Research progress of augmentation plate for femoral shaft nonunion after intramedullary nail fixation_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

ZHANG Wei , ZHANG Zhuo ,  CHEN Hua

Department of Orthopedics, General Hospital of Chinese PLA, Beijing, 100853, P.R.China;

Corresponding author：

CHEN Hua, Email: chenhua0270@126.com

Keywords：

Femoral shaft fracture; augmentation plate; intramedullary nail; nonunion

DOI：

10.7507/1002-1892.201903073

Video：

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Objective To review the history, current situation, and progress of augmentation plate (AP) for femoral shaft nonunion after intramedullary nail fixation.Methods The results of the clinical studies about the AP in treatment of femoral shaft nonunion after intramedullary nail fixation in recent years were widely reviewed and analyzed.Results The AP has been successfully applied to femoral shaft nonunion after intramedullary nail fixation since 1997. According to breakage of the previous nailing, AP is divided into two categories: AP with retaining the previous intramedullary nail and AP with exchanging intramedullary nail. AP is not only suitable for simple nonunion, but also for complex nonunion with severe deformity. Compared with exchanging intramedullary nail, lateral plate, and dual plate, AP has less surgical trauma, shorter healing time, higher healing rate, and faster returning to society. However, there are still some problems with the revision method, including difficulty in bicortical screw fixation, lack of anatomic plate suitable for femoral shaft nonunion, and lack of postoperative function and quality of life assessment.Conclusion Compared with other revision methods, AP could achieve higher fracture healing rate and better clinical prognosis for patients with femoral shaft nonunion. However, whether patients benefit from AP in terms of function and quality of life remain uncertain. Furthermore, high-quality randomized controlled clinical studies are needed to further confirm that AP are superior to the other revision fixations.

Citation： ZHANG Wei, ZHANG Zhuo, CHEN Hua. Research progress of augmentation plate for femoral shaft nonunion after intramedullary nail fixation. Chinese Journal of Reparative and Reconstructive Surgery, 2019, 33(12): 1467-1473. doi: 10.7507/1002-1892.201903073 Copy

