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Augmentation plating leaving the nail in situ is an excellent option for treating femoral shaft nonunion after IM nailing: a multicentre study

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In recent years, plate augmentation over a retained intramedullary (IM) nail has been shown to be an effective option for managing femur fracture nonunions because it improves the biomechanical environment of the fracture site without causing additional biological damage. In the current study, we present outcome data from 22 consecutive patients treated with plate augmentation for femoral shaft nonunion leaving the nail in situ.

Patients and methods

Between 2015 and 2018, 22 consecutive patients with femoral shaft aseptic nonunion after IM nailing were treated with plate augmentation over a retained nail at four different institutions. Nonunion was categorized based on its anatomical location and was classified according to the Weber and Cech classification. Cortical defects greater than 1.0 cm, the type of nailing procedure, and the number of previous interventions were recorded. Patients were assessed clinically and radiographically to measure the healing of nonunion sites. The time to fracture union and complications were recorded. Descriptive statistics were used when applicable.


One site location was supra-isthmic, 12 were isthmic, and 9 were infra-isthmic. There were 10 cases of vascular nonunion and 12 cases of avascular nonunion. A cortical defect greater than 1.0 cm was observed in three patients. Antegrade nailing was performed in 11 patients, and retrograde nailing was performed in 11 patients. Reaming was performed in 12 patients. In eight patients, the fracture was openly reduced during the IM nailing index procedure. The average number of previous interventions before augmentation plating was 1.6 (1–4). Bone union was achieved in 19 patients after augmentation plating with an average follow-up of 23.5 months (12–51 months). Excellent and good clinical results were observed in all patients. There was no plate or screw breakage, and no patient developed infection.


Augmentation plating leaving the nail in situ is an excellent option for treating femoral shaft nonunion after IM nailing, with a high union rate and few complications. We believe the technique should gradually replace exchange nailing as the standard of care for the majority of femoral shaft nonunions that occur after IM nailing.

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Correspondence to Vincenzo Giordano.

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Uliana, C.S., Bidolegui, F., Kojima, K. et al. Augmentation plating leaving the nail in situ is an excellent option for treating femoral shaft nonunion after IM nailing: a multicentre study. Eur J Trauma Emerg Surg 47, 1895–1901 (2021).

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