Management Of Nonunion Research Articles

Use of locked plates and mono-rail fixator in segmental tibial defects: A prospective interventional study

IntroductionThe management of gap non-union is a major challenge to both the clinician and the patient as it is technically difficult, time-intensive, and physically arduous for the patient along with an unpredictable result. Gap non-union can arise from extrusion of bony fragment at the time of trauma or after debridement of unhealthy bone later. Moreover, Tibia because of its subcutaneous anatomy can easily undergo bone-loss and segmental defect. Among various methods available for managing gap non-union of tibia distraction osteogenesis using either ilizarov fixator or mono-rail fixator is the most popular one. Here we present functional and bony outcomes of combined use of locking plate and Limb Reconstruction System (LRS) in tibial gap non-union and assess whether it decreases fixator time and related complications. Patients and methodsA prospective intervention study constituting 10 patients with Paley's type B1 tibial gap non-union over a period of 22months. In first stage, debridement was done; tibial locking plate and mono-rail fixator were applied along with corticomy at proximal tibia. Distraction was started 7–14 days later. At the end of distraction phase, fixator was removed and transported segment was fixed with screws with or without bone grafting at docking site. Patients were followed up every 6 weeks for radiological and clinical assessment. Functional assessment using Application for the Study and Application of the Method of Ilizarov (ASAMI) functional score, and Musculoskeletal Tumour Society (MSTS) functional score while bone outcome was assessed with ASAMI bone score. Quality of regenerate was assessed by Fernandez-Esteve grading. Detailed scoring was done at the time of index surgery, at the time of LRS removal and at the time of consolidation phase. ResultsAll the 10 patients were male with mean age of 33 years. The mean defect size was 4.94 cm after debridement. Minimum duration of follow up was 30 weeks after removal of LRS. Mean duration between trauma and inclusion in the study was 17.7 months. The median external fixator index was 15.63 days/cm. The complication rate was 1.3/patient. According to Paley's classification, there were eleven problems and two obstacles, and no true complications. Both ASAMI bone score and functional scores were excellent in three and good in six patients. The median MSTS composite score was 76.66%. ConclusionThe integrated fixation is an effective and satisfactory method enabling early external fixator removal with low rate of complication. So, this technique can be recommended for the management of segmental tibial defects. Level of evidenceII.

Results of Antibiotic-Impregnated Cement/Polymer-Coated Intramedullary Nails in the Management of Infected Nonunion and Open Fractures of Long Bones.

Background Fractures of long bones can sometimes lead to complications such as infection or nonunion, resulting in significant patient morbidity. Surgical intervention and antibiotics are often necessary to treat these complications. Antibiotic-impregnated cement/polymer-coated intramedullary nails have emerged as an effective surgical treatment for infected nonunion and open fractures. These implants elude high concentrations of antibiotics at the infection site while stabilizing the fracture. Extensive research has shown promising results, with success rates ranging from 60% to 100%. Benefits of these implants include stable fracture fixation, early weight-bearing, and reduced need for prolonged antibiotic therapy. However, concerns remain regarding antibiotic resistance and potential toxicity. This study aims to evaluate the efficacy and safety of these implants in managing infected nonunion and open fractures of the femur and tibia. Methods This prospective hospital-based study aimed to assess the efficacy and safety of antibiotic-impregnated cement/polymer-coated intramedullary nails for managing infected nonunion and open fractures of the femur and tibia. The study included patients aged 18 or older who received treatment with these implants between January 1, 2021 and December 31, 2022. Patients allergic to vancomycin or teicoplanin, with gap nonunion >2 cm, or lost to follow-up were excluded. Data on demographics, fracture details, previous treatment, surgery, antibiotics, and outcomes were collected using a structured proforma. Surgeries involved implant removal, debridement, culture testing, reaming, fracture reduction, and stabilization with an antibiotic-impregnated cement/polymer-coated intramedullary nail. Postoperatively, patients received antibiotics, had wound inspections, and were gradually allowed weight-bearing. Follow-up appointments and radiographic/laboratory assessments were conducted at regular intervals. The primary outcome was successful bone union, and secondary outcomes included time to union, infection rate, nonunion rate, and revision surgery. Results The majority of participants were male, with a mean age of 39.76 years. Most fractures were Gustilo-Anderson grade 3 (46.7%) and involved the tibia (73.3%). The mean bone gap after debridement was 1.3 cm. The median follow-up period was 8.21 months. Infection was controlled in 93.3% of patients, with the tibia being the most common site (70.0%). Successful bone union was achieved in 90.0% of patients, with a mean union rate of 22.13 weeks for tibial fractures and 17.21 weeks for femoral fractures. Among patients with bone union, 60.0% did not require additional procedures. Most patients had excellent bony (76.7%) and functional (70.0%) outcomes. The most common complications were the persistence of bone nonunion, impingement of proximal nail, and debonding of nail cement, each occurring in 10.0% of patients. Conclusion The study concluded that antibiotic-impregnated cement/polymer-coated intramedullary nails are effective in managing infected nonunion and open fractures of the femur and tibia. The procedure demonstrated a high success rate in controlling infections (93.3%) and achieving bone union (90.0%). Paley's criteria showed excellent bony and functional outcomes in the majority of patients. These findings support the use of this treatment option for such fractures.

