Tongue and groove (v-shaped) osteotomy in treatment of non-union of long bones--a novel surgical technique.

BACKGROUND

To treat long-bone non-unions it is important to create a stable mechanical environment in which fracture healing can take place securely. Interfaces such as transverse or step-cut osteotomy can still be improved. The method of tongue and groove osteotomy (Figure 1) described here is a viable option in difficult non-union surgery.

Figure 1

Tongue and groove osteotomy

METHODS

Four patients treated for non-union of humerus (closed injury) and one for non-union of femur fracture (open injury leading to below-knee amputation) were followed up for 5 years (2003–2008).

After the fracture site was exposed and freshened, a 45-degree (Figure 1) tongue-shaped tower end was created at the proximal end of the distal fragment using an oscillating saw (Figure 2). On the distal part of the proximal end a corresponding ‘groove’ was made. Dynamic compression plating for humerus and intramedullary nailing for femur was used (Figures 3 and 4) with appropriate early postoperative mobilisation.

Figure 2

Intraoperative picture showing creation of tongue in groove (black arrow: tongue; white arrow: groove)

Figure 3

Pre and post-operative images with evidence of healing - humeral non-union

Figure 4

Pre and post-operative images with evidence of healing - femoral non-union

DISCUSSION

Humeral non-unions united between four and six months and the femoral non-union united in six months. Radiological signs of union were achieved earlier in each case than clinical union. Long-term follow-up showed satisfactory result in all cases.

In a study conducted with frozen porcine femur model it was observed that v-shaped osteotomy with a docking angle between 45 and 90 degrees can withstand a strong compression load. The tongue-and-groove osteotomy in long-bone non-union surgery is better than step cut osteotomy because of increased contact surface area, improved rotational stability, and easy reproducibility. Clinical results of similar surgical procedures are unavailable in the published English literature.