Paediatric infected femoral nonunion; mid-term results of a rare problem with a single-stage treatment and up to eleven and half years follow-up

  • Gamal Ahmed Hosny
  • Abdel-Salam Abdel-Aleem AhmedEmail author
Original Paper



Nonunion of femur fractures is a devastating disabling complication which is rare in children. The purpose of this study was to report the outcomes of treating infected femur nonunions in children by the Ilizarov fixator in one stage.

Patients and methods

The study included 13 patients with unilateral infected nonunion of the femur with an average age of 9.1 years. The nonunion duration averaged 10.69 months. Ten cases were draining nonunions, and three patients had quiescent sinuses. Associated problems include shortening in all cases (mean 3.5 cm), joint stiffness (9 cases), and angular deformity (7 cases). The quiescent cases were treated by bloodless monofocal compression-distraction. Four draining cases were treated by debridement and compression with relengthening through nonunion site. The remaining six cases were treated by bifocal technique.


The mean follow-up duration was 60.15 months. External fixation period averaged 5.3 months. Successful union was achieved in all patients. Recurrences of infection occurred in two cases including one with refracture and another one with late pathological fracture. Other complications included pin tract infections, one delayed union, two residual angular deformities, and 6 cm residual shortening in one patient. ASAMI bone results were excellent (8 patients), good (3 patients), fair (one patient), and poor (one patient). The functional results were excellent (9 cases), good (3cases), and fair (one case).


The Ilizarov method provided a viable treatment option for treating paediatric infected femur nonunions in single stage of management with infection control in most cases and satisfactory outcomes.


Nonunion Paediatric femur Infection External fixator Ilizarov 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this retrospective type of study formal consent is not required.