The use of 3D printing technology in limb reconstruction. Inspirations and challenges

The management of septic non-unions with associated bone necrosis is challenging, especially when the resulting bone defect after the debridement is extensile. Different techniques have been described in the literature for the treatment of these demanding cases, with the most prominent being free vascularized Fibular graft and bone transport with distraction osteogenesis principles. Recently, 3D printing technology has been increasingly utilized in many complex orthopaedic pathologies. However, the application of those advancements regarding septic non-unions with residual bone defect has not been previously studied. This study presents a novel 3D printing technique for the management of an infected critical bone deficit of the tibia. Queries, challenges and future perspectives concerning the recruiting of 3D printing technology in limb reconstruction are also being discussed. Clinical Evidence Level: IV.

Valgus osteotomy in management of non-union of inter-trochanteric fracture: A case report

Valgus osteotomy in management of non-union of inter-trochanteric fracture: A case report

Managing Recurrent Clavicle Nonunion and Construct Failure: A Case Report

Case A 36-year-old male who suffered a left midshaft clavicle fracture, following a fall from a mountain bike, was treated unsuccessfully with two ORIF surgeries. Smoking cessation and management of hypovitaminosis was addressed preoperatively before final revision with a dual plate construct and tibial autologous bone graft. Follow-up radiographs taken at 12 months from the initial surgery showed intact hardware and full bone healing. Conclusion Successful management of clavicle nonunions can be optimized through optimal plate selection, plate positioning, number of plates, construct biomechanics, biologic augmentation, and preoperative risk optimization. Efforts to minimize controllable risk factors for nonunion, such as smoking cessation or vitamin D supplementation, should be utilized both preoperatively and postoperatively.

Septic Tibial Nonunions on Proximal and Distal Metaphysis-A Systematic Narrative Review.

Infected nonunion of the tibia represents a challenging complication for orthopedic surgeons and poses a major financial burden to healthcare systems. The situation is even more compounded when the nonunion involves the metaphyseal region of long bones, a rare yet demanding complication due to the poor healing potential of infected cancellous bone; this is in addition to the increased likelihood of contamination of adjacent joints. The purpose of this study was to determine the extent and level of evidence in relation to (1) available treatment options for the management of septic tibial metaphyseal nonunions; (2) success rates and bone healing following treatment application; and (3) functional results after intervention. We searched the MEDLINE, Embase, and CENTRAL databases for prospective and retrospective studies through to 25 January 2021. Human-only studies exploring the efficacy of various treatment options and their results in the setting of septic, quiescent, and metaphyseal (distal or proximal) tibia nonunions in the adult population were included. For infection diagnosis, we accepted definitions provided by the authors of source studies. Of note, clinical heterogeneity rendered data pooling inappropriate. In terms of the species implicated in septic tibial nonunions, staphylococcus aureus was found to be the most commonly isolated microorganism. Many authors implemented the Ilizarov external fixation device with a mean duration of treatment greater than one year. Exceptional or good bone and functional results were recorded in over 80% of patients, although the literature is scarce and possible losses of the follow-up were not recorded. A demanding orthopedic condition that is scarcely studied is infected metaphyseal tibial nonunion. External fixation seems promising, but further research is needed. PROSPERO No. CRD42020205781.

