Effectiveness of additional anti-rotation steel plate assisted intramedullary nail technology in aseptic femoral non-union_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

WANG Wei ¹ , YANG Miaomiao ² , DENG Xiaowen ¹ , LI Fan ³ , LI Wenbo ¹ , SHEN Weiwei ¹ , SHI Peisheng ¹ , SHI Jie ¹ , LI Chuangbing ¹ , XUE Yun ¹ ,  GAO Qiuming ¹

1. Department of Orthopaedics and Traumatology, the 940th Hospital of Joint Logistics Support Force of Chinese PLA, Lanzhou Gansu, 730050, P. R. China;
2. Outpatient Department, the 940th Hospital of Joint Logistics Support Force of Chinese PLA, Lanzhou Gansu, 730050, P. R. China;
3. Emergency Department, the 940th Hospital of Joint Logistics Support Force of Chinese PLA, Lanzhou Gansu, 730050, P. R. China;

Corresponding author：

GAO Qiuming, Email: gaoqiuming@163.com

Keywords：

Femoral non-union; intramedullary nail; anti-rotation steel plate; internal fixation

DOI：

10.7507/1002-1892.202506036

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Objective To explore the effectiveness of additional anti-rotation steel plate assisted intramedullary nail technology in treatment of aseptic femoral non-union patients. Methods A retrospective analysis was conducted on 21 patients with aseptic femoral non-union who admitted between September 2020 and October 2024 and treated with additional anti-rotation steel plate assisted intramedullary nail technology. There were 17 males and 4 females, aged 25-67 years (mean, 44 years). There were 19 cases of femoral anterograde intramedullary nail fixation, 1 case of femoral retrograde intramedullary nail fixation, and 1 case of steel plate fixation with fatigue fracture. There were 9 cases of hypertrophic non-union and 12 cases of atrophic non-union. All patients had varying degrees of fracture end atrophy/sclerosis. Among them, 20 patients who were fixed with intramedullary nails underwent removal of soft tissue and hardened bone at the fracture end, and cortical treatment resulted in the appearance of "chili sign" at the fracture end. Iliac bone grafting and anti-rotation steel plate fixation were performed. One patient who was fixed with steel plate was removed and replaced with a retrograde intramedullary nail, while the hardened bone at the fracture end was removed, iliac bone grafting and anti-rotation steel plate fixation were performed. Postoperative follow-up observation included the incision healing, maximum knee flexion range of motion, bone healing, length of lower limbs, and subjective satisfaction. The Lower Extremity Functional Scale (LEFS) score was used to evaluate the lower limb function. Results All incisions healed by first intention. All patients were followed up 7-26 months (mean, 15.5 months). At last follow-up, the femoral fracture healed with the obvious callus formation at the fracture end; the maximum knee flexion range of motion was 95°-127° (mean, 112.67°). The LEFS score increased from 29.9±6.7 before operation to 75.9±3.0 at last follow-up, and the difference was significant (t=−29.622, P<0.001). Except for 1 patient who underwent intramedullary nail dynamic treatment before operation and had a lower limb shortening of about 0.9 cm, the rest of the patients had bilateral lower limbs of equal length. All patients had no postoperative infections, mal-union of fractures, deep vein thrombosis, joint stiffness or other complications. Conclusion The use of additional anti-rotation steel plate assisted intramedullary nail technology in the treatment of aseptic femoral non-union not only overcomes the drawbacks of insufficient stability at the fracture end of intramedullary nails, but also overcomes the shortcomings of biased fixation with steel plates. It has the advantages of minimal trauma, effective maintenance of fracture stability, and ideal postoperative functional recovery, making it an effective treatment for aseptic femoral non-union.

1.	Qiang H, Congming Z, Teng M, et al. Plate augmentation and hybrid bone grafting are effective treatments for atrophic nonunion of the femur with the original intramedullary nail retained in situ. Sci Rep, 2024, 14(1): 7089. doi: 10.1038/s41598-024-57809-1.
2.	Padilla-Eguiluz NG, Gómez-Barrena E. Epidemiology of long bone non-unions in Spain. Injury, 2021, 52 Suppl 4: S3-S7.
3.	Uliana CS, Bidolegui F, Kojima K, et al. Augmentation plating leaving the nail in situ is an excellent option for treating femoral shaft nonunion after IM nailing: a multicentre study. Eur J Trauma Emerg Surg, 2021, 47(6): 1895-1901.
4.	Lu Y, Sun L, Wang Q, et al. Osteoperiosteal decortication and bone grafting combined with wave plating for femoral shaft aseptic atrophic nonunion after intramedullary nailing. J Int Med Res, 2022, 50(11): 3000605221139667. doi: 10.1177/03000605221139667.
5.	Özdemir A, Odabaşı E, Eravsar E, et al. Treatment of recalcitrant femur nonunion with pedicled corticoperiosteal medial femoral condyle flap. Sci Rep, 2023, 13(1): 20326. doi: 10.1038/s41598-023-47432-x.
6.	Wu CC. Aseptic femoral nonunion treated with exchange locked nailing with intramedullary augmentation cancellous bone graft. J Orthop Surg Res, 2022, 17(1): 339. doi: 10.1186/s13018-022-03229-8.
7.	Borzunov DY, Kolchin SN. Nonunion of the femoral shaft associated with limb shortening treated with a combined technique of external fixation over an intramedullary nail versus the Ilizarov method. Arch Orthop Trauma Surg, 2022, 142(9): 2185-2192.
8.	Zhang Z, Wang X, Zhou Q, et al. A novel classification for aseptic femoral shaft nonunion after intramedullary nailing: a retrospective study. BMC Musculoskelet Disord, 2025, 26(1): 340. doi: 10.1186/s12891-025-08576-1.
9.	张伟, 陈华, 唐佩福. 股骨干无菌性骨不连的最新治疗进展. 中国修复重建外科杂志, 2018, 32(5): 519-525.
10.	Wu Q, Wang Q, Sun X, et al. Use of controlled nail dynamization technique for femoral shaft hypertrophic nonunion. Front Surg, 2025, 12: 1547793. doi: 10.3389/fsurg.2025.1547793.
11.	Tsang ST, Mills LA, Baren J, et al. Exchange nailing for femoral diaphyseal fracture non-unions: Risk factors for failure. Injury, 2015, 46(12): 2404-2409.
12.	Kim JW, Oh CW, Park KH, et al. The role of an augmentative plating in the management of femoral subtrochanteric nonunion. Arch Orthop Trauma Surg, 2023, 143(8): 4915-4923.
13.	Wang ZH, Li KN, Lan H, et al. A comparative study of intramedullary nail strengthened with auxiliary locking plate or steel wire in the treatment of unstable trochanteric fracture of femur. Orthop Surg, 2020, 12(1): 108-115.
14.	Mimata H, Matsuura Y, Yano S, et al. Mechanical evaluation of revision surgery for femoral shaft nonunion initially treated with intramedullary nailing: Exchange nailing versus augmentation plating. Injury, 2023, 54(12): 111163. doi: 10.1016/j.injury.2023.111163.
15.	Taheriazam A, Mir Ahmadi A, Abbaszadeh A, et al. Double plating and iliac crest bone graft can safely fix femoral shaft nonunion. Sci Rep, 2024, 14(1): 28988. doi: 10.1038/s41598-024-79513-w.

