COMPLEX NONUNION OF FRACTURES OF THE FEMORAL

SHAFT TREATED BY WAVE-PLATE OSTEOSYNTHESIS

DAVID RING, JESSE B. JUPITER, RICHARD A. SANDERS, JAIME QUINTERO,
VINCENT M. SANTORO, REINHOLD GANZ, RENE K. MARTI

From Massachusetts General Hospital, Boston, USA

We have treated 42 consecutive complex ununited

fractures of the femoral shaft by wave-plate
osteosynthesis at five different medical centres. There
were 13 with previous infection, 12 with segmental
cortical defects, and 3 were pathological fractures. In 39
cases there had been previous internal fixation and 21
patients had had more than one earlier operation.
Union was achieved in 41 patients at an average of six
months, although three had required a second bone
graft. Two patients had recurrence of infection and in
one this resulted in the persistence of nonunion. There
were no failures of the implant. All 41 patients with
union are now fully weight-bearing, but four have a
leg-length discrepancy, one has axial malalignment, and
nine have residual stiffness of the knee. These results
are surprisingly good, despite the complexity of the
initial problem, and appear to confirm the biological
and mechanical advantages of the wave plate over the
conventional plate for such cases.
J Bone Joint Surg [Br] 1997;79-B:289-94.
Received 2 May 1996; Accepted after revision 17 September 1996

It is difficult to achieve union of an ununited fracture of the

femoral shaft or osteotomy when the intrinsic or extrinsic
blood supply has been damaged by infection or multiple
operations, or if bone has been lost or is abnormal. The
results of internal fixation with an intramedullary nail or a
conventional plate combined with autogenous corticocancellous or vascularised bone grafts or allografts are
1-8
unpredictable.
9
Blatter, Gasser and Weber first suggested the use of
wave-plate osteosynthesis. The wave plate has a contour
bent into its midportion so that it stands away from the
10
bone at the abnormal area. It is claimed to have both
biological and mechanical advantages. Its use preserves the
local blood supply by reducing the need for operative
dissection and the area of plate-bone contact. It also allows
autogenous bone grafts on the lateral cortex to share the
9-12
axial compressive loads with the plate more effectively.
We report a retrospective review of the use of the wave
plate in the treatment of complex, ununited fractures of the
femoral shaft in 42 consecutive patients.
PATIENTS AND METHODS

D. Ring, MD
Harvard Combined Orthopaedic Residency, ACC 527, 15 Parkman Street,
Boston, Massachusetts 02114, USA.
J. B. Jupiter, MD, Director of Hand Surgery, Department of Orthopaedics,
Massachusetts General Hospital, ACC 527, 15 Parkman Street, Boston,
Massachusetts 02114, USA.
R. A. Sanders, MD
Alabama Sports Medicine and Orthopaedic Centre, 1201 11th Avenue
South, Suite 200, Birmingham, Alabama 35205, USA.
J. Quintero, MD,
Centro Medico Almirante Colon, Carrera 16, No. 84A-09 [310], COBogota, Columbia.
V. M. Santoro, MD
Hartford Hospital, Hartford, Connecticut, USA.
R. Ganz, MD, Director of Orthopaedics
University Clinic, Inselspital, CH-3010 Berne, Switzerland.
, , MD, Director of Orthopaedics
Academisch Medisch Centre, Meibergdreef 9, 1105 AZ Amsterdam, The
Netherlands.
Correspondence should be sent to Dr J.B. Jupiter.
1997 British Editorial Society of Bone and Joint Surgery
0301-620X/97/26886 $2.00
VOL. 79-B, NO. 2, MARCH 1997

Between November 1985 and February 1992, 42 patients

with ununited fractures of the femoral shaft were treated by
a wave plate combined with bone grafting. This series
represents consecutive operations at five different medical
centres. The limited indications for this operation have
been discussed above; all ununited fractures of the femoral
shaft managed by conventional internal fixation and bone
grafting have been excluded.
The average age of the patients was 35 years (13 to 81);
29 were male and 13 female. The failure of union followed
an osteotomy in four patients, a leg-lengthening procedure
in two and a fracture in 36. Three of the fractures were
through abnormal bone: one through a metastasis of a
renal-cell carcinoma, one through a fibrosarcoma and one
at the site of old chronic osteomyelitis. The other 33
fractures were traumatic in origin; they were caused by a
fall in four patients, a motor-vehicle accident in 28 and a
motorcycle accident in one. Eight of the fractures were
open.
The initial treatment had included intramedullary fixation
in three of the four osteotomies and five of the fractures,
289

