND (ununited OR union delay OR Fracture Healing OR pseudarthrosis OR delayed union* OR delayed union OR nonunion* OR nonunion* OR nonunion*) Limits: Humans, English, German, Dutch, All adult: 19 + years |
Years | Author | Reason for exclusion |
---|---|---|
1969 | Werner | Case report |
1972 | Esah | Case report |
1975 | Kostuik | Comparison of several treatments |
1984 | Müller | Analysis bridgeplate, no patient information |
1985 | Slatis | 5 cases |
1986 | Johnson | Double serie |
1986 | Kreusch | Femur and tibia, mixed group |
1986 | Klemm | Primary treatment |
1990 | Wood | 5 cases |
1990 | Blatter | Case report |
1992 | Johnson | Comparison of several treatments |
1992 | Hou | 5 cases |
1997 | Wei | No nonunion |
1998 | Ueng | 5 cases |
1998 | Ueng | 5 cases |
1998 | Johnson | Double serie |
2000 | Giannoudis | No intervention |
2000 | Kim | <5 patients with femur nonunion |
2001 | Devnani | Location not mentioned |
2001 | Bellabarba | Double serie |
2002 | Ebraheim | Case report |
2002 | Pihlajamäki | Comparison of several treatments |
2002 | Menon | <5 patients with femur nonunion |
2003 | Brinker | 5 cases |
2003 | Canadian Orthopaedic Trauma Society | No nonunion |
2003 | Wu | Associated femoral neck fracture |
2007 | Crowley | Review |
2007 | Alt | 1 case and double fracture |
2007 | Morasiewicz | Femur and tibia, mixed group |
2009 | Prasarn | 5 cases |
2009 | Taitsman | No intervention |
2010 | Wedemeyer | Case report |
2011 | Wedemeyer | Case report |
2011 | Kim | Classification |
Data extraction
Methodological quality
Level I: High-quality prospective randomized clinical trial Level II: Prospective comparative study Level III: Retrospective case control study Level IV: Case series Level V: Expert opinion |
Evidence supporting that treatment Grade A: Treatment options are supported by strong evidence (consistent with level I or II studies) Grade B: Treatment options are supported by fair evidence (consistent with level III or IV studies) Grade C: Treatment options are supported by either conflicting or poor quality evidence (level IV studies) Grade D: Insufficient evidence exists to make a recommendation |
Results
Discussion
Dynamization
Recommendation grade D
Reamed nailing after plate
Years | Author | Number of patients | Primary treatment | Secondary treatment | Complications | Union rate n (%) |
---|---|---|---|---|---|---|
1999 | Wu | 21 | Plate | Reamed nail | Not mentioned | 21 (100) |
2001 | Wu | 8 | Plate | Nailing + bone graft | 0 | 7 (93) |
2008 | Emara* | 20 | Plate | Nailing + bone graft | 5 | 20 (100) |
2008 | Emara* | 20 | Plate | Nailing | 1 | 20 (100) |
2009 | Megas | 30 | Plate | Nailing | 8 | 27 (91) |
Time to union (months) | Remarks |
---|---|
6 | |
4 (3–6) | |
4.8 ± 1.15 | RCT |
4.9 ± 1.33 | RCT |
7.9 ± 3.3 |
Recommendation grade C
Exchange reamed nailing
Years | Author | Number of patients | Primary treatment | Secondary treatment | Complications | Union n (%) |
---|---|---|---|---|---|---|
1997 | Wu | 35 | IM nail | Exchange nailing | 0 | 35 (100) |
1999 | Wu* | 8 | IM nail | Exchange nailing | 0 | 8 (100) |
1999 | Wu* | 15 | IM nail | Nailing and bone graft | 0 | 15 (100) |
1999 | Furlong | 25 | IM nail | Exchange nailing | 0 | 24 (96) |
2000 | Weresh | 19 | IM nail | Exchange nailing | 0 | 10 (53) |
2000 | Hak | 23 | IM nail | Exchange nailing | Not mentioned | 18 (78) |
2002 | Wu | 36 | IM nail | Exchange nailing | 0 | 33 (92) |
2002 | Yu | 36 | IM nail | Exchange nailing | 0 | 36 (100) |
2003 | Banaszkiewicz | 19 | IM nail | Exchange nailing | 2 infection, 2 failed nails, 2 delayed union | 11 (58) |
2005 | Wu | 11 | IM nail | Exchange nailing | 0 | 9 (80) |
2007 | Wu# | 34 | IM nail | 1 mm overreaming | 0 | 31 (91) |
2007 | Wu# | 40 | IM nail | >2 mm overreaming | 0 | 37 (93) |
2009 | Shroeder | 42 | IM nail | Exchange nailing | 0 | 36 (86) |
Time to union (months) | Remarks |
---|---|
4 | Pseudo-RCT |
4.4 ± 0.9 | |
5.7 ± 1.5 | |
7 | |
? | |
– | All 5 nonunions in smokers |
4 (3–8) | |
4 (3–8) | |
9 | |
4 | Broken screws and shortened >1.5 cm, one death because of other reason |
4 (3–6) | |
4 (3–8) | |
4 |
Recommendation grade C
Augmentative plate fixation