  1. 1.
    SawyerJR SDD (2017) Fractures and dislocations in children. In: Azar F, Canale ST, Beaty J (eds) Campbell’s operative orthopaedics, 13th edn. Elsevier/Mosby, Philadelphia, pp 1424–1569Google Scholar
  2. 2.
    Zura R, Kaste SC, Heffernan MJ, Accousti WK, Gargiulo D, Wang Z et al (2018) Risk factors for nonunion of bone fracture in pediatric patients: an inception cohort study of 237,033 fractures. Medicine (Baltimore) 97:e11691. CrossRefGoogle Scholar
  3. 3.
    Hosny GA, Ahmed AA (2018) Infected tibial nonunion in children: is radical debridement mandatory? Injury 50:590–597. CrossRefPubMedGoogle Scholar
  4. 4.
    Kelly BA, Shore BJ (2015) Adolescent femoral diaphyseal fracture nonunion. Curr Orthop Pract 26:481–486. CrossRefGoogle Scholar
  5. 5.
    Soldado F, Knörr J, Haddad S, Corona PS, Barrera-Ochoa S, Collado D et al (2015) Vascularized tibial periosteal graft in complex cases of bone nonunion in children. Microsurgery 35:239–243. CrossRefPubMedGoogle Scholar
  6. 6.
    Zhen P, Lu H, Gao MX, Li XS, Qi T (2012) Successful management of atrophic nonunion of a severely osteoporotic femoral shaft in a child. J Pediatr Orthop B 21:592–595. CrossRefPubMedGoogle Scholar
  7. 7.
    Arslan H, Özkul E, Gem M, Alemdar C, Şahin İ, Kişin B (2015) Segmental bone loss in pediatric lower extremity fractures: indications and results of bone transport. J Pediatr Orthop 35:e8–e12. CrossRefPubMedGoogle Scholar
  8. 8.
    Arslan H, Subaşý M, Kesemenli C, Ersuz H (2002) Occurrence and treatment of nonunion in long bone fractures in children. Arch Orthop Trauma Surg 122:494–498. CrossRefPubMedGoogle Scholar
  9. 9.
    Daoud A, Saighi-Bouaouina A (1989) Treatment of sequestra, pseudarthroses, and defects in the long bones of children who have chronic hematogenous osteomyelitis. J Bone Joint Surg Am 71(10):1448–1468. CrossRefPubMedGoogle Scholar
  10. 10.
    Lewallen RP, Peterson HA (1985) Nonunion of long bone fractures in children: a review of 30 cases. J Pediatr Orthop 5:135–142. CrossRefPubMedGoogle Scholar
  11. 11.
    Sales de Gauzy J, Fitoussi F, Jouve JL, Karger C, Badina A, Masquelet AC (2012) French Society of Orthopaedic Surgery and Traumatology (SoFCOT). Traumatic diaphyseal bone defects in children. Orthop Traumatol Surg Res 98:220–226. CrossRefPubMedGoogle Scholar
  12. 12.
    Yeo JH, Jung ST, Kim MC, Yang HY (2018) Diaphyseal nonunion in children. J Orthop Trauma 32:e52–e58. CrossRefPubMedGoogle Scholar
  13. 13.
    Galle SE, Zamorano DP (2018) Tibial nonunions. In: Agarwal A (ed) Nonunions diagnosis, evaluation and management. Springer Science+Business Media LLC, New York, pp 287–308Google Scholar
  14. 14.
    Barral JP, Gil DR, Vergara SS (1991) Atlas for the insertion of transosseous wires. In: Bianchi-Maiocchi A, Aronson J (eds) Operative principles of Ilizarov; fracture treatment, non-union, osteomyelitis, lengthening, deformity correction. Williams and Wilkins, Baltimore, pp 463–549Google Scholar
  15. 15.
    Paley D, Catagni MA, Argnani F, Villa A, Benedetti GB, Cattaneo R (1989) Ilizarov treatment of tibial nonunions with bone loss. Clin Orthop Relat Res 241:146–165. CrossRefGoogle Scholar
  16. 16.
    Flynn JM, Schwend RM (2004) Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg 12(5):347–359. CrossRefPubMedGoogle Scholar
  17. 17.
    Boyette MY, Herrera-Soto JA (2012) Treatment of delayed and nonunited fractures and osteotomies with pulsed electromagnetic field in children and adolescents. Orthopedics 35(7):e1051–e1055. CrossRefPubMedGoogle Scholar
  18. 18.
    Greenbaum B, Zionts LE, Ebramzadeh E (2001) Open fractures of the forearm in children. J Orthop Trauma 15(2):111–118. CrossRefPubMedGoogle Scholar
  19. 19.
    Liow RY, Montgomery RJ (2002) Treatment of established and anticipated nonunion of the tibia in childhood. J Pediatr Orthop 22:754–760. CrossRefPubMedGoogle Scholar
  20. 20.
    Bell A, Templeman D, Weinlein JC (2016) Nonunion of the femur and tibia: an update. Orthop Clin North Am 47(2):365–375. CrossRefPubMedGoogle Scholar
  21. 21.
    Hosny GA, Ahmed AA, Hussein MA (2018) Clinical outcomes with the corticotomy- first technique associated with the Ilizarov method for the management of the septic long bones non-union. Int Orthop 42(12):2933–2939. CrossRefPubMedGoogle Scholar
  22. 22.
    Ahmed AA, Singer MS, El Bigawi HA (2018) Neglected tibial pilon fractures: can arthrodesis be avoided? J Orthop Trauma 32(7):369–375. CrossRefPubMedGoogle Scholar
  23. 23.
    Masquelet AC, Fitoussi F, Bégué T, Muller GP (2000) Reconstruction des os longs par membrane induite et autogreffe spongieuse. Ann Chir Plast Esthet 45:346–353PubMedGoogle Scholar
  24. 24.
    Gouron R, Deroussen F, Plancq MC, Collet LM (2013) Bone defect reconstruction in children using the induced membrane technique: a series of 14 cases. Orthop Traumatol Surg Res 99(7):837–843. CrossRefPubMedGoogle Scholar
  25. 25.
    Gouron R (2016) Surgical technique and indications of the induced membrane procedure in children. Orthop Traumatol Surg Res 102:S133–S139. CrossRefPubMedGoogle Scholar
  26. 26.
    Hissnauer TN, Stiel N, Babin K, Rupprecht M, Ridderbusch K, Rueger JM, Stuecker R, Spiro AS (2017) Recombinant human bone morphogenetic protein-2 (rhBMP-2) for the treatment of nonunion of the femur in children and adolescents: a retrospective analysis. Biomed Res Int 2017:3046842. CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Soldado F, Fontecha CG, Barber I, Velez R, Llusa M, Collado D, Rodriguez-Baeza A, Martinez-Ibañez V (2012) Vascularized fibular periosteal graft: a new technique to enhance bone union in children. J Pediatr Orthop 32(3):308–313. CrossRefPubMedGoogle Scholar
  28. 28.
    Patwardhan S, Shyam AK, Mody RA, Sancheti PK, Mehta R, Agrawat H (2013) Reconstruction of bone defects after osteomyelitis with nonvascularized fibular graft: a retrospective study in twenty-six children. J bone joint Surg am 95(9):e56, S1. CrossRefGoogle Scholar

Copyright information

© SICOT aisbl 2020

Authors and Affiliations

  1. 1.Department of Orthopaedic Surgery, Faculty of MedicineBenha UniversityBenhaEgypt

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