1.	Neumann MV, Südkamp NP, Strohm P. Management of femoral shaft fractures. Acta Chir Orthop Traumatol Cech, 2015, 82(1): 22-32.
2.	Rommens PM, Hessmann MH. Intramedullary nailing. Berlin: Springer, 2015: 419-452.
3.	Tarr RR, Wiss DA. The mechanics and biology of intramedullary fracture fixation. Clin Orthop Relat Res, 1986, (212): 10-17.
4.	Giannoudis PV, MacDonald DA, Matthews SJ, et al. Nonunion of the femoral diaphysis. The influence of reaming and non-steroidal anti-inflammatory drugs. J Bone Joint Surg (Br), 2000, 82(5): 655-658.
5.	Tzioupis C, Giannoudis PV. Prevalence of long-bone non-unions. Injury, 2007, 38(Suppl 2): S3-S9.
6.	Hak DJ, Fitzpatrick D, Bishop JA, et al. Delayed union and nonunion: epidemiology, clinical issues, and financial aspects. Injury, 2014, 45(Suppl 2): S3-S7.
7.	McMillan TE, Johnstone AJ. Technical considerations to avoid delayed and non-union. Injury, 2017, 48(Suppl 1): S64-S68.
8.	Pihlajamäki HK, Salminen ST, Böstman OM. The treatment of nonunions following intramedullary nailing of femoral shaft fractures. J Orthop Trauma, 2002, 16: 394-402.
9.	Gelalis ID, Poltis AN, Arnaoutolou CM, et al. Diagnostic and treatment modalities in nonunions of the femoral shaft: a review. Injury, 2012, 43(7): 980-988.
10.	张伟, 陈华, 唐佩福. 股骨干无菌性骨不连的最新治疗进展. 中国修复重建外科杂志, 2018, 32(5): 519-525.
11.	Rupp M, Biehl C, Budak M, et al. Diaphyseal long bone nonunions — types, aetiology, economics, and treatment recommendations. Int Orthop, 2018, 42(2): 247-258.
12.	Garnavos C. Treatment of aseptic non-union after intramedullary nailing without removal of the nail. Injury, 2017, 48(Suppl 1): S76-S81.
13.	Somford MP, van den Bekerom MP, Kloen P. Operative treatment for femoral shaft nonunions, a systematic review of the literature. Strategies Trauma Limb Reconstr, 2013, 8(2): 77-88.
14.	Bell A, Templeman D, Weinlein JC. Nonunion of the femur and tibia: an update. Orthop Clin North Am, 2016, 47(2): 365-375.
15.	Medlock G, Stevenson IM, Johnstone AJ. Uniting the un-united: should established non-unions of femoral shaft fractures initially treated with IM nails be treated by plate augmentation instead of exchange IM nailing? A systematic review. Strategies Trauma Limb Reconstr, 2018, 13(3): 119-128.
16.	Brinker MR, O’Connor DP. Exchange nailing of ununited fractures. J Bone Joint Surg (Am), 2007, 89(1): 177-188.
17.	Weresh MJ, Hakanson R, Stover MD, et al. Failure of exchange reamed intramedullary nails for ununited femoral shaft fractures. J Orthop Trauma, 2000, 14(5): 335-338.
18.	Shroeder JE, Mosheiff R, Khoury A, et al. The outcome of closed, intramedullary exchange nailing with reamed insertion in the treatment of femoral shaft nonunions. J Orthop Trauma, 2009, 23(9): 653-657.
19.	Yang KH, Kim JR, Park J. Nonisthmal femoral shaft nonunion as a risk factor for exchange nailing failure. J Trauma Acute Care Surg, 2012, 72(2): E60-E64.
20.	Park K, Kim K, Choi YS. Comparison of mechanical rigidity between plate augmentation leaving the nail in situ and interlocking nail using cadaveric fracture model of the femur. Int Orthop, 2011, 35(4): 581-585.
21.	马显志, 张伯松, 王满宜, 等. 辅助钢板治疗股骨干骨折髓内钉固定术后骨折不愈合的生物力学研究. 中华创伤骨科杂志, 2016, 18(2): 158-162.