Years | Author | Number of patients | Primary treatment | Secondary treatment | Complications | Union rate n (%) |
---|---|---|---|---|---|---|
1997 | Ueng | 17 | IM nail | Augmentative plate | Not mentioned | 17 (100) |
2005 | Choi | 15 | IM nail | Augmentative plating + bone graft | 0 | 15 (100) |
2008 | Nadkarni | 7 | IM nail | Augmentative plate | 0 | 7 (100) |
2008 | Roetman | 32 | IM nail | Augmentative plate | 0 | 29 (91) |
2010 | Chen | 50 | IM nail | Augmentative plating + bone graft | 1 | 50 (100) |
Time to union (months) | Remarks |
---|---|
7 (6–10) | |
7 (5–11) | |
7 (6–8) | |
5 | |
6 (4.5–8) | 8 distal and 7 proximal fractures |
Recommendation grade C
Plate fixation
Recommendation grade C
Remaining papers
Years | Author | Number of patients | Primary treatment | Secondary treatment |
---|---|---|---|---|
1975 | Oh | 15 | Several | Nailing |
1984 | Harper | 16 | Several | Fluted rod |
1985 | Heiple | 25 | 16 conservative, 7 plate, 1 IM nail | Fluted rod |
1986 | Webb | 101 | Several | Reamed nail |
1986 | Kempf | 27 | Several | Reamed nail |
1987 | Jupiter | 7 | 1–9 earlier operations | Vascularized fibula graft |
1988 | Johnson | 6 | Several | Exchange nailing |
1988 | Barquet | 13 | Several | AO tubular external fixation |
1992 | Wu | 64 | Several | Exchange nailing |
1992 | Wu | 20 | Several | Exchange nailing |
1992 | Wu | 17 | Several | Nailing and lengthening |
1996 | Meng-Hai | 16 | 11 plate, 5 IM nail | Cast with BMP in the bone |
1996 | Weise | 28 | Several | Reamed nail |
1996 | Matelic | 7 | Several | Lateral and endosteal plating |
1997 | Ring | 42 | 21 patients more than 1 operation | Wave plate |
1997 | Cove | 44 | Several | 43 plaat, 1 nagel, 8 ook fibula |
1999 | Bungaro | 7 | IM nail | Plate + graft, removal of nail |
1999 | Wu | 56 | Several | Locked nail, graft and lengthening |
2000 | Richter | 145 | 112 plate, 24 IM nail, 9 external fixation | Several |
2000 | Johnson | 30 | Several | Cortical bone carrier with BMP |
2001 | Bellabarba | 23 | IM nail | Angled blade plate |
2001 | Rompe | 24 | Several | Extracorporeal shockwave |
2002 | Finkemeier | 39 | Several | Reamed nail |
2004 | Abdel-Aa | 16 | Plate | Plate |
2004 | Wu | 32 | Several | Nailing and grafting |
2005 | Inan | 11 | IM nail | Cyclic compression and distraction |
2007 | Niedzwiedzki | 22 | Several | Nailing (+bone graft in 9 patients) |
2008 | Oh | 32 | 2 plate, 12 IM nail, 1 conservatively | Exchange nailing |
2009 | Steinberg | 16 | Several | Expandable nail |
2009 | Schulz | 75 | 3 conservative, 5 external fixation, others plate | Wave plate |
2010 | Blum | 50 | Several | Distraction osteogenesis (+bone graft in 15 patients) |
2010 | Park | 18 | IM nail | 7 exchange nailing, 11 augmentative plating |
2010 | Benazzo | 7 | Several | (Exchange) nailing |
Complications | Union rate n (%) | Time to union (months) | Remarks |
---|---|---|---|
0 | 15 (100) | – | |
1 infection | 12 (75) | 7 (2–12) | |
0 | 24 (96) | – | |
2 migration of nail, 2 pain, 2 rotation deformity | 101 (96) | 5 | |
2 infection | 25 (93) | 4 | |
0 | 5 (71) | 4–6 | |
0 | 6 (100) | 5 | |
4 | – | 9 | Infected nonunions |
1 infection, 3 failed nails | 58 (91) | 3–5 | |
1 infection, 1 plate failure | 12 (60) | 4 | |
2 | 17 (100) | 5 | |
0 | 15 (94) | 6 | |
0 | 26 (93) | – | |
3 | 6 (88) | 19.2 (15–36) | 1 pertrochanteric femur fracture |
0 | 35 (100) | 5,1 | Pseudo-RCT |
2 infection, of which 1 amputation | 41 (98) | – | |
1 amputation, 17 > 2 cm shortening, 10 loss of knee flexion | 33 (75) | 12 | |
0 | 7 (100) | 4 (3–7) | |
0 | 44 (78) | 4 (3–8) | |
– | 79 (55) | – | |
6 plate failure | 24 (80) | 6 (3–9) | |
2 plate failure | 21 (91) | 4 (2.5–6) | |
0 | 18 (75) | 4 (2–7) | Osteotomy and fracture |
1 TE, 1 infection | 29 (74) | 19 (4–75) | |
2 | 15 (91) | 4.9 (4–6) | 3 infected nonunions |
0 | 31 (97) | 4.5 (3–6) | 1 hip disarticulation |
1 osteomyelitis, 11 pain, 12 pintract infection, 1 bacterial arthritis, 1 broken pin | 11 (100) | 6 (5–8) | |
– | 20 (92) | – | |
1 dynamization | 31 (97) | – | 1 infected nonunion |
1 infection | 14 (88) | 4 | |
3 plate failures | 64 (85) | 7 | Osteotomy and fracture |
63 | 50 (100) | 20.7 (12–35) | Infected nonunion w bone defect |
0 | EN 2(28), AP 11(100) | 7 (4–16) | |
1 heterotopic ossification | 6 (86) | 7 |