1. Qiang H, Congming Z, Teng M, et al. Plate augmentation and hybrid bone grafting are effective treatments for atrophic nonunion of the femur with the original intramedullary nail retained in situ. Sci Rep, 2024, 14(1): 7089. doi: 10.1038/s41598-024-57809-1.
2. Padilla-Eguiluz NG, Gómez-Barrena E. Epidemiology of long bone non-unions in Spain. Injury, 2021, 52 Suppl 4: S3-S7.
3. Uliana CS, Bidolegui F, Kojima K, et al. Augmentation plating leaving the nail in situ is an excellent option for treating femoral shaft nonunion after IM nailing: a multicentre study. Eur J Trauma Emerg Surg, 2021, 47(6): 1895-1901.
4. Lu Y, Sun L, Wang Q, et al. Osteoperiosteal decortication and bone grafting combined with wave plating for femoral shaft aseptic atrophic nonunion after intramedullary nailing. J Int Med Res, 2022, 50(11): 3000605221139667. doi: 10.1177/03000605221139667.
5. Özdemir A, Odabaşı E, Eravsar E, et al. Treatment of recalcitrant femur nonunion with pedicled corticoperiosteal medial femoral condyle flap. Sci Rep, 2023, 13(1): 20326. doi: 10.1038/s41598-023-47432-x.
6. Wu CC. Aseptic femoral nonunion treated with exchange locked nailing with intramedullary augmentation cancellous bone graft. J Orthop Surg Res, 2022, 17(1): 339. doi: 10.1186/s13018-022-03229-8.
7. Borzunov DY, Kolchin SN. Nonunion of the femoral shaft associated with limb shortening treated with a combined technique of external fixation over an intramedullary nail versus the Ilizarov method. Arch Orthop Trauma Surg, 2022, 142(9): 2185-2192.
8. Zhang Z, Wang X, Zhou Q, et al. A novel classification for aseptic femoral shaft nonunion after intramedullary nailing: a retrospective study. BMC Musculoskelet Disord, 2025, 26(1): 340. doi: 10.1186/s12891-025-08576-1.
9. 张伟, 陈华, 唐佩福. 股骨干无菌性骨不连的最新治疗进展. 中国修复重建外科杂志, 2018, 32(5): 519-525.
10. Wu Q, Wang Q, Sun X, et al. Use of controlled nail dynamization technique for femoral shaft hypertrophic nonunion. Front Surg, 2025, 12: 1547793. doi: 10.3389/fsurg.2025.1547793.
11. Tsang ST, Mills LA, Baren J, et al. Exchange nailing for femoral diaphyseal fracture non-unions: Risk factors for failure. Injury, 2015, 46(12): 2404-2409.
12. Kim JW, Oh CW, Park KH, et al. The role of an augmentative plating in the management of femoral subtrochanteric nonunion. Arch Orthop Trauma Surg, 2023, 143(8): 4915-4923.
13. Wang ZH, Li KN, Lan H, et al. A comparative study of intramedullary nail strengthened with auxiliary locking plate or steel wire in the treatment of unstable trochanteric fracture of femur. Orthop Surg, 2020, 12(1): 108-115.
14. Mimata H, Matsuura Y, Yano S, et al. Mechanical evaluation of revision surgery for femoral shaft nonunion initially treated with intramedullary nailing: Exchange nailing versus augmentation plating. Injury, 2023, 54(12): 111163. doi: 10.1016/j.injury.2023.111163.
15. Taheriazam A, Mir Ahmadi A, Abbaszadeh A, et al. Double plating and iliac crest bone graft can safely fix femoral shaft nonunion. Sci Rep, 2024, 14(1): 28988. doi: 10.1038/s41598-024-79513-w.

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