290

D. RING,

Fig. 1a

Fig. 1d

J. B. JUPITER,

R. A. SANDERS,

ET AL

Fig. 1b

Fig. 1e

Fig. 1c

Fig. 1f

Fig. 1g

A 75-year-old man sustained a fracture of his left proximal femur at the site of a metastasis from a renal-cell carcinoma. The initial fixation was by a
condylar blade plate. Methylmethacrylate cement was placed in the fracture site (a,b). Failure of union was treated by a second plating with an
intramedullary Rush rod, more cement and autogenous cancellous bone grafting (c), but one year later the second plate fractured and the fracture
remained ununited (d). Four years after wave-plate osteosynthesis anteroposterior and lateral radiographs show healing of the fracture (e,f), and this
remained intact at eight years (g).
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supplemented by a cerclage wire in one. The fourth osteotomy and the three fractures through abnormal bone had
been fixed by a plate and screws. Methylmethacrylate had
been used to fill the metastatic lesion and in the other two
cases with abnormal bone autogenous cancellous bone
from the iliac crest was used. Of the remaining fractures, 24
had been treated by a plate and screws, one by pins
incorporated into a plaster cast, two in skeletal traction, and
one in a hip spica.
The average duration of nonunion before the wave-plate
osteosynthesis was 17 months (6 to 86). One or more
secondary operations had been performed in 21 patients
(mean 2; range 1 to 6) (Fig. 1 and Table I). There were
segmental cortical defects in 12 patients with an average
bony defect of 4 cm (1 to 8).
In 13 patients, there had been infection either after the

initial operation or a secondary procedure. The organism

responsible was Staphylococcus aureus in five with Klebsiella pneumoniae as a second organism in one, Staphylococcus epidermidis in five, Klebsiella pneumoniae alone
and Pseudomonas aeruginosa in one patient each. In the
patient with a history of chronic osteomyelitis, Staphylococcus aureus had been isolated from the original infection.
Before the wave-plate procedure in this patient, infection
had been treated by operations for debridement and culture
of the organism to enable specific parenteral antibiotics to
be used. No fracture was actively discharging at the time of
the wave-plate operation. Details of the patients are given
in Table I.
Operative technique. The ununited fracture was stabilised
by a wave plate and screws and then grafted with autogenous corticocancellous bone from the iliac crest. In four

Table I. Details and results of treatment in 42 patients

Gender

Duration of
nonunion
Previous
(mth)
operations

Previous
infection

Follow-up
(mth)

38
20
22
36
26

M
M
M
F
F

12
12
18
11
60

3
5
4
3
7

Yes
Yes
Yes
Yes
Yes

66
36
24
27
60

6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

26
60
58
48
16
13
75
41
20
15
70
27
42
81
64

M
M
M
F
F
M
M
M
F
M
M
M
M
M
M

15
6
86
19
20
8
48
6
41
12
12
62
12
6
24

2
2
2
1
2
1
2
1
4
1
3
4
1
1
2

21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42

25
32
30
29
28
23
60
24
40
14
26
28
37
40
63
15
52
40
20
18
20
28

M
F
F
M
M
F
M
M
F
M
F
M
M
F
F
F
M
M
M
M
M
M

8
12
15
14
6
6
12
6
8
6
15
14
6
12
15
12
18
15
20
6
12
6

3
1
4
0
1
1
1
1
2
1
1
2
2
1
1
1
2
2
1
0
1
0

Age
(yr)

1
2
3
4
5

Case

Yes

Yes
Yes
Yes
Yes

Yes
Yes

Yes

29
44
52
35
37
20
60
15
60
12
12
60
24
24
44
12
66
19
12
12
18
36
52
53
18
12
12
56
61
17
36
13
13
24
37
25
51

