title: Exchange nailing for nonunion of diaphyseal fractures of the tibia: our results and an analysis of the risk factors for failure.
abstract: OBJECTIVE
  The aim of this study was to identify risk factors for the failure of exchange nailing in nonunion of tibial diaphyseal fractures.
  
  
  METHODS
  A cohort of 102 tibial diaphyseal nonunions in 101 patients with a mean age of 36.9 years (15 to 74) were treated between January 1992 and December 2012 by exchange nailing. Of which 33 (32%) were initially open injuries. The median time from primary fixation to exchange nailing was 6.5 months (interquartile range (IQR) 4.3 to 9.8 months). The main outcome measures were union, number of secondary fixation procedures required to achieve union and time to union. Univariate analysis and multiple regression were used to identify risk factors for failure to achieve union.
  
  
  RESULTS
  Multiple causes for the primary nonunion were found for 28 (27%) tibiae, with infection present in 32 (31%). Six patients were lost to follow-up. Further surgical procedures were required in 35 (36%) nonunions. Other fixation modalities were required in five fractures. A single nail exchange procedure achieved union in 60/96 (63%) of all nonunions. Only 11 out of 31 infected nonunions (35.4%) healed after one exchange nail procedure. Up to five repeated exchange nailings, with or without bone grafting, ultimately achieved union in 89 (93%) fractures. The median time to union after exchange nailing was 8.7 months (IQR 5.7 to 14.0 months). Univariate analysis confirmed that an oligotrophic/atrophic pattern of nonunion (p = 0.002), a bone gap of 5 mm or more (p = 0.04) and infection (p < 0.001), were predictive for failure of exchange nailing Multiple regression analysis found that infection was the strongest predictor of failure (p < 0.001).
  
  
  CONCLUSIONS
  Exchange nailing is an effective treatment for aseptic tibial diaphyseal nonunion. However, in the presence of severe infection with a highly resistant organism, or extensive sclerosis of the bone, other fixation modalities, such as Ilizarov treatment, should be considered.
  
  
  CONCLUSIONS
  Exchange nailing is an effective treatment for aseptic tibial diaphyseal nonunion.
authors.affiliation: Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK.
authors.forename: S T J
authors.initials: ST
authors.lastname: Tsang
authors.affiliation: Royal Aberdeen Children's Hospital, Aberdeen, UK.
authors.forename: L A
authors.initials: LA
authors.lastname: Mills
authors.affiliation: Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK.
authors.forename: J
authors.initials: J
authors.lastname: Frantzias
authors.affiliation: Leeds General Infirmary, Great George St, Leeds, West Yorkshire LS1 3EX, UK.
authors.forename: J P
authors.initials: JP
authors.lastname: Baren
authors.affiliation: Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK.
authors.forename: J F
authors.initials: JF
authors.lastname: Keating
authors.affiliation: Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK.
authors.forename: A H R W
authors.initials: AH
authors.lastname: Simpson
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001858:Bone Nails; D018483:Diaphyses / Q000293:injuries / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D005594:Fracture Fixation, Intramedullary / Q000379:methods*; D017102:Fracture Healing; D005599:Fractures, Ununited / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors; D013978:Tibial Fractures / Q000601:surgery; D016896:Treatment Outcome; D055815:Young Adult
keywords: Fracture nonunion; exchange nailing; tibia