22.	Paul Tornetta Ⅲ, William Ricci, Court-Brown CM, et al. Rockwood and Green’s fracture in adults. 5th ed. Philadelphia: Lippincott Williams and Wilkins, 2015: 2216-2221.
23.	张伟, 陈华, 刘浩, 等. 无菌性和感染性股骨骨不连患者的临床对照研究. 中华骨与关节外科杂志, 2018, 11(2): 118-123.
24.	Olszewski D, Streubel PN, Stucken C, et al. Fate of patients with a " surprise” positive culture after nonunion surgery. J Orthop Trauma, 2016, 30(1): e19-e23.
25.	Ueng SW, Chao EK, Lee SS, et al. Augmentative plate fixation for the management of femoral nonunion after intramedullary nailing. J Trauma, 1997, 43(4): 640-644.
26.	Ueng SW, Shih CH. Augmentative plate fixation for the management of femoral nonunion with broken interlocking nail. J Trauma, 1998, 45(4): 747-752.
27.	Choi YS, Kim KS. Plate augmentation leaving the nail in situ and bone grafting for non-union of femoral shaft fractures. Int Orthop, 2005, 29(5): 287-290.
28.	Park J, Kim SG, Yoon HK, et al. The treatment of nonisthmal femoral shaft nonunions with IM nail exchange versus augmentation plating. J Orthop Trauma, 2010, 24(2): 89-94.
29.	Nadkarni B, Srivastav S, Mittal V, et al. Use of locking compression plates for long bone nonunions without removing existing intramedullary nail: review of literature and our experience. J Trauma, 2008, 65(2): 482-486.
30.	Ekere AU, Echem RC. Dual implant application in the treatment of aseptic femoral shaft non-unions—case series. West Afr J Med, 2008, 27(2): 117-119.
31.	Said GZ, Said HG, el-Sharkawi MM. Failed intramedullary nailing of femur: open reduction and plate augmentation with the nail in situ. Int Orthop, 2011, 35(7): 1089-1092.
32.	Wang Z, Liu C, Liu C, et al. Effectiveness of exchange nailing and augmentation plating for femoral shaft nonunion after nailing. Int Orthop, 2014, 38(11): 2343-2347.
33.	Birjandinejad A, Ebrahimzadeh MH, Ahmadzadeh-Chabock H. Augmentation plate fixation for the treatment of femoral and tibial nonunion after intramedullary nailing. Orthopedics, 2009, 32(6): 409.
34.	Chen CM, Su YP, Hung SH, et al. Dynamic compression plate and cancellous bone graft for aseptic nonunion after intramedullary nailing of femoral fracture. Orthopedics, 2010, 33(6): 393.
35.	张建政, 孙天胜, 刘智, 等. 附加钢板治疗髓内钉固定后长骨干肥大性骨不连. 中华医学杂志, 2010, 90(27): 1902-1906.
36.	Gao KD, Huang JH, Tao J, et al. Management of femoral diaphyseal nonunion after nailing with augmentative locked plating and bone graft. Orthop Surg, 2011, 3(2): 83-87.
37.	Hakeos WM, Richards JE, Obremskey WT. Plate fixation of femoral nonunions over an intramedullary nail with autogenous bone grafting. J Orthop Trauma, 2011, 25(2): 84-89.
38.	Ye J, Zheng Q. Augmentative locking compression plate fixation for the management of long bone nonunion after intramedullary nailing. Arch Orthop Trauma Surg, 2012, 132(7): 937-940.
39.	Lin CJ, Chiang CC, Wu PK. Effectiveness of plate augmentation for femoral shaft nonunion after nailing. J Chin Med Assoc, 2012, 75(8): 396-401.
40.	Park J, Yang KH. Indications and outcomes of augmentation plating with decortication and autogenous bone grafting for femoral shaft nonunions. Injury, 2013, 44(12): 1820-1825.
41.	王飞达, 高耀祖, 苑伟, 等. 附加锁定加压钢板联合植骨治疗股骨干骨折髓内钉固定术后无菌性骨不连. 中国骨伤, 2014, 27(10): 815-818.
