Intramedullary nails (IMN) are now the standard treatment for diaphyseal fractures of long bones; despite recent advances in techniques and designs of nails, some cases of nonunion are still encountered. The causes of nonunion following IMN as summarized by Said et al. are unstable fixation because of undersized nails, comminution, or poor reduction or devitalization of the soft tissue envelope by trauma or surgery. Choi and Kim concluded that the most important factor of the nonunion over IMN was instability at the fracture site. Many lines of treatment have been described for the treatment of nonunited diaphyseal fractures over IMN. Conversion of nail to plate with grafting was first described for excision of nonunion, closure of gaps, and rigid fixation . Exchange nailing is the most accepted line of treatment; it obviates the need for graft, and the retained nail maintains alignment and stability of the fracture . Augmentation plating with grafting combines the advantage of retaining the nail with its role in intramedullary stability and alignment and the rigidity of fixation with plates . Park et al. , in their cadaveric study on a fracture model of the femur fixed with IMN in one group and IMN and an augmentation plate in the other group, found a 2.5-fold increase in bending stiffness and a 3.3-fold increase in torsional stiffness in plate augmentation, leaving the nail in situ compared with an interlocking nail only in the distal third fracture of the femur. Augmentative Ilizarov external fixation is retained for resistant cases of nonunion for closure of large gaps from without and in the presence of excessive scarring
Nadkarni et al. , in their study of 11 cases of nonunion over IMN in femoral tibial and femoral fractures, used locked plates and bone grafting, leaving the nail in situ with union in all cases on an average of 6.2 months. We used a locked plate in one tibial fracture case and we found that a locked plate has the advantage of unicortical fixation, especially in the presence of a medullary fitting nail, but has one disadvantage that when the screw locks into the plate, the purchase of the screw in the bone cannot be guaranteed; we preferred the bone use of DCP.
In some fractures with marked comminution, healing was not anticipated after nailing, but the aim was to splint the fracture until an improvement in soft tissue condition and transformation of a multifragmentary fracture into two or three fragments; then, the procedure of augmentation plating and grafting is performed. In these situations, we can consider primary nailing and secondary plating and grafting as a two-stage operation.
There was controversy in terms of plating and periosteal stripping following IMN. According to the study by Cole , the blood supply recovered within 2 weeks in all cortical areas, including the periosteal and endosteal area, after the insertion of a reamed or an undreamed nail. Wolnisky et al. reported that blood supply would be recovered by 6–12 weeks. Thus, problems related to insufficient blood supply will not arise if sufficient time is allowed to pass between two procedures.