Management of aseptic non-union of shaft femur using intramedullary nailing combined with bone grafting: a case report


  • Saikrishna B. Rengerla Mahatma Gandhi Institute of Medical Sciences and Kasturba Hospital
  • Akhil H. Lohkare
  • Nikhil R. Warade
  • Supratim Roy
  • Aniket K. Wankhede



Aseptic non-union, Bone grafting, Intramedullary nailing


Despite the advances in trauma care, improved surgical techniques, latest implants and therefore the evolution of new adjuvants to healing, biologic agents, non-union still persists thanks to high energy trauma as initial event. Non-union of femur shaft represents a significant socioeconomic problem to the patient, related to prolonged patient morbidity, inability to return to figure, gait abnormality, re-operations and psycho-emotional impairment. Here we discuss the case of such non-union of fracture shaft femur presented to us with shortening of 3.5 cm managed with bone graft and intramedullary nailing. 22-year-old male patient had a history of trauma due to fall from bike due to dash from behind by tractor (high velocity road traffic accident) sustaining injury over right thigh leading to closed fracture mid-shaft femur of the same side treated immediately by femur nailing. After 6 months post-surgery, he noticed swelling over operated thigh which was increasing and causing difficulty in walking. X-rays revealed broken nail, re-operated at the same centre with dynamic compression plating (DCP) probably after freshening the fracture edges using 12-hole DCP, implant failure with whole plate and screw construct extrusion and re-fracture at the same site. This time patient presented to our institute. We planned of implant removal and intramedullary nailing with bone grafting. Management of aseptic femoral non-union with fracture gap of 2.5-4 cm range with intramedullary nailing combined with autologous fibular cortical and cancellous grafts showed good functional results at the end of 1 year post operative interval after prior repetitive failure of implants due to non-union. 


Gelalis ID, Politis AN, Arnaoutoglou CM, Korompilias AV, Pakos EE, Vekris MD, et al. Diagnostic and treatment modalities in nonunions of the femoral shaft: a review. Injury. 2012;43(7):980-8.

Okhotsky VP, Souvalyan AG. The treatment of nonunion and pseudarthrosis of the long bones with thick nails. Injury. 1978;10:92-8.

Kempf I, Grosse A, Rigaut P. The treatment of noninfected pseudarthrosis of the femur and tibia with locked intramedullary nailing. Clin Orthop Relat Res. 1986;212:142-54.

Christensen NO. Kuntscher intramedullary reaming and nail fixation for nonunion of fracture of the femur and tibia. J Bone Joint Surg Br. 1973;55:312-8.

Johnson E, Simpson LA, Helfet DL. Delayed intramedullary nailing after failed external fixation of the tibia. Clin Orthop Relat Res. 1990;253:251-7.

Kessler SB, Hallfeldt KJ, Perren SM, Schweiberer L. The effects of reaming and intramedullary nailing on fracture healing. Clin Orthop Relat Res. 1986;212:18-25.

Johnson E, Simpson LA, Helfet DL. Delayed intramedullary nailing after failed external fixation of the tibia. Clin Orthop Relat Res. 1990;253:251-7.

El Moumni M, Leenhouts PA, ten Duis HJ, Wendt KW. The incidence of non- union following undreamed intramedullary nailing of femoral shaft fractures. Injury. 2009;40:205-8.

Heiple KG, Figgie III HE, Lacey SH, Figgie MP. Femoral shaft nonunions treated by a fluted intramedullary rod. Clin Orthop Relat Res. 1985;194:218-25.

Wu CC. Exchange nailing for aseptic nonunion of femoral shaft: a retrospective cohort study for effect of reaming size. J Trauma. 2007;63:859-65.

Muller ME. Treatment of nonunions by compression. Clin Orthop Relat Res. 1965;43:83-92.

Rosen H. Compression treatment of long bone pseudarthroses. Clin Orthop Relat Res. 1979;138:154-66.

Ring D, Jupiter JB, Sanders RA, Quintero J, Santoro VM, Ganz R, et al. Complex nonunion of fractures of the femoral shaft treated by wave-plate osteosynth- esis. J Bone Joint Surg Br. 1997;79:289-94.

Cove JA, Lhowe DW, Jupiter JB, Silski JM. The management of femoral diaphy- seal nonunions. J Orthop Trauma. 1997;11:513-20.

Wu CC. Treatment of femoral shaft aseptic nonunion associated with plating failure: emphasis on situation of screw breakage. J Trauma. 2001;51:710-3.

Wu CC, Lee ZL. Treatment of femoral shaft aseptic nonunion associated with broken distal locked screws and shortening. J Trauma. 2005;58:837-40.

Bellabarba C, Ricci WM, Bolhofner BR. Results of indirect reduction and plating of femoral shaft nonunions after intramedullary nailing. J Orthop Trauma. 2001;15:254-63.

Choi YS, Kim KS. Plate augmentation leaving the nail in situ and bone grafting for non-union of femoral shaft fractures. Int Orthop. 2005;29:287-90.

Kim SJ, Shin SJ, Yang KH, Moon SH, Lee SC. Endoscopic bone graft for delayed union and nonunion. Yonsei Med J. 2000;41:107-11.

Steinberg EL, Keynan O, Sternheim A, Drexler M, Luger E. Treatment of diaphy- seal nonunion of the femur and tibia using an expandable nailing system. Injury. 2009;40:309-14.

Wu CC, Shih CH, Chen WJ, Tai CL. Effect of reaming bone grafting on treating femoral shaft aseptic nonunion after plating. Arch Orthop Trauma Surg. 1999;119:303-7.

Goldberg VM, Stevenson S. Bone transplantation. In: Surgery of the Musculoskeletal System. New York: Churchill Livingstone. 1989: 54-81.

Cypher TJ, Grossman JP. Biological principles of bone graft healing. Foot Ankle Surg. 1996;35:413-7.

Urist MR. Bone: formation by autoinduction. Science. 1965;150:893-9.

Enneking WF, Burchardt H, Phyl JJ. Physical and biological aspects of repair in dog cortical‐bone transplants. J Bone Joint Surg Am. 1975;57:237-52.