Management of aseptic nonunions and severe bone defects: let us get this thing healed!

Effective nonunion and bone defect management requires consideration of multiple potential contributing factors including biomechanics, biology, metabolic, and patient factors. This article reviews these factors as well as several potential nonunion or bone defect treatments including bone grafts, bone graft substitutes, the induced membrane technique, and distraction osteogenesis. A summary of these concepts and guidelines for an overall approach to management are also provided.

Outcome analysis of ilizarov and monorail fixators in the treatment of nonunion of long bones: A systematic review and proportion meta-analysis

IntroductionNonunion of long bones is a major complication following fractures that requires a substantial amount of investment both monetary and time from patients and surgeons. The need to comprehensively understand the complications, outcomes and distraction capability is profound, which necessitates a review of current evidence on special fixators used for distraction. The current systematic review aims to study the available literature on distraction osteogenesis using special fixators (Ilizarov and Limb Reconstruction System) in the management of nonunion (infected and non-infected). MethodsCochrane Library, PubMed, Scopus were searched until January 2022. The review included all original studies which used Ilizarov or Monorail Fixators/LRS in the treatment of nonunion of long bones. The quality of studies was assessed using the Modified Coleman Methodology Score. ResultsA total of 35 original studies with Ilizarov (n = 29) and LRS (n = 8) were selected including two comparative studies. The pooled data meta-analysis and the subgroup analysis of these studies found both Ilizarov and LRS fixator yield similar functional outcomes for the treatment of long bones nonunion. ConclusionThe review was conducted to understand the scenario of nonunion in long bones. Pin tract infection is found to be the most common complication followed by adjacent joint stiffness and deformity. In our review we observed that both external fixator time and index were lower in LRS compared to Ilizarov group. Further RCT are required comparing Ilizarov and LRS fixators to effectively comment upon the superiority of the implants.

Pedicled Bone Transfer Of The First Rib In The Treatment Of Failed Surgical Management Of Clavicular Non-Union

Pedicled Bone Transfer Of The First Rib In The Treatment Of Failed Surgical Management Of Clavicular Non-Union

Management of Non-union Distal Femur Fractures With Augmentation Nail Plate Construct.

Background and objective A non-union distal femur fracture is a challenging fracture to treat. Common treatment modalities for non-union distal femur fractures include dual plating, intramedullary nails, ilizarov, and hybrid fixators. Despite the availability of a wide armamentarium of constructs, the clinical and functional outcome of these modalities is often complicated by significant morbidity, joint stiffness, and delayed union. The augmentation of the intramedullary nail with a locking plate results in a robust architecture, improving the likelihood of union. The use of this nail plate construct improves biomechanical stability and restores limb alignment, which enables early rehabilitation and weight bearing and lowers the likelihood of fixation failure. Methodology A prospective study was conducted at the Government Institute of Medical Science, Greater Noida, from January 2021 to January 2022 on 10 patients with non-union of the distal femur. All the patients were operated on with nail plate construct. The minimum follow-up period was 12 months. Results A total of 10 patients with a mean age of 55 years were included. Six were earlier treated with an intramedullary nail and four with extramedullary implants. All patients were managed with implant removal and fixation with nail plate construct and bone grafting. The average duration of the union was 10.3 months. The International Knee Documentation Committee (IKDC) score improved from 30.6 preoperatively to 67.3 postoperatively. Only one patient developed a superficial infection, which was managed by wound debridement and targeted antibiotic therapy. Conclusion In our experience, this relatively novel technique of combining nail plate constructs offers encouraging outcomes in the management of non-union of distal femur fractures, especially in elderly and osteopenic patients.

