Systematic review of dynamization vs exchange nailing for delayed/non-union femoral fractures

Table 1 Overall outcomes of surgeries studied

Surgical procedure	Surgical subtype	No. of articles reporting on secondary procedure (patient number)	Average union %	Average reported time to union
Dynamization	All	7 (131)	66.412b	4.769 ± 1.986 mo (26 pts)a
Exchange nailing	All	26 (644)	84.785b	5.193 ± 2.310 mo (372 pts)a
Exchange nailing	Static locking	15 (235 pts)	84.259	5.149 ± 2.366 mo (103 pts)
Exchange nailing	Dynamic locking	13 (211 pts)	82.381	5.208 ± 2.475 mo (84 pts)

^bP < 0.0001, significant;

^aP = 0.3622, not significant.

Table 2 Overall demographics of patients involved in studies

	Exchange nailing		Dynamization		EN vs dynam
	Union/total reported	Significant vs total union rate	Union/total reported	Significant vs total union rate	P-values
No. of patients	556/644	-	84/131	-	P < 0.0001
Ages
Mean	38.002	-	32.234	-	-
Gender
Male	244/284	NS	37/66	NS	P < 0.0001
Female	72/86	NS	17/26	NS	NS
Tobacco use
Yes	54/74	P = 0.0023	2/3	NS	NS
No	49/62	NS	0/3	P = 0.0500	P = 0.0128
NSAIDs use
Yes	4/8	P = 0.0166	0/0	-	-
No	38/52	P = 0.0093	2/6	NS	P = 0.0463
Diabetic
Yes	0/0	-	0/0	-	-
No	10/19	P = 0.0006	0/0	-	-
IDDM (type 1)	0/0	-	0/0	-	-

NS: Not significant; NSAID: Nonsteroidal antiinflammatory drug; IDDM: Insulin-dependent diabetes mellitus.

Table 3 Fracture information of patients involved throughout studies

	Exchange nailing		Dynamization		EN vs dynam
	Union/total reported	Significant vs total union rate	Union/total reported	Significant vs total union rate	P-values
No. of patients	556/644	-	84/131	-	P < 0.0001
Mechanism of injury
Crush	2/2	NS	0/0	-	-
Gun shot wound	2/2	NS	0/0	-	-
Motorcycle Accident	27/35	NS	0/0	-	-
Pedestrain/bike vs motor vehicle	2/6	P = 0.0045	0/0	-	-
Motor vehicle accident	146/163	NS	14/24	NS	P = 0.0004
Fall	1/5	P = 0.0017	0/0	-	-
Sporting accident	1/1	NS	0/0	-	-
Industrial accident	2/3	NS	0/0	-	-
Non-traumatic	0/0	-	0/0	-	-
Bombing injury	0/0	-	0/0	-	-
Location of injury
Proximal shaft	26/30	NS	2/3	NS	NS
Mid-shaft/isthmal	139/154	NS	32/51	NS	P < 0.0001
Distal shaft	38/43	NS	1/3	NS	NS
Supra-isthmal	10/16	P = 0.0172	1/1	NS	NS
Sub-trochanteric	4/4	NS	2/3	NS	NS
Infra-isthmal	5/9	P = 0.0265	0/0	-	-
Fracture pattern
Oblique	21/21	NS	0/0	NS	-
Segmental	0/0	-	2/5	NS	-
Transverse	14/14	NS	0/0	NS	-
Commimuted	19/21	NS	17/30	NS	P = 0.0219
Open vs closed
Closed	133/162	NS	14/24	NS	P < 0.0001
Opened	25/32	NS	0/0	-	-
I	1/2	NS	0/0	-	-
II	2/4	NS	0/0	-	-
IIIA	1/2	NS	0/0	-	-
IIIB/C	1/1	NS	0/0	-	-
Winquist-Hansen classification
Stable	41/64	P < 0.0001	20/29	NS	NS
O	7/13	P = 0.0054	0/0	-	-
I	18/23	NS	12/17	NS	NS
II	16/27	P = 0.0007	6/9	NS	NS
Unstable	14/23	P = 0.0028	22/36	NS	NS
III	11/17	P = 0.0234	6/9	NS	NS
IV	3/6	P = 0.0387	2/2	NS	NS
V	0/0	-	2/2	NS	-
Presence of fracture graph
Present	0/0	-	29/44	NS	-
No gap	0/0	-	1/1	NS	-

NS: Not significant.

Table 4 Nonunion/delayed union information including secondary surgery information

	Exchange nailing		Dynamization		EN vs dynam
	Union/total reported	Significant vs total union rate	Union/total reported	Significant vs total union rate	P-values
No. of patients	556/644	-	84/131	-	P < 0.0001
Reamed vs unreamed
Reamed	516/598	NS	NA	-	-
Unreamed	19/22	NS	NA	-	-
Static vs dynamic
Dynamic	97/115	NS	NA	-	-
Static	173/210	NS	NA	-	-
No locking (/Kuntschner)	35/36	NS	NA	-	-
Delayed union	25/27	NS	45/55	P = 0.0228	P = 0.3199
Nonunion (+type)	491/567	NS	24/57	P = 0.0063	P < 0.0001
Elephant	6/7	NS	0/0	-	-
Horse	12/18	P = 0.0310	0/0	-	-
Oligotrophic	22/22	NS	16/22	NS	P = 0.0211
Hypotrophic	9/13	NS	0/0	-	-
Atrophic	80/99	NS	5/12	NS	P = 0.0064
Hypertrophic	72/83	NS	9/11	NS	NS
Bone grafting used
Yes	98/106	NS	2/2	NS	NS
No	165/190	NS	32/53	NS	P < 0.0001
Infected	19/30	P = 0.0019	0/0	-	-
Patients lost to follow-up	28	-	4	-	-
Major complications following surgery	45	-	13	-	NS
Patients achieving union after additional surgery vs surgeries attempted	82/92	-	34/34	-	-

NA: Not available; NS: Not significant.

Table 5 Union rates of each peer-reviewed article by procedure type

PMID	Procedure(s) analyzed	Union rate (%)
21726859	Dynamization	33.333
9462352	Dynamization	41.667
8370009	Dynamization	45.455
9291371	Dynamization	58.33
22841533	Dynamization	71.795
12142827	Dynamization	78.947
10088839	Dynamization	90
20101132	Exchange nailing	28.571
10926240	Exchange nailing	55.56
12719163	Exchange nailing	57.895
24978947	Exchange nailing	69.444
6488644	Exchange nailing	75
26489394	Exchange nailing	75.676
22327999	Exchange nailing	78.049
10791668	Exchange nailing	78.26
1738973	Exchange nailing	81.25
25300373	Exchange nailing	81.966
19897987	Exchange nailing	85.714
22338431	Exchange nailing	90.698
18579143	Exchange nailing	90.909
12142827	Exchange nailing	90.909
12479620	Exchange nailing	91.667
18090018	Exchange nailing	91.892
10476292	Exchange nailing	96
4707299	Exchange nailing	100
10088839	Exchange nailing	100
20820792	Exchange nailing	100
Kim JR1	Exchange nailing	100
9253919	Exchange nailing	100
10513972	Exchange nailing	100
1126078	Exchange nailing	100
7965294	Exchange nailing	100
22009873	Exchange nailing	100

¹No accessible PMID[36].