Clinical Orthopaedics and Related Research®

, Volume 472, Issue 2, pp 759–764

The Efficacy of Single-stage Open Intramedullary Nailing of Neglected Femur Fractures

  • P. R. J. V. C. Boopalan
  • Azad Sait
  • Thilak Samuel Jepegnanam
  • Thomas Matthai
  • Viju Daniel Varghese
Clinical Research



Neglected femur fractures are not rare in the developing world. Treatment options include single-stage open reduction and intramedullary nailing, or open release, skeletal traction, and then second-stage open intramedullary nailing, with bone grafting. Single-stage procedures have the potential advantage of avoiding neurovascular complications secondary to acute lengthening, but they require a second operation, with potentially increased resource use and infection risk.


We sought to determine the (1) likelihood of union, (2) complications and reoperations, and (3) functional results with single-stage open intramedullary nailing without bone grafting in patients with neglected femur fractures.


Between January 2003 and December 2007, 17 consecutive patients presented to our practice with neglected femoral shaft fractures. All were treated with single-stage nailing without bone grafting. There were 15 men and two women with a median age of 27 years. The average time from fracture to treatment was 13 weeks (range, 4–44 weeks). Eleven patients underwent open nailing with interlocked nails and six were treated with cloverleaf Kuntscher nails. Patients were followed for a minimum of 6 months (mean, 33 months; range, 6–72 months). The mean preoperative ROM of the knee was 28° (range, 10°–150°) and femoral length discrepancy was 3.1 cm (range, 1–5 cm).


All fractures united and the mean time to union was 16 weeks (range, 7–32 weeks). There were no neurologic complications secondary to acute lengthening. The mean postoperative ROM of the knee was 130° (range, 60°–150°). All patients were able to return to preinjury work. Sixteen patients regained their original femoral length.


One-stage open intramedullary nailing of neglected femoral diaphyseal fractures without bone grafting was safe and effective, and obviated the need for a two-stage approach. Although the findings need to be replicated in larger numbers of patients, we believe this technique may be useful in treating patients with this injury, and may offer advantages in resource-constrained environments.

Level of Evidence

Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.


  1. 1.
    Akinyoola L, Orekha O, Odunsi A. Open intramedullary nailing of neglected femoral shaft fractures: indications and outcome. Acta Orthop Belg. 2011;77:73–77.PubMedGoogle Scholar
  2. 2.
    Brumback RJ, Uwagie-Ero S, Lakatos RP, Poka A, Bathon GH, Burgess AR. Intramedullary nailing of femoral shaft fractures: Part II. Fracture-healing with static interlocking fixation. J Bone Joint Surg Am. 1988;70:1453–1462.PubMedGoogle Scholar
  3. 3.
    Cauchoix J, Morel G. One stage femoral lengthening. Clin Orthop Relat Res. 1978;136:66–73.PubMedGoogle Scholar
  4. 4.
    Gahukamble A, Nithyananth M, Venkatesh K, Amritanand R, Cherian VM. Open intramedullary nailing in neglected femoral diaphyseal fractures. Injury. 2009;40:209–212.PubMedCrossRefGoogle Scholar
  5. 5.
    Goulet JA, Senunas LE, DeSilva GL, Greenfield ML. Autogenous iliac crest bone graft: complications and functional assessment. Clin Orthop Relat Res. 1997;339:76–81.PubMedCrossRefGoogle Scholar
  6. 6.
    Herron LD, Amstutz HC, Sakai DN. One stage femoral lengthening in the adult. Clin Orthop Relat Res. 1978;136:74–82.PubMedGoogle Scholar
  7. 7.
    Kempf I, Grosse A, Beck G. Closed locked intramedullary nailing: its application to comminuted fractures of the femur. J Bone Joint Surg Am. 1985;67:709–720.PubMedGoogle Scholar
  8. 8.
    Mahaisavariya B, Laupattarakasem W. Late open nailing for neglected femoral shaft fractures. Injury. 1995;26:527–529.PubMedCrossRefGoogle Scholar
  9. 9.
    Marsh J, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA, Prokuski L, Sirkin MS, Ziran B, Henley B, Audige L. Fracture and dislocation classification compendium-2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21(10 suppl):S1–S133.PubMedCrossRefGoogle Scholar
  10. 10.
    Mukherjee SK, Jain V. Neglected femoral diaphyseal fracture. Clin Orthop Relat Res. 2005;431:72–79.PubMedCrossRefGoogle Scholar
  11. 11.
    Onuminya JE. The role of the traditional bonesetter in primary fracture care in Nigeria. S Afr Med J. 2004;94:652–658.PubMedGoogle Scholar
  12. 12.
    Onuminya JE, Onabowale BO, Obekpa PO, Ihezue CH. Traditional bone setter’s gangrene. Int Orthop. 1999;23:111–112.PubMedCentralPubMedCrossRefGoogle Scholar
  13. 13.
    Wu CC. Locked nailing for shortened subtrochanteric nonunions: a one-stage treatment. Clin Orthop Relat Res. 2009;467:254–259.PubMedCrossRefGoogle Scholar
  14. 14.
    Wu CC, Lee ZL. One-stage lengthening using a locked nailing technique for distal femoral shaft nonunions associated with shortening. J Orthop Trauma. 2004;18:75–80.PubMedCrossRefGoogle Scholar
  15. 15.
    Wu CC, Lee ZL. Treatment of femoral shaft aseptic nonunion associated with broken distal locked screws and shortening. J Trauma. 2005;58:837–840.PubMedCrossRefGoogle Scholar
  16. 16.
    Younger EM, Chapman MW. Morbidity at bone graft donor sites. J Orthop Trauma. 1989;3:192–195.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2013

Authors and Affiliations

  • P. R. J. V. C. Boopalan
    • 1
  • Azad Sait
    • 1
  • Thilak Samuel Jepegnanam
    • 1
  • Thomas Matthai
    • 1
  • Viju Daniel Varghese
    • 1
  1. 1.Department of Orthopaedics Unit IIIChristian Medical CollegeVelloreIndia

Personalised recommendations