Double plate fixation technique for prolonged non-weight baring induced severe disuse atrophy in hypertrophic non-union of left femur: a case report

Cokorda Gde Oka Dharmayuda, Cokorda Krishna Dalem Pemayun, I. Ketut Wahyu Trisaputra, Richard Afandi, Sri Mahadhana, Made Winatra Satya Putra, I. Gusti Ngurah Indra Wiguna


Hypertrophic non-union differs from other forms of non-union due to its the biological capacity for union, in which it results from mechanical instability, namely the implant being unable to provide long lasting stability. Non-weight bearing state will cause bone resorption and further bone-mass loss with worsened prognosis. A 64-year-old female patient presented with inability to walk normally resulting from prolonged non-weight bearing-induced severe disuse atrophy in hypertrophic non-union of the left femur. Implant revision and osteoclasis were performed, followed by an urgent implant revision a few days later using double plating technique by placing the second plate on the anterior part of the femur. Post-operative X-ray showed satisfactory two implants placement and physiological alignment was achieved. Inappropriate initial treatment on the acute phase has led to prolonged non weight bearing state, resulting in disuse atrophy of the bone. This should have been predicted during the first implant revision on drilling both cortices, since even the slightest distraction resulted in severe consequences. Double plating system leads to absolute stability so acceptable union can be achieved. Initial treatment on acute setting of fracture should maximize every effort to restore proper functional state and should promote early mobilization. Any maltreatment will result in prolonged morbidity and will require more reconstruction effort with less than normal end result. Robust fixation and alignment can be achieved with double plating system; however, prolonged immobilization should be anticipated.


Disuse atrophy, Double plate fixation, Hypertrophic non-union, Prolonged non-weight bearing

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Lynch JR, Taitsman LA, Barei DP, Nork SE. Femoral Nonunion: Risk Factors and Treatment Options. J Am Acad Orthop Surg. 2008;16:88–97.

Somford MP, Kloen P, van den Bekerom MPJ. Operative treatment for femoral shaft nonunions, a systematic review of the literature. Strateg Trauma Limb Reconstr 2013;8:77–88.

Oryan A, Monazzah S, Bigham-sadegh A. Bone Injury and Fracture Healing Biology Bone Injury and Fracture Healing Biology. Epub ahead of print 2015. DOI: 10.3967/bes2015.006.

Uzun M, Çakar M, Bülbül AM, Kara A. Treatment of Aseptic Hypertrophic Nonunion of the Lower Extremity with Less Invasive Stabilization System (New Approach to Hypertrophic Nonunion Treatment of Aseptic Hypertrophic Nonunion of the Lower Extremity with Less Invasive Stabilization System N. Epub ahead of print 2016. DOI: 10.1155/2015/631254.

Ma Y-G, Hu G-L, Hu W, Liang F. Surgical factors contributing to nonunion in femoral shaft fracture following intramedullary nailing. Chinese J Traumatol. 2016;19:109–12.

Sk S. Fracture Non-Union: A Review of Clinical Challenges and Future Research Needs. 2019;13:1–10.

Partridge NC, Remodeling B. REVIEWS Physiological Bone Remodeling: Systemic Regulation and Growth Factor Involvement. 2021: 233–245.

Alexandre C, Alexandre C, Vico L. Pathophysiology of bone loss in disuse osteoporosis Pathophysiology of bone loss in disuse osteoporosis. Jt Bone Spine. 2011;78:572–6.

Elbarbary AN, Hassen S, Badr IT. Outcome of intramedullary nail for fixation of osteoporotic femoral shaft fractures in the elderly above 60. Injury. 2021;52:602–5.

Imam MA, Torieh A, Matthana A. Double plating of intra-articular multifragmentary C3-type distal femoral fractures through the anterior approach. Eur J Orthop Surg Traumatol. 2018;28:121-30.