Result*
ROM 0 to 90
ROM 0 to 110
2 cm LLD, ROM 0 to 60
ROM 0 to 90
Amputation for fungal
infection 2 years postoperatively

ROM -10 to 140

ROM -10 to 140

ROM 0 to 90
Infected nonunion. Refused
further operation
1 cm LLD

2.5 cm LLD, ROM 0 to 110

ROM 0 to 90
ROM 0 to 90
2.5 cm LLD, FROM

ROM 0 to 90

* unless stated otherwise, patients were fully weight-bearing, had equal leg length (LL) and a full range of knee
movement (ROM; degrees)
VOL. 79-B, NO. 2, MARCH 1997

291

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D. RING,

J. B. JUPITER,

patients with large bony defects (mean 7.5 cm) a vascularised fibular graft was also used. In one patient allograft
bone was used to supplement the autogenous graft.
Preoperative planning included the use of an overlay
technique using radiographs of the uninvolved side to
determine the ideal bony alignment and the length, size and
contour of the plate. At operation, the exposure was limited
to the portion of the bone on which the plate would lie. An
AO/ASIF femoral distractor (Synthes Ltd, Paoli, Pennsylvania) was applied and used to correct the length and
alignment of the femur without direct exposure or manipulation of the abnormal area. This technique reduced the
need for stripping and devitalising soft tissue.
The AO/ASIF compression plate (Synthes Ltd, Paoli,
Pennsylvania) was contoured using a plate-bending device
to provide three or four gently sloping bends to lift the
midportion of the plate 0.5 to 1.0 cm away from the bone in
the region of the nonunion. The bends were placed in order
to avoid direct contact with bone within the distance of one
screw hole both proximally and distally from the abnormal
area. The length of the plate was chosen so that at least
three screws could be placed both proximally and distally.
More were used if the underlying bone was seen to be
osteoporotic. We used a 4.5 mm broad dynamic compression plate in 35 patients with an average length of 14 holes
(10 to 21). Three patients had condylar blade plates, two
with 12 holes and one with 20 holes. Two had dynamic
condylar screw-plates 14 holes in length, one had a 16-hole
condylar buttress plate and one a 13-hole limited contact
4.5 mm dynamic compression plate (Synthes Ltd, Paoli,
Pennsylvania). Corticocancellous bone graft from the iliac
crest was placed between the plate and the bone across the
abnormal area (Fig. 2).
Postoperative management included exercises for the hip
and knee, starting on the second or third day. Union was
judged clinically by the absence of pain on weight-bearing
and on radiographs by evidence of incorporation of bone
graft at the site of nonunion and cortical changes in the
cancellous graft. Weight-bearing on the operated leg was
limited until radiographs showed evidence of union. A
progressive increase in weight-bearing was then allowed.
All patients were reviewed at regular intervals with serial
radiographs and clinical examination. At final follow-up,
the capacity to bear weight, any leg-length discrepancy,
alignment and the range of movement in the joints of the
leg were noted.
RESULTS
The mean follow-up was 33 months (12 to 66) (Table I).
The nonunion had healed in 41 patients at an average of 6
months (3 to 18).
Two patients with previous infection had recurrence. One
of the fractures failed to unite; the other healed, but developed a draining fistula. Another patient with persistent
nonunion had a second bone-grafting procedure 12 months