Prospective evaluation of the role of limb reconstruction system in fracture non-union of femur: a case series

Traditionally the Ilizarov’s ring fixator was used in the management of non-union of long bones, especially in the cases with infection. But limb reconstruction system (LRS) is a viable lightweight, technically easier alternative for the same. The aim of this study was to assess the functional outcome, the radiological outcome and the complications associated with the management of fracture non-union femur treated with LRS. A prospective case series was undertaken comprising of 10 patients. Both infected and non-infected shaft of femur fractures were enrolled. Patients underwent debridement, implant removal and definitive fixation with LRS. Post-operative radiological outcome and functional outcome using the ASAMI (Association for the Study and Application of the Method of Ilizarov group) score. In 70% cases the mechanism of injury was road traffic accident. Mean period of non-union before admission was 11.9 months, mean time for union was 10.10 months, with 90.0% cases successfully uniting. 70% cases underwent lengthening following Ilizarov’s principles. ASAMI radiological outcome was excellent in 70%, good in 10%, fair in 10% and poor in 10% cases. ASAMI functional outcome was excellent in 60%, good in 10%, fair in 10% and poor in 20% cases. Pin tract infection was the most common problem at 70.0% while knee stiffness at 40% was the most common true complication. Thus by this study it can be expressed that LRS is a feasible alternative to ring fixators for the management of fracture non-union shaft of femur.

Cancellous compression bone grafting using headless screw as a strut in scaphoid nonunion by a single volar approach

PurposeAn array of fixation and grafting techniques for scaphoid nonunion have been described over time, achieving varied results pertaining to union and scaphoid alignment. The aim of this study was to check for union rates and correction of scaphoid parameters achieved by our technique of using screw as a strut and cancellous compression grafting harvested from the distal radius by a single volar approach.MethodsRetrospective analysis of all patients operated by the said technique was done from 2013 to 2019. Thirty-eight patients including 36 males and two females in the age range of 20–56 years were analyzed. Union rates, change in scaphoid alignment parameters and graft site characteristics were documented.ResultsOf the patients analyzed, 5/38 were nonunions of proximal pole, 19/38 of waist and 14/38 were of distal pole which included nonunions of cystic type or with humpback deformity. Patients were followed up for an average of 22.2 months and union was achieved in all cases with a mean period of 15.7 ± 3.7 weeks. There was significant improvement in the scaphoid alignment postoperatively. One case of implant migration and one case of scaphoid nonunion advanced collapse were noted. The mean duration of donor site healing was noted to be 16.9 ± 2.5 weeks except two outliers which took longer time. There were no cases of donor site fracture or other complications.ConclusionUnion rates, correction of scaphoid parameters and minimal complications justifies this technique as a novel one in the management of scaphoid nonunion at all levels, with minimal donor site morbidity and attained by the single volar approach.

Strain reduction screws for nonunions following fixation around the elbow - A case series and review of the literature

BackgroundNonunions following fracture fixation result in significant patient morbidity and financial burden. Traditional operative management around the elbow consists of removal of metalwork, debridement of the nonunion and re-fixation with compression, often with bone grafting. Recently, some authors in the lower limb literature have described a minimally invasive technique used for select nonunions where simply placing screws across the nonunion facilitates healing by reducing inter-fragmentary strain. To our knowledge, this has not been described around the elbow, where traditional more invasive techniques continue to be employed. AimsThe aim of this study was to describe the application of strain reduction screws for management of select nonunions around the elbow. Methods & ResultsWe describe 4 cases (two humeral shaft, one distal humerus and one proximal ulna) of established nonunion following previous internal fixation, where minimally invasive placement of strain reduction screws were used. In all cases, no existing metal work was removed, the nonunion site was not opened, and no bone grafting or biologic stimulation was used. Surgery was performed between 9 and 24 months after the original fixation. 2.7 mm or 3.5 standard cortical screws were placed across the nonunion without lagging. Three fractures went on to unite with no further intervention required. One fracture required revision fixation using traditional techniques. Failure of the technique in this case did not adversely affect the subsequent revision procedure and has allowed refinement of the indications. ConclusionStrain reduction screws are safe, simple and effective technique to treat select nonunions around the elbow. This technique has potential to be a paradigm shift in the management of these highly complex cases and is the first description in the upper limb to our knowledge.

Management of Sternal Wounds, Infections, and Sternal Non-Union with Plate Fixation: Result from a Single Site Experience.

