International Orthopaedics

, Volume 42, Issue 11, pp 2675–2683 | Cite as

Healing, nonunion, and re-operation after internal fixation of diaphyseal and distal femoral fractures: a systematic review and meta-analysis

  • Riikka E. Koso
  • Cristina Terhoeve
  • R. Grant SteenEmail author
  • Robert Zura
Original Paper



Nonunion is a highly morbid complication that exacerbates the pain, disability and financial burden of distal and diaphyseal femur fractures. This study examined the modern rates of healing, nonunion, and other complications requiring reoperation of different fixation methods for distal and diaphyseal femur fractures.


A systematic review and meta-analysis of all records from PubMed, Embase and the Cochrane Review system was performed. Included studies had >20 acute, non-pathologic distal or diaphyseal femur fractures treated with primary internal fixation. Excluded were studies on abnormal patient/fracture populations, external fixation, or cement/bone graft use.


Thirty-eight studies with 2,829 femoral shaft fractures and 11 studies with 505 distal femur fractures were included. Distal fractures had a lower healing rate (86.6% vs. 93.7%) and a higher re-operation rate (13.4% vs 6.1%) than shaft fractures (p < 0.00001), primarily due to higher rates of mechanical failure (p < 0.00001). Nonunion was the most frequent complication, occurring in 4.7% of distal fractures and 2.8% of shaft fractures. There was no difference between plate and nail fixation of distal fractures in healing, nonunion, or other causes of re-operation. Shaft fractures developed nonunion in 6.6% of unreamed nails and 2.1% of reamed nails (p = 0.002). Nonunion occurred in 2.3% of antegrade nailed fractures and 1.5% of retrograde nailed fractures (p = 0.66).


Approximately one out of every eight distal fractures and one of every 16 shaft fractures requires re-operation. The most common cause of fixation failure is nonunion. Further research is needed to improve outcomes, particularly in distal femur fractures.


Femoral shaft fracture Mechanical failure Plate fixation Unreamed nail Reamed nail 


Compliance with ethical standards

Conflict of interest

The authors declare they have no conflict of interest. There was no funding source for this study. This article does not contain any studies with human participants or animals performed by any of the authors. This study was IRB exempt; informed consent from individual participants was not applicable to study methods.

Supplementary material

264_2018_3864_MOESM1_ESM.docx (20 kb)
ESM 1 (DOCX 20 kb)


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Copyright information

© SICOT aisbl 2018

Authors and Affiliations

  • Riikka E. Koso
    • 1
  • Cristina Terhoeve
    • 2
  • R. Grant Steen
    • 2
    Email author
  • Robert Zura
    • 2
    • 3
  1. 1.UT Health San AntonioSan AntonioUSA
  2. 2.Louisiana State University Health Sciences CenterNew OrleansUSA
  3. 3.Bioventus LLCDurhamUSA

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