Managing Nonunion of Right Femur Fracture: Expert Opinions and Options

Unhealed closed fracture with displacement of the right femur?

Because the area of my right thigh has had a comminuted fracture that hasn't healed for 6 to 7 years, a physician at one hospital suggested removing the steel nail at the knee to allow compression on the non-healed area to promote growth.
However, another physician at a different hospital said that after so many years, the bone that hasn't healed is already necrotic and will not grow.
They recommended removing the steel nail and plate to perform bone grafting, then using a plate for protection, and once the bone heals, the plate can be removed.
What should I do? Could you please provide some advice? Thank you!

A Guo, 30~39 year old female. Ask Date: 2017/02/20

Dr. Shi Guozheng reply Orthopedics

The choice of surgical method depends on whether there is any bone defect.
If the bone has not healed properly over the years, the best option may be bone grafting combined with fixation using screws or plates.

Reply Date: 2017/02/20

More Info

Managing a nonunion of a right femur fracture, especially after such a long duration of 6 to 7 years, can be quite complex and requires careful consideration of various factors. Nonunion occurs when a fractured bone fails to heal properly, which can lead to persistent pain, instability, and functional limitations. In your case, the two differing opinions from the orthopedic surgeons highlight the complexity of your situation.

Understanding Nonunion
Nonunion can be classified into two types: hypertrophic and atrophic. Hypertrophic nonunion occurs when there is an adequate blood supply and some motion at the fracture site, leading to a callus formation but insufficient stability for healing. Atrophic nonunion, on the other hand, is characterized by a lack of biological activity at the fracture site, often due to inadequate blood supply or a lack of mechanical stability. Given that your fracture has not healed for several years, it is likely that you are dealing with an atrophic nonunion.

Treatment Options
1. Removal of Hardware: The first option suggested by one of the surgeons involves removing the hardware (the steel pins) to allow for compression at the nonunion site. This method is based on the principle that mechanical stability and compression can stimulate bone healing. However, this approach may not be effective if the bone has already undergone significant necrosis (death of bone tissue) due to the prolonged nonunion.

2. Bone Grafting: The second opinion suggests removing the hardware and performing a bone graft to promote healing. This is often a more aggressive approach and involves taking bone from another site in your body (autograft) or using synthetic or donor bone (allograft) to fill the gap at the nonunion site. This method can provide the necessary biological stimulus for healing and is often used in cases of atrophic nonunion.

3. Stabilization with Plates or External Fixators: After addressing the nonunion, stabilization is crucial. This can be achieved using plates, screws, or external fixators to maintain the alignment of the bone during the healing process. The choice of stabilization method will depend on the specific characteristics of your fracture and the surgeon's preference.

Factors to Consider
- Time Since Injury: Given that your injury occurred 6 to 7 years ago, the likelihood of spontaneous healing is low. The bone may have developed a fibrous nonunion, which is less likely to heal without intervention.

- Symptoms and Functionality: Consider how the nonunion affects your daily life. If you experience significant pain or functional limitations, pursuing surgical intervention may be warranted.

- Surgeon’s Experience: It is essential to choose a surgeon who has experience with nonunion cases and is familiar with the latest techniques in orthopedic surgery. Discussing the potential risks and benefits of each approach with your surgeon can help you make an informed decision.

Recommendations
1. Seek a Third Opinion: Given the conflicting advice, it may be beneficial to consult a third orthopedic surgeon who specializes in nonunion cases. This can provide you with additional insights and options.

2. Consider Imaging Studies: Advanced imaging studies, such as MRI or CT scans, can provide detailed information about the state of the bone and surrounding tissues, helping to guide treatment decisions.

3. Discuss Rehabilitation: Regardless of the surgical approach, a comprehensive rehabilitation program will be crucial for recovery. Physical therapy can help restore function and strength after surgery.

4. Evaluate Risks: Every surgical intervention carries risks, including infection, complications from anesthesia, and the possibility of further nonunion. Discuss these risks with your surgeon to weigh them against the potential benefits of surgery.

In conclusion, managing a nonunion of the femur after several years requires a tailored approach based on the specific characteristics of your fracture, your overall health, and your functional goals. Engaging in thorough discussions with orthopedic specialists and considering all available options will be key to achieving the best possible outcome.

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