Exchange intramedullary nailing combined with auxiliary plate versus dual plating for the treatment of aseptic femoral shaft nonunion: a single-center retrospective comparative cohort study of 77 cases

Femoral shaft nonunion severely impairs lower-limb function and quality of life, yet the optimal surgical strategy remains controversial. This study aimed to compare the clinical efficacy of exchange intramedullary nailing combined with an auxiliary plate versus dual plating in the treatment of aseptic femoral shaft nonunion, and to evaluate the differences between the two surgical procedures in terms of fracture healing, lower-limb functional recovery, and complications, so as to provide evidence for clinical decision-making. This retrospective study analyzed 77 patients with fracture nonunion who underwent revision surgery at our Level III trauma center between January 2019 and July 2024. The mean follow-up duration was 20.74 ± 9.49 months. Patients were divided into two groups according to the surgical procedure received. Group A (32 patients) underwent exchange intramedullary nailing combined with an auxiliary plate, while Group B (45 patients) received dual plating. Baseline data were collected and compared between the two groups, along with radiographic fracture healing outcomes (assessed dynamically using the modified Radiographic Union Scale for Tibial fractures (mRUST)at 3, 6, 9, and 12 months postoperatively), surgical parameters, and clinical outcomes. A total of 77 patients were enrolled in this study, including 32 in the auxiliary plate group and 45 in the dual plating group. Although the mean radiographic healing time in the exchange intramedullary nailing combined with auxiliary plate group was shorter than that in the dual plating group (9.16 ± 2.59 vs. 9.58 ± 2.44 months), the difference was not statistically significant. At the 3 and 6 month follow-ups, the exchange intramedullary nailing combined with auxiliary plate group demonstrated a trend toward better healing compared with the dual plating group (mRUST 5.53 ± 1.87 vs. 4.47 ± 1.31; 9.38 ± 1.93 vs. 7.73 ± 2.38, P < 0.05). At the 3 month follow-up, the exchange intramedullary nailing combined with auxiliary plate group showed significantly better early functional recovery than the dual plating group (50.16 ± 4.86 vs. 42.40 ± 2.66, P < 0.001). Both exchange intramedullary nailing combined with an auxiliary plate and dual plating with autologous iliac crest bone grafting can achieve satisfactory therapeutic outcomes for femoral shaft nonunion. However, compared with dual plating, exchange intramedullary nailing combined with an auxiliary plate demonstrated certain advantages in early radiographic healing and functional recovery, although the two groups showed comparable long-term functional outcomes and final union rates. Algorithm for internal fixation strategy selection