Combined Transosseous and Locked Intramedullary Osteosynthesis in Management of Pseudoarthrosis of the Femoral Diaphysis

Twenty eight patients with pseudarthrosis of the femoral diaphysis were treated with the use of combined techniques of transosseous osteosynthesis and locked intramedullary nailing. Their outcomes were compared with 36 patients that also had pseudarthrosis of the femoral diaphysis that was managed with classical Ilizarov transosseous osteosynthesis techniques. Patients of both groups had posttraumatic pseudoarthrosis. Combined techniques were used in three variants: 1) sequential use of distraction osteosynthesis with the Ilizarov apparatus and locked intramedullary nailing in 11 patients with pseudarthrosis and stiff deformities of the femur; 2) simultaneous use of distraction osteosynthesis with the Ilizarov apparatus and intramedullary nailing in 14 patients with pseudarthrosis associated with limb length discrepancy and in one patient with diaphyseal defect of the femur; 3) simultaneous use of compression and intramedullary osteosynthesis in three patients with pseudoarthrosis of the femoral diaphysis when it was impossible to use reosteosynthesis with intramedullary implants.

In the first group, the angulation was 38.5±3.6° and required gradual correction with the Ilizarov apparatus. In the second group, limb discrepancy was 5.3±0.4 that required segment lengthening. In the third group, dynamization of the nail and Ilizarov transosseous osteosynthesis were performed. Compression of the pseudoarthrosis area was used in the postoperative period.

In the first group, correction of angulation with the apparatus averaged 14.0±1.7 days. Consolidation was achieved from 3 to 5 months after the removal of the apparatus.

In the second group, mean lengthening of the femur was 3.9±0.2 cm and restored a mean of 85.4±4.0% of bone loss. Distraction period was 34.7±1.8 on average and the index of transosseous osteosynthesis was 12.8±0.9 days/cm. Distraction regenerates were formed in all the cases. Pseudarthrosis union was achieved in 12 patients (80%) in the period from 4 to 9 months.

In the third group, fixation in the apparatus continued 90.0±15.6 days. Pseudarthrosis union was achieved in all the cases.

Classical technologies of transosseous osteosynthesis require the use of external fixation during the entire period of treatment. Combined osteosynthesis enables to obtain good and satisfactory treatment outcomes at a long-term. Moreover, it provides a 3.5-fold reduction of the external fixation period when it is simultaneous and a 6.5-fold reduction when it is sequential.