R. A. SANDERS,

ET AL

after the insertion of a wave plate and the fracture had

united by 18 months. Two of the four patients in whom a
large bony defect had been treated with a vascularised
fibular graft required an additional grafting procedure
before union.
All 41 patients in whom union had been achieved were
able to bear full weight without pain at the latest followup (Table I). There was a leg-length discrepancy in four
patients, with an average shortening of 2 cm (1 to 2.5).
One patient healed with 16 varus angulation. All patients
had full mobility at the hip and ankle, and 31 regained
full movement at the knee. Seven had residual limitation
of knee flexion and two lacked 10 of extension. One
patient with severe limitation of knee flexion required
quadriceps lengthening, which gave a range of 1 to 60
at the latest follow-up. One patient had residual knee
instability.
One patient whose fracture had healed and who had
resumed full weight-bearing had a fungaemia during the
treatment of an autoimmune disorder with immunosuppresive drugs two years after the wave-plate procedure. This
led to catastrophic infection and amputation was necessary
two years later.
DISCUSSION
A wave-plate osteosynthesis combines a number of features
13-17
It emphasises preservation of
of biological plating.
the residual blood supply to the bone and surrounding soft
tissues. Bone healing is enhanced beneath the plate both by
11
the graft and by a better mechanical environment.
The use of wide exposures for injuries or reconstructive
surgery of the femoral shaft has decreased because of
problems inherent in the manipulation of the skeletal frag18
ments at operation and the development of versatile
intramedullary nails which can be inserted with minimal
19-23
exposure.
Our series was treated using indirect bony
reduction. Axial realignment and bone lengthening were
achieved by the use of a femoral distractor applied to the
femoral shaft proximal and distal to the ununited
8,13,15
The Schantz screws used to attach the disregion.
tractor to the bone were inserted in the plane of the
deformity, either through the wound or percutaneously.
This enabled realignment without the use of bone clamps or
retractors which would threaten the circulation at the site of
application.
This emphasis on the preservation of the blood supply is
of fundamental importance for the reincorporation of iliaccrest bone graft, placed between the plate and the bony
defect.
On the femoral shaft, a plate provides the best stabilisation when it is applied as a tension band on the lateral
aspect. The bone itself then absorbs the axial compressive
24-26
Plates are weakest in bending and torsion and
forces.
will fatigue and ultimately fail if they are cyclically loaded
24,27
in these modes.
In the presence of medial or segmental
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COMPLEX NONUNION OF FRACTURES OF THE FEMORAL SHAFT TREATED BY WAVE-PLATE OSTEOSYNTHESIS

Fig. 2a

Fig. 2e

Fig. 2b

Fig. 2f

Fig. 2c

Fig. 2g

Fig. 2d

Fig. 2h

A 16-year-old woman sustained a pathological fracture of her femur through a fibrosarcoma which was successfully treated by resection,
radiation and chemotherapy. The initial plate fixation with autogenous cancellous bone graft failed to heal and the plate fractured (a,b).
A second plate and graft also failed (c,d). Two years after wave-plate osteosynthesis, the fracture had united (e,f) and remained
satisfactory at seven years (g,h).
VOL. 79-B, NO. 2, MARCH 1997

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D. RING,

J. B. JUPITER,

bony defects, as in our series, a conventional plate is

subjected to a local concentration of bending forces which
28
may induce failure; the contouring of a plate into a wave
form enhances its mechanical role. The bends in the plate
could have an adverse effect by increasing the moment
14,25,26
arm,
but an intact or reconstituted lateral cortex will
support the compressive forces on the femur and allow the
9,11
plate to function as a lateral tension band.
A complete segmental bony defect will allow the plate to
be subject to cyclical bending loads until the bone graft has
consolidated, but the long contour of the bent section may
be less likely to fail than a conventional plate because
cyclical loading is distributed over a wide area rather than
at a local fulcrum. Biomechanical tests have shown that the
wave plate tended to fail at a remote screw hole rather than
9
at the axis of the bending moment.
The use of a more flexible section of plate deviates from
the theoretical goal of inherent stability of a plate-bone
29
construct. This theory was based on the principles of
direct bony apposition, prevention of movement at the
fracture or nonunion and axial compression, often enhanced
24
by interfragmentary screw fixation. The aim was the socalled primary bone healing. The flexibility of the waveplate configuration is intended to transfer load to healing
26,27
bone and thereby enhance callus formation.
Decreasing
stiffness of plates has been shown to promote more vigor30
ous callus formation in a rabbit model.
Our results have shown that wave-plate osteosynthesis
for complicated nonunion of the femoral shaft gives a high
rate of eventual union with no failures of the implant.
Complications were few and the functional results were
generally good. The success of the wave plate derives from
both biological and mechanical advantages over conventional plate fixation.
No benefits in any form have been received or will be received from a
commercial party related directly or indirectly to the subject of this
article.
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THE JOURNAL OF BONE AND JOINT SURGERY