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Ilizarov Compression Over a Nail for Aseptic Femoral Nonunions That Have Failed Exchange Nailing: A Report of Five Cases

Objective To evaluate a new operative treatment of femoral nonunion following failed exchange nailing. Design Retrospective review, consecutive series. Setting Office-based orthopaedic practice. Patients Five consecutive patients (ages 31–67 years) were referred in with a femoral nonunion following exchange nailing an average of 28 months (range 11–55) after the initial traumatic injury. The patients had undergone an average of 5 (range 2–8) previous surgeries on the femur. No patient had signs or history of bone infection or segmental bone loss at presentation. All patients had diaphyseal or diaphyseal-metaphyseal oligotrophic nonunions and had failed an average of 2 (range 1–3) previous exchange nailings. Intervention Slow compression (0.25 to 0.50 mm per day) of the nonunion site over a new, smaller diameter nail using an Ilizarov external fixator. Main Outcomes Measurements Clinical and radiographic evidence of bone union, ambulation, pain, residual deformity, or shortening. Results All nonunions healed without the need for further nonunion surgery. The external fixator was removed at an average of 133 days (range 86–238 days). No deep infections occurred in any patient. All patients experienced some degree of pin site irritation. At the most recent follow-up (average 45 months; range 12–75 months), all patients had improved their functional ambulatory status and had discontinued or decreased the use of assistive devices to walk. All patients were full weight bearing. Average pain, as rated on a 0 to 10 Visual Analogue Scale, decreased from 8 of 10 before treatment to 1 of 10 after treatment. No patient experienced a clinically significant worsening of leg length discrepancy. Conclusions Slow compression over an intramedullary nail using external fixation successfully promotes the healing of problematic femoral nonunions that have failed one or more prior exchange nailings.