42.	Chiang JC, Johnson JE, Tarkin IS. Plate augmentation for femoral nonunion: more than just a salvage tool? Arch Orthop Trauma Surg, 2016, 136(2): 149-156.
43.	Jhunjhunwala HR, Dhawale AA. Is augmentation plating an effective treatment for non-union of femoral shaft fractures with nail in situ? Eur J Trauma Emerg Surg, 2016, 42(3): 339-343.
44.	Vaishya R, Agarwal AK, Gupta N, et al. Plate augmentation with retention of intramedullary nail is effective for resistant femoral shaft non-union. J Orthop, 2016, 13(4): 242-245.
45.	Park KC, Oh CW, Kim JW, et al. Minimally invasive plate augmentation in the treatment of long-bone non-unions. Arch Orthop Trauma Surg, 2017, 137(11): 1523-1528.
46.	Yang KH, Won Y, Kim SB, et al. Plate augmentation and autologous bone grafting after intramedullary nailing for challenging femoral bone defects: a technical note. Arch Orthop Trauma Surg, 2016, 136(10): 1381-1385.
47.	Verma R, Sharma P, Gaur S. Augmentation plating in management of failed femoral nailing. Injury, 2017, 48(Suppl 2): S23-S26.
48.	Sancheti KH, Pradhan C, Patil A, et al. Effectiveness of exchange K-nail and augmented plating in aseptic femoral diaphyseal non-union. Injury, 2017, 48(2): S61-S65.
49.	茹江英, 仓海滨, 胡传亮, 等. 两种方法治疗股骨干骨折髓内钉固定后非感染性骨不连的疗效比较. 中国修复重建外科杂志, 2013, 27(1): 25-29.
50.	Ru JY, Niu YF, Cong Y, et al. Exchanging reamed nailing versus augmentative compression plating with autogenous bone grafting for aseptic femoral shaft non-union: a retrospective cohort study. Acta Orthop Traumatol Turc, 2015, 49(6): 668-675.
51.	Jiang L, Pan Z, Zheng Q. Augmentation plating in hypertrophic non-union after nail fixation of femoral shaft fracture compared with exchange plating. Chin Med J (Engl), 2014, 127(16): 2900-2905.
52.	Zhang W, Zhang Z, Li J, et al. Clinical outcomes of femoral shaft nonunion: dual plating versus exchange nailing with augmentation plating. J Orthop Surg Res, 2018, 13(1): 295-301.
53.	张伟, 朱正国, 常祖豪, 等. 经股直肌旁入路治疗股骨干无菌性骨不连的临床疗效. 解放军医学院学报, 2018, 39(1): 31-35.
54.	Roberts JW, Grindel SI, Rebholz B, et al. Biomechanical evaluation of locking plate radial shaft fixation: unicortical locking fixation versus mixed bicortical and unicortical fixation in a sawbone model. J Hand Surg (Am), 2007, 32(7): 971-975.
55.	Gautier E, Summer C. Guidelines for the clinical application of the LCP. Injury, 2003, 34(Suppl 2): B63-B76.
56.	Buijze GA, Richardson S, Jupiter JB. Successful reconstruction for complex malunions and nonunions of the tibia and femur. J Bone Joint Surg (Am), 2011, 93(5): 485-492.
57.	Hackl S, Hierholzer C, Friederichs J, et al. Long-term outcome following additional rhBMP-7 application in revision surgery of aseptic humeral, femoral, and tibial shaft nonunion. BMC Musculoskeletal Disorders, 2017, 18(1): 342-351.
58.	Zollera SD, Caob LA, Smitha RA, et al. Staged reconstruction of diaphyseal fractures with segmental defects: surgical and patient-reported outcomes. Injury, 2017, 48(10): 2248-2252.
59.	Kanakeshwara RB, Jayaramarajua D, Agraharam D, et al. Management of resistant distal femur non-unions with allograft strut and autografts combined with osteosynthesis in a series of 22 patients. Injury, 2017, 48(Suppl 2): S14-S17.

