The Use of a Free Fibular Strut as a “Biological Intramedullary Nail” for the Treatment of Complex Nonunion of Long Bones

BACKGROUND: Nonunion of long-bone fractures is difficult to treat, especially when the bones are osteoporotic or there is a large bone gap as a result of repeated failure of the metallic nails or implants. In such cases, the use of an autologous intramedullary fibular strut graft may be a viable treatment option. METHODS: Twenty-two patients with a complex nonunion of the shaft of the femur, humerus, or tibia were managed with a free autologous fibular strut graft for intramedullary fixation with use of closed or open methods. All patients had evidence of moderate to severe local osteoporosis and had a bone gap ranging from 4 to 20 mm. Nineteen patients had had 1 to 4 prior operations. The mean age was 51.5 years. The duration of nonunion ranged from 9 months to 4 years. RESULTS: The mean time to union was 17 weeks (range, 8 to 26 weeks), and the mean duration of follow-up was 4 years (range, 6 months to 17 years). All but 2 patients had healing at the time of the latest follow-up. CONCLUSIONS: The identification of a viable option for the treatment of difficult nonunion in osteoporotic bones has been a challenge. The insertion of a free autologous intramedullary fibular strut graft provided mechanical stability, and osteogenesis occurred inside the medullary canal of the host bone. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.