Femoral Nonunion: Causes, Treatments, and Recovery Options

Femoral healing

Hello, doctor.
In October 2015, I was in a car accident and suffered a fracture of the left femur.
My attending physician used an intramedullary nail for fixation.
In January 2017, without any external force, just turning normally, the intramedullary nail inside my leg broke.
After a follow-up visit, the doctor said that my bone had poor healing, which caused the nail to break, but during previous follow-ups (which occurred at least every three months), I was told there were no issues.
I remember that a size 12 nail was used.
After the removal of the broken nail in January 2017 and re-fixation with a size 14 nail, as of July 2020, my femur still has not fully healed.
The doctor has suggested that I undergo another surgery to use bone graft from my hip to supplement the femur.
I would like to ask if my situation is common.
Do I really need to have another surgery? Are there other methods for long bone healing? After using bone graft from the hip, will there be any sequelae or other inconveniences? Additionally, I do not smoke, drink, or chew betel nut; however, due to my job, I work approximately 15 hours a day, starting with night shifts.

Niming, 20~29 year old female. Ask Date: 2020/07/02

Dr. Wang Shouji reply Orthopedics

Hello, the healing time for fractures varies from person to person.
Generally, if a fracture has not healed, full weight-bearing should be avoided.
If it has not healed after six months, procedures such as iliac bone grafting or additional fixation reinforcement should be considered, and most cases will heal.
For fractures that have not healed, applying force can lead to metal fatigue and breakage of the screws, which is not uncommon in clinical practice.
If a fracture has not healed for a long time, bone grafting and reinforcement fixation is the method with the highest success rate.
The site for iliac bone harvesting in the pelvis initially presents only with wound pain, and long-term issues are minimal.
Changhua Hospital cares about your health.
Wang Shou-ji.

Reply Date: 2020/07/02

More Info

Understanding femoral nonunion is crucial for patients who have experienced significant trauma, such as fractures from accidents. In your case, the history of a femoral fracture treated with intramedullary nailing, followed by a nonunion and subsequent complications, highlights the complexity of bone healing and the challenges faced in orthopedic recovery.

Causes of Femoral Nonunion:
Femoral nonunion occurs when a fractured femur fails to heal properly, leading to a lack of bone union. Several factors can contribute to this condition:
1. Insufficient Stabilization: The initial fixation method may not provide adequate stability, especially if the fracture is complex or if there is significant movement at the fracture site.

2. Biological Factors: Factors such as poor blood supply to the fracture site, smoking, diabetes, or other systemic conditions can impede healing.

3. Mechanical Factors: Excessive weight-bearing or premature return to activity can disrupt the healing process. In your case, the fact that the intramedullary nail broke during normal activity suggests that there may have been underlying issues with bone healing.

4. Infection: Although not mentioned in your case, infections can also lead to nonunion.

5. Nutritional Deficiencies: Lack of essential nutrients, particularly calcium and vitamin D, can affect bone healing.

Treatment Options:
The treatment for femoral nonunion typically involves surgical intervention, especially in cases like yours where the bone has not healed after a significant period. The options include:
1. Revision Surgery: This may involve removing the broken intramedullary nail and replacing it with a larger nail, as your doctor suggested with the 14 mm nail. This approach aims to provide better stabilization.

2. Bone Grafting: Using bone grafts, such as from the hip (iliac crest) or synthetic bone substitutes, can help stimulate healing. The use of bone grafts can be beneficial in cases of nonunion, as they provide the necessary biological material to promote bone growth.

3. Bone Stimulation: In some cases, electrical stimulation devices can be used to promote healing in nonunion fractures.

4. External Fixation: In certain situations, an external fixator may be applied to stabilize the fracture while allowing for some degree of movement.

Recovery and Risks:
Recovery from surgery can vary depending on the individual and the extent of the procedure. Generally, patients can expect several months of rehabilitation, including physical therapy to regain strength and mobility.
Using bone grafts from the hip can lead to some discomfort at the donor site, but serious complications are rare. The risks associated with surgery include infection, bleeding, and potential complications related to anesthesia.
Conclusion:
In your situation, it is not uncommon for patients with complex femoral fractures to experience nonunion, especially after initial surgical interventions. While the recommendation for further surgery may seem daunting, it is often the most effective way to achieve proper healing. It is essential to discuss all your concerns with your orthopedic surgeon, including the risks and benefits of the proposed surgery, alternative treatments, and the expected recovery timeline.
Additionally, consider lifestyle factors that may affect your healing, such as your long working hours. Adequate rest, nutrition, and following your doctor's advice regarding activity levels are crucial for a successful recovery.

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