1. Neumann MV, Südkamp NP, Strohm P. Management of femoral shaft fractures. Acta Chir Orthop Traumatol Cech, 2015, 82(1): 22-32.
2. Rommens PM, Hessmann MH. Intramedullary nailing. Berlin: Springer, 2015: 419-452.
3. Tarr RR, Wiss DA. The mechanics and biology of intramedullary fracture fixation. Clin Orthop Relat Res, 1986, (212): 10-17.
4. Giannoudis PV, MacDonald DA, Matthews SJ, et al. Nonunion of the femoral diaphysis. The influence of reaming and non-steroidal anti-inflammatory drugs. J Bone Joint Surg (Br), 2000, 82(5): 655-658.
5. Tzioupis C, Giannoudis PV. Prevalence of long-bone non-unions. Injury, 2007, 38(Suppl 2): S3-S9.
6. Hak DJ, Fitzpatrick D, Bishop JA, et al. Delayed union and nonunion: epidemiology, clinical issues, and financial aspects. Injury, 2014, 45(Suppl 2): S3-S7.
7. McMillan TE, Johnstone AJ. Technical considerations to avoid delayed and non-union. Injury, 2017, 48(Suppl 1): S64-S68.
8. Pihlajamäki HK, Salminen ST, Böstman OM. The treatment of nonunions following intramedullary nailing of femoral shaft fractures. J Orthop Trauma, 2002, 16: 394-402.
9. Gelalis ID, Poltis AN, Arnaoutolou CM, et al. Diagnostic and treatment modalities in nonunions of the femoral shaft: a review. Injury, 2012, 43(7): 980-988.
10. 张伟, 陈华, 唐佩福. 股骨干无菌性骨不连的最新治疗进展. 中国修复重建外科杂志, 2018, 32(5): 519-525.
11. Rupp M, Biehl C, Budak M, et al. Diaphyseal long bone nonunions — types, aetiology, economics, and treatment recommendations. Int Orthop, 2018, 42(2): 247-258.
12. Garnavos C. Treatment of aseptic non-union after intramedullary nailing without removal of the nail. Injury, 2017, 48(Suppl 1): S76-S81.
13. Somford MP, van den Bekerom MP, Kloen P. Operative treatment for femoral shaft nonunions, a systematic review of the literature. Strategies Trauma Limb Reconstr, 2013, 8(2): 77-88.
14. Bell A, Templeman D, Weinlein JC. Nonunion of the femur and tibia: an update. Orthop Clin North Am, 2016, 47(2): 365-375.
15. Medlock G, Stevenson IM, Johnstone AJ. Uniting the un-united: should established non-unions of femoral shaft fractures initially treated with IM nails be treated by plate augmentation instead of exchange IM nailing? A systematic review. Strategies Trauma Limb Reconstr, 2018, 13(3): 119-128.
16. Brinker MR, O’Connor DP. Exchange nailing of ununited fractures. J Bone Joint Surg (Am), 2007, 89(1): 177-188.
17. Weresh MJ, Hakanson R, Stover MD, et al. Failure of exchange reamed intramedullary nails for ununited femoral shaft fractures. J Orthop Trauma, 2000, 14(5): 335-338.
18. Shroeder JE, Mosheiff R, Khoury A, et al. The outcome of closed, intramedullary exchange nailing with reamed insertion in the treatment of femoral shaft nonunions. J Orthop Trauma, 2009, 23(9): 653-657.
19. Yang KH, Kim JR, Park J. Nonisthmal femoral shaft nonunion as a risk factor for exchange nailing failure. J Trauma Acute Care Surg, 2012, 72(2): E60-E64.
20. Park K, Kim K, Choi YS. Comparison of mechanical rigidity between plate augmentation leaving the nail in situ and interlocking nail using cadaveric fracture model of the femur. Int Orthop, 2011, 35(4): 581-585.
21. 马显志, 张伯松, 王满宜, 等. 辅助钢板治疗股骨干骨折髓内钉固定术后骨折不愈合的生物力学研究. 中华创伤骨科杂志, 2016, 18(2): 158-162.
22. Paul Tornetta Ⅲ, William Ricci, Court-Brown CM, et al. Rockwood and Green’s fracture in adults. 5th ed. Philadelphia: Lippincott Williams and Wilkins, 2015: 2216-2221.
23. 张伟, 陈华, 刘浩, 等. 无菌性和感染性股骨骨不连患者的临床对照研究. 中华骨与关节外科杂志, 2018, 11(2): 118-123.
24. Olszewski D, Streubel PN, Stucken C, et al. Fate of patients with a " surprise” positive culture after nonunion surgery. J Orthop Trauma, 2016, 30(1): e19-e23.
25. Ueng SW, Chao EK, Lee SS, et al. Augmentative plate fixation for the management of femoral nonunion after intramedullary nailing. J Trauma, 1997, 43(4): 640-644.
26. Ueng SW, Shih CH. Augmentative plate fixation for the management of femoral nonunion with broken interlocking nail. J Trauma, 1998, 45(4): 747-752.
27. Choi YS, Kim KS. Plate augmentation leaving the nail in situ and bone grafting for non-union of femoral shaft fractures. Int Orthop, 2005, 29(5): 287-290.
28. Park J, Kim SG, Yoon HK, et al. The treatment of nonisthmal femoral shaft nonunions with IM nail exchange versus augmentation plating. J Orthop Trauma, 2010, 24(2): 89-94.
29. Nadkarni B, Srivastav S, Mittal V, et al. Use of locking compression plates for long bone nonunions without removing existing intramedullary nail: review of literature and our experience. J Trauma, 2008, 65(2): 482-486.
30. Ekere AU, Echem RC. Dual implant application in the treatment of aseptic femoral shaft non-unions—case series. West Afr J Med, 2008, 27(2): 117-119.
31. Said GZ, Said HG, el-Sharkawi MM. Failed intramedullary nailing of femur: open reduction and plate augmentation with the nail in situ. Int Orthop, 2011, 35(7): 1089-1092.
