Tibial Non Unions - Wheeless' Textbook of Orthopaedics

- Discussion:
    - non union general discussion
    - frx healing discussion
- definition: no evidence of healing over 3 months;
- FDA definition: frx that is over 9 months old and that has not shown radiographic signs of progression toward healing for 3 consecutive months;
   - final stage of a nonunited fracture is formation of pseudoarthrosis;
    - prognostic signs
- high velocity, open frx w/ skin & bone loss & 100% displacement are at risk for non union;
- more common w/ infection, distraction, or inability to bear weight;
- motion at the fracture site;
- clinically there is pain at the fracture site
- radiographically, there is an absence of bridging callus & persistence of the fracture lines;
    - factors involved in fracture healing:
           - fracture stability
           - fracture gap
           - tibial frx vascular supply;  ( ref: Delayed unions and nonunions of open tibial fractures. Correlation with arteriography results.)
           - smoking:
         - Nicotine on the revascularization of bone graft. An experimental study in rabbits.
       - Effects of nicotine on cellular function in UMR 106-01 osteoblast-like cells.
           - Effect of smoking on tibial shaft fracture healing.
       - Deleterious effect of smoking on healing of open tibia-shaft fractures.
       - Impact of smoking on fracture healing and risk of complications in limb-threatening open tibia fractures.

- Non Operative Treatment:
- wt bearing should be begun with in 6 weeks of injury;
- w/ suspected delayed union in a non-wt bearing patient, wt bearing should be begun in a LLC

- Operative Treatment:
- pre-operative planning:
- generally, operative intervention is warrented if there are no radiographic signs of healing by 3-5 months;
- classify the non union:
- interaction between fracture pattern, previous fixation, blood supply to tibia, soft tissue, infection, and host factors;
- treatment will partly depend on the shape of the bone ends;
- infected non union
- it is essential that prior to any attempt at operative treatment of a non-union, that it is first established that an infected non unions is not present;
- an infected delayed union requires débridement, soft-tissue coverage, bone stabilization and bone-grafting;
- atrophic non union
- characterized by a deficient biologic process;
- oligotrophic:
- hypertrophic union;
- characterized by abundant callus but insufficient mechanical stability for completion of fracture-healing;
- note that even apparent hypertrophic nonunions (on x-ray) may have relative avascularity;
- radiographs:
- right and left oblique radiographs (in addition to AP and lateral views) help define plane of the fracture,
and help show faint calus formation (which may be visible on only on one view);

- bone grafting for tibial fracture:
- bone morphogenic proteins
- references:
- Distal metaphyseal tibial nonunion. Deformity and bone loss treated by open reduction, internal fixation, and human bone morphogenetic protein (hBMP).
- posterolateral bone grafting:
- papineau technique: (historical technique)
- references:
- Central grafting for persistent nonunion of the tibia. A lateral approach to the tibia, creating a central compartment.
- Treatment of infected non-unions and segmental defects of the tibia with staged microvascular muscle transplantation and bone-grafting.
- Treatment of tibial defects and nonunions using ipsilateral vascularized fibular transposition.

- fixation methods:
- circular wire fixators:
- references:
- Ilizarov treatment of tibial nonunions with bone loss.
- Ilizarov external fixator: acute shortening and lengthening versus bone transport in the management of tibial non-unions.
- plating techniques:
- references:
- Indirect reduction and tension-band plating of tibial non-union with deformity.
- Compression plating for non-union after failed external fixation of open tibial fractures.
- Indirect reduction and tension-band plating of tibial non-union with deformity.
- intramedullary nails for tibial fracture: (see tibial reaming);
- note that reaming should often be performed open (thru frx site) inorder to verify that the reamer is not passing eccentrically through cortical surface;
- in the study by CC Wu et al (JTO 1999) exchange nailing was performed closed (w/o opening frx site);
- these authors do not advise open bone grafting as long as a segmental bone defect is not present;
- expect 5-9 months before complete fracture union;
- always send IM marrow contents for culture to rule out occult infection;
- cautions:
- treating an infected or previously infected tibial delayed union with reamed tibial nailing is associated with a high risk of infection;
- reaming followed by exchange IM nailing should never be performed for an infected tibial non union;
- in this case, reaming will only theoretically debride the infection site, and therefore, there is little to guarantee that infection will not re-occur;
- non the less, in cases of non infected non union, reaming followed by IM nailing may stimulate frx healing;
- references:
- Locked nailing for nonunion of the tibia.
- The treatment of nonunion of proximal tibial osteotomy with internal fixation.
- Intramedullary nailing with reaming to treat non-union of the tibia.
- Intramedullary nailing of tibial nonunions.
- Nonunion of Tibial Shaft Fractures Treated With Locked Intramedullary Nailing Without Bone Grafting.
- Exchange reamed intramedullary nailing for delayed union and nonunion of the tibia.
- Treatment of tibial malunions and nonunions with reamed intramedullary nails.
- High success rate with exchange nailing to treat a tibial shaft aseptic nonunion. CC Wu et al. JOT. Vol 13. No 1. p 33-38.
- Nonunions of the Distal Tibia Treated by Reamed Intramedullary Nailing.
- Infected non-union of the tibial shaft treated by Kuntscher intramedullary reaming and n ail fixation. A report of four cases.
- Treatment of infected nonunion and delayed union of tibia fractures with locking intramedullary nails.
- The treatment of noninfected pseudarthrosis of the femur and tibia with locked intramedullary nailing.
- Treatment of failures after plating of tibial fractures.
- High success rate with exchange nailing to treat a tibial shaft aseptic nonunion.
- Exchange intramedullary nailing. Its use in aseptic tibial nonunion.
- Treatment of femoral and tibial diaphyseal nonunions using reamed intramedullary nailing without bone graft.

- technique pearls:
- compression of a non union w/ shortening of > 2 cm, may cause excess folding of soft tissues, vessels, and nerves;
- fibula intact:
- if the fibula is intact or has healed, resection of 1 inch of fibula may improve loading of the fracture site and stimulate union;
- some authors reserve fibulectomy for cases in which gross angulatory deformity is present which requires frx re-alignment;

- Case Example:
- 30 year old male who sustained a tibial fracture which was treated with two different external fixators
and two separate autogenous bone grafting procedures, none of which resulted in union;
- he was treated with a reamed IM nail along w/ additional bone graft;
- due to the sclerotic nature of the non union, the medullary canal was exposed and curretted free of fibrous tissue and sclerotic bone;

An alternative method for the treatment of nonunion of the tibia with bone loss.

Use of locking compression plates for long bone nonunions without removing existing intramedullary nail: review of literature and our experience.