| Objective:The objective of this study was to evaluate the outcomes of revision with locking plates for diaphyseal long bone nonunions of lower extremities.Methods:A total of 54 patients with diaphyseal long bone nonunions of lower extremities were retrospectively studied.The background of patient,details of the fracture and the consequent treatments were studied.AO/OTA classification was adopted to describe the pattern and severity of fractures.The Gustilo-Anderson(GA)classification was used to assess soft tissue damage for open fractures.The Weber and Cech classification was used to describe the biological condition of the nonunions.The X-rays after primary surgery of fracture were studied to evaluate fixation stability and fracture reduction.Radiology findings which may contribute to the development of nonunions were recorded.Any fracture gap resulted from bone loss or comminution or distraction between the fragments was classified as poor bony contact.Problems such as wrong choice of implants,undersized nail or plate,implants breakage,insufficient screw number or purchase were documented as inappropriate fixation.Local infections were diagnosed by elevated blood C-reactive protein(CRP),ESR,and positive bacterial tests.All nonunions were divided into aseptic and septic groups.Patients diagnosed with aseptic nonunions had revision surgeries including removal of the previous fixation devices,excision of nonunions,restablization using locking plates with or without grafting.For 8 septic nonunions,a two-stage surgery strategy were used.The first stage operations included removal of internal fixation,debridement,restablization with external fixator and placement with anti-biotic beads.Then 2 weeks’ intravenous antibiotics treatment was initiated for the patients according to the intraoperative culture.The second stage procedures were done after 4-6 weeks depending on the control of the infection and the local condition of the soft tissues.Locking plates combined with iliac crest bone grafting(ICBG)or free vascularized fibular graft(FVFG)were performed for the second surgery.Results:There were 14 females and 40 males with an average age of 39.65 years(range from 13 to 70).Each patient finished at least two-year follow-up.There were 46 aseptic and 8 septic nonunions.In the aseptic group,approximate 69.6%(32 of 46)of the cases were classified as type B or C fractures according to AO/OTA classification.4 cases had open fractures.28 of 46 aseptic nonunions were located at either proximal or distal part of the diaphysis.There were 27 hypertrophic,14 oligotrophic and 5 atrophic nonunions.There were 8 cases who already had revision surgeries at other institutes before enrollment in our hospital.Among all the 46 aseptic cases,21 cases received intramedullary nail(IMN)with or without cable cerclage fixation,19 cases were treated by plating(one patient had primary bone grafting),5 cases had external fixation and one case received plaster fixation for primary fracture treatment.After revision surgery with locking plates with or without grafting,all patients achieved healing and the average union time was 8.28 months.Only two cases in the aseptic group had second procedure and the rest were cured with one surgery by our group.In septic group,there were 4 open and 4 closed fractures.Each fracture was complex(AO classification type B or C).There were 7 atrophic and 1 hypertrophic nonunions.Only 2 cases were non-draining and the rest of 6 cases were all with active draining infections.We performed two-stage surgeries for all septic nonunions.FVFG was performed in 5 cases while ICBG was used in other 3 cases.All 8 patients achieved healing and the average union time was 10.25 months.Conclusion:This study showed that locking plate was a good fixation method to treat diaphyseal long bone nonunions of lower extremities.It is easy to combine with different bone grafting methods for the treatment of infected and non-infected nonunions,providing enough stability for healing. |
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