32. Wang Z, Liu C, Liu C, et al. Effectiveness of exchange nailing and augmentation plating for femoral shaft nonunion after nailing. Int Orthop, 2014, 38(11): 2343-2347.
33. Birjandinejad A, Ebrahimzadeh MH, Ahmadzadeh-Chabock H. Augmentation plate fixation for the treatment of femoral and tibial nonunion after intramedullary nailing. Orthopedics, 2009, 32(6): 409.
34. Chen CM, Su YP, Hung SH, et al. Dynamic compression plate and cancellous bone graft for aseptic nonunion after intramedullary nailing of femoral fracture. Orthopedics, 2010, 33(6): 393.
35. 张建政, 孙天胜, 刘智, 等. 附加钢板治疗髓内钉固定后长骨干肥大性骨不连. 中华医学杂志, 2010, 90(27): 1902-1906.
36. Gao KD, Huang JH, Tao J, et al. Management of femoral diaphyseal nonunion after nailing with augmentative locked plating and bone graft. Orthop Surg, 2011, 3(2): 83-87.
37. Hakeos WM, Richards JE, Obremskey WT. Plate fixation of femoral nonunions over an intramedullary nail with autogenous bone grafting. J Orthop Trauma, 2011, 25(2): 84-89.
38. Ye J, Zheng Q. Augmentative locking compression plate fixation for the management of long bone nonunion after intramedullary nailing. Arch Orthop Trauma Surg, 2012, 132(7): 937-940.
39. Lin CJ, Chiang CC, Wu PK. Effectiveness of plate augmentation for femoral shaft nonunion after nailing. J Chin Med Assoc, 2012, 75(8): 396-401.
40. Park J, Yang KH. Indications and outcomes of augmentation plating with decortication and autogenous bone grafting for femoral shaft nonunions. Injury, 2013, 44(12): 1820-1825.
41. 王飞达, 高耀祖, 苑伟, 等. 附加锁定加压钢板联合植骨治疗股骨干骨折髓内钉固定术后无菌性骨不连. 中国骨伤, 2014, 27(10): 815-818.
42. Chiang JC, Johnson JE, Tarkin IS. Plate augmentation for femoral nonunion: more than just a salvage tool? Arch Orthop Trauma Surg, 2016, 136(2): 149-156.
43. Jhunjhunwala HR, Dhawale AA. Is augmentation plating an effective treatment for non-union of femoral shaft fractures with nail in situ? Eur J Trauma Emerg Surg, 2016, 42(3): 339-343.
44. Vaishya R, Agarwal AK, Gupta N, et al. Plate augmentation with retention of intramedullary nail is effective for resistant femoral shaft non-union. J Orthop, 2016, 13(4): 242-245.
45. Park KC, Oh CW, Kim JW, et al. Minimally invasive plate augmentation in the treatment of long-bone non-unions. Arch Orthop Trauma Surg, 2017, 137(11): 1523-1528.
46. Yang KH, Won Y, Kim SB, et al. Plate augmentation and autologous bone grafting after intramedullary nailing for challenging femoral bone defects: a technical note. Arch Orthop Trauma Surg, 2016, 136(10): 1381-1385.
47. Verma R, Sharma P, Gaur S. Augmentation plating in management of failed femoral nailing. Injury, 2017, 48(Suppl 2): S23-S26.
48. Sancheti KH, Pradhan C, Patil A, et al. Effectiveness of exchange K-nail and augmented plating in aseptic femoral diaphyseal non-union. Injury, 2017, 48(2): S61-S65.
49. 茹江英, 仓海滨, 胡传亮, 等. 两种方法治疗股骨干骨折髓内钉固定后非感染性骨不连的疗效比较. 中国修复重建外科杂志, 2013, 27(1): 25-29.
50. Ru JY, Niu YF, Cong Y, et al. Exchanging reamed nailing versus augmentative compression plating with autogenous bone grafting for aseptic femoral shaft non-union: a retrospective cohort study. Acta Orthop Traumatol Turc, 2015, 49(6): 668-675.
51. Jiang L, Pan Z, Zheng Q. Augmentation plating in hypertrophic non-union after nail fixation of femoral shaft fracture compared with exchange plating. Chin Med J (Engl), 2014, 127(16): 2900-2905.
52. Zhang W, Zhang Z, Li J, et al. Clinical outcomes of femoral shaft nonunion: dual plating versus exchange nailing with augmentation plating. J Orthop Surg Res, 2018, 13(1): 295-301.
53. 张伟, 朱正国, 常祖豪, 等. 经股直肌旁入路治疗股骨干无菌性骨不连的临床疗效. 解放军医学院学报, 2018, 39(1): 31-35.
54. Roberts JW, Grindel SI, Rebholz B, et al. Biomechanical evaluation of locking plate radial shaft fixation: unicortical locking fixation versus mixed bicortical and unicortical fixation in a sawbone model. J Hand Surg (Am), 2007, 32(7): 971-975.
55. Gautier E, Summer C. Guidelines for the clinical application of the LCP. Injury, 2003, 34(Suppl 2): B63-B76.
56. Buijze GA, Richardson S, Jupiter JB. Successful reconstruction for complex malunions and nonunions of the tibia and femur. J Bone Joint Surg (Am), 2011, 93(5): 485-492.
57. Hackl S, Hierholzer C, Friederichs J, et al. Long-term outcome following additional rhBMP-7 application in revision surgery of aseptic humeral, femoral, and tibial shaft nonunion. BMC Musculoskeletal Disorders, 2017, 18(1): 342-351.
58. Zollera SD, Caob LA, Smitha RA, et al. Staged reconstruction of diaphyseal fractures with segmental defects: surgical and patient-reported outcomes. Injury, 2017, 48(10): 2248-2252.
59. Kanakeshwara RB, Jayaramarajua D, Agraharam D, et al. Management of resistant distal femur non-unions with allograft strut and autografts combined with osteosynthesis in a series of 22 patients. Injury, 2017, 48(Suppl 2): S14-S17.

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