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Infra-isthmal fracture is a risk factor for nonunion after femoral nailing: a case–control study

  • Original Article
  • Published:
Journal of Orthopaedic Science

Abstract

Background

The rates of nonunion after femoral nailing are currently reported to be 4.1–12.5 %. The purpose of this study was to identify the risk factors of noninfected nonunion after femoral nailing, focusing in particular on the effects of the length of the distal main fragment.

Methods

A case–control study was conducted with 105 patients, with a case (nonunion group)–control (control group) ratio of 1:2. The nonunion group (n = 35) comprised patients with consecutive symptomatic nonunions after femoral nailing who were treated in our institute; the control group (n = 70) were matched by age to the nonunion group. Type of fracture, soft tissue injury, length of femur and nail length, incidence of screw breakage, nail diameter, mean length of distal main fragment, and any episode of dynamization were retrospectively examined. Univariate and multivariate analyses were performed to elucidate the risk factors of nonunion after femoral nailing.

Results

Increased risk of nonunion after femoral nailing was associated with (1) open fracture, (2) screw breakage, (3) shorter length of a distal fragment, and (4) any episodes of dynamization. Receiver operating characteristic analysis showed that a distal fragment length of <43 % of the total femur length was the cutoff level for nonunion after nailing. The odds ratio for nonunion was 6.40 (95 % CI 2.70–15.2) when the length of the distal main fragment was <43 % of the femur length. Multivariate logistic analysis revealed that the risk of nonunion after femoral nailing increased (1) with breakage of locking screws (p = 0.0021), (2) with dynamization (p = 0.0029), (3) with a shorter distal fragment length (p = 0.0379), and (4) with an open fracture (p = 0.0397).

Conclusion

The elucidated risk factors of nonunion after femoral nailing were identified as open fracture, infra-isthmal femoral fracture, breakage of locking screw, and inappropriate dynamization. We believe that the surgeon should be consciously aware of the need for additional surgical fixation for the distal fragment when performing femoral nailing of infra-isthmal femoral fractures.

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Conflict of interest

No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this article.

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan

    Yoshinobu Watanabe, Nobuyuki Takenaka, Makoto Kobayashi & Takashi Matsushita

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  1. Yoshinobu Watanabe
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  2. Nobuyuki Takenaka
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  3. Makoto Kobayashi
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  4. Takashi Matsushita
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Correspondence to Yoshinobu Watanabe.

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Watanabe, Y., Takenaka, N., Kobayashi, M. et al. Infra-isthmal fracture is a risk factor for nonunion after femoral nailing: a case–control study. J Orthop Sci 18, 76–80 (2013). https://doi.org/10.1007/s00776-012-0316-7

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  • DOI: https://doi.org/10.1007/s00776-012-0316-7

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