Surgical Options for Slow-Healing Femur Fractures

Inquiry about reoperation for femoral fracture and bone grafting?

Hello, Doctor.
I had a comminuted fracture in my thigh a year and a half ago.
Currently, I am seeing two doctors for follow-up appointments.
Both doctors mentioned that my bone is healing, but the progress is slow.
During my appointment at the end of March, Doctor A suddenly requested a CT scan.
The X-ray showed some surface healing, but the CT scan indicated minimal growth.
Doctor A suggested surgery to supplement the bone (using a thicker intramedullary nail, debridement, and autologous bone grafting), while the other doctor advised to let it heal slowly since there is some growth.
I feel that I am getting better; I force myself to do 200 squats daily and walk 5 to 6 kilometers.
I would like to ask the doctor: 1.
Is it possible to avoid surgery? (I am concerned that not having surgery might lead to the intramedullary nail breaking or the locking mechanism loosening.) 2.
If I do undergo surgery, how long would it take before I can return to work? (The job involves sitting in an office and does not require physical labor.) 3.
If the CT results show no significant growth after more than a year, does that mean the likelihood of healing is very low?

Xiao Liangliang, 40~49 year old female. Ask Date: 2019/03/29

Dr. Shi Guozheng reply Orthopedics

In my experience, comminuted fractures typically heal more slowly, sometimes taking two to three years for complete healing.
If you currently do not experience any pain and can walk 5-6 kilometers, it is reasonable to continue monitoring the situation.
It is possible that bone growth may occur in another six months to a year.
Therefore, my recommendation is to continue observation, as the necessity for surgery is low at this time, and there is no need for surgery currently.

Reply Date: 2019/03/29

More Info

When dealing with slow-healing femur fractures, particularly after a complex injury such as a comminuted fracture, it is essential to understand the surgical options available and the implications of each choice. Based on your situation, where you have been monitored by two different orthopedic surgeons, it seems there is a divergence in their recommendations regarding whether to proceed with surgery or allow for continued conservative management.

1. Can you avoid surgery?
Yes, it is possible to avoid surgery if the fracture is showing signs of healing, even if it is slow. However, the concern with non-surgical management is the risk of complications, such as the potential for the intramedullary nail to break or for the fracture site to become unstable. If the fracture is not healing adequately, it may lead to nonunion or malunion, which can cause long-term functional issues. If you feel that your condition is improving and you are able to perform activities like deep squats and walking, this may be a positive sign. However, it is crucial to have regular follow-ups and imaging to monitor the healing process.

2. If surgery is performed, how long will recovery take?
If you opt for surgery involving the exchange of the intramedullary nail, debridement, and autologous bone grafting, the recovery time can vary. Generally, patients can expect to return to a sedentary job, such as office work, within 2 to 6 weeks post-surgery, depending on individual healing rates and the extent of the procedure. Physical therapy will likely be recommended to regain strength and mobility, and you may need to avoid high-impact activities for several months to allow for proper healing.

3. What does the CT scan indicate about healing?
The CT results indicating minimal healing after over a year can be concerning. While some bone healing may be visible on X-rays, CT scans provide a more detailed view of the bone structure and can reveal areas that are not healing well. If there is little to no new bone formation observed on the CT scan, the likelihood of spontaneous healing decreases significantly. In such cases, surgical intervention may be warranted to promote healing and prevent further complications.

In summary, the decision to proceed with surgery or continue conservative management should be made collaboratively with your orthopedic surgeons, considering the risks and benefits of each approach. If you choose to avoid surgery, it is vital to maintain regular follow-ups and imaging to ensure that healing is progressing adequately. If surgery is chosen, be prepared for a recovery period that may require adjustments to your daily activities, but with the goal of returning to full function in the long term. Always prioritize open communication with your healthcare providers to make informed decisions about your treatment plan.

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