Background: Patients with sternal wounds, infection, or non-union after cardiac surgery continue to have increased morbidity and mortality rates compared with those without sternal complications. Reconstructive methods have largely centered on soft tissue approaches, including muscle or omental flaps, which result in functional loss. Some data show early positive advantages using sternal rigid plate fixation (SRPF), however, it is debated in the setting of active infection. The goal of this study is to examine the outcomes of SRPF in patients with and without infections. Patients and Methods: This is a retrospective study of consecutive patients who underwent SRPF by a single plastic surgeon from April 2013 to August 2021. Patients treated without SRPF, lacking at least six months of follow-up, or those plated more than once were excluded. Ninety-seven patients were included. Demographic and peri-operative factors associated with sternal infection after SRPF were evaluated. Results: Sixty-eight patients were clinically infected/culture positive or open (INFECTED), and 29 were clean/primary plating (CLEAN). Sixteen percent of the INFECTED cases (11/68) returned with infection. Fourteen percent of the CLEAN cases (4/29) had subsequent infections. Additionally, we did note a decrease in rates of infections overall (p < 0.0001) as experience and frequency of plate fixation increased (p < 0.0001). Regardless of infection status, all but one patient had a healed and stable sternum at the end of data collection. Conclusions: There is no statistically significant difference between wound class prior to SRPF and development of infection after SRPF. Even in infected settings, patients can be treated successfully with SRPF. Further study is needed.

Management of Infected Femoral Nonunion by Arched External Fixator Augmented by Flexible Intramedullary Nails

Abstract Purpose: The aim of this study is to evaluate the functional and radiological outcome of the management of infected femoral nonunion by arched frame augmented by flexible intramedullary nails. Patients and Methods: In this retrospective case series study, 20 cases were included. All patients had chronically infected nonunited fracture femur. The mean age of the included patients was 33 years. The site of the femoral fracture was midshaft in 12 patients, proximal third of femur in 6 patients, and distal third in 2 cases. Initially, the fracture was open in 17 patients and closed in 3 patients. Four of the included patients had diabetes mellitus. Ten cases were smokers and six of them were heavy smokers. All cases were managed by arched frames, augmented by flexible intramedullary nails. Functional and radiological evaluation was performed using the Association for the Study and Application of the Methods of Ilizarov (ASAMI) scoring system. Results: The mean follow-up was 18.45 months. All cases achieved union except two cases (10%). According to ASAMI bony score, 11 patients (55%) were excellent, 6 (30%) were good, 1 was fair (5%), and 2 (10%) showed poor results. According to ASAMI functional score, 3 patients were excellent, 15 (75%) were good, 3 (15%) were fair, and 2 (10%) showed poor results. Conclusion: The management of infected nonunion of the femur by arched frame and intramedullary flexible nails provides a stable fixation, with acceptable functional and radiological results. Level of Evidence: Level IV case series study.

Plate over nail and bone graft for management of tibial non union after intramedullary fixation

Abstract Non union after intramedullary nail fixation is difficult to treat. Many options are available for its management including nail exchange, bone graft while keeping the nail, nail removal and plating. Each method has its advantages and disadvantages. The aim of this study is to evaluate the results of management of tibial non union after intramedullary fixation using plate augmentation. Between January 2012 and December 2019, thirty four patients with nonunited fracture tibia previously treated with locked intramedullary nails were included in this study. The ages of patients ranged from 20 to 62 years ( an average age: 43 years). All patients were diagnosed to have aseptic nonunion. All patients achived bony union except 2. Bone union was achieved in a time ranged from 3 to 9 months (an average time 5 months). The average limb length discrepancy was 1 cm ( range 0 to 1.5 cm ). The reported complications were superficial wound infection in 2 cases, joint stiffness in 3 patients and nonunion in 2 cases. There were no intraoperative complications. All patients reported no pain at the fracture site during weight bearing at the final follow-up. We concluded that augmentation plate fixation is a good option for treatment of tibial nonunion after intramedullary nail.

Use of the limb reconstruction system for the management of non-union of the tibia: A prospective case series

Introduction: Management of fracture non-unions of the tibia are demanding due to the hampered vascular supply, poor bone quality and the deficient soft tissue cover. Instead of the traditional Ilizarov’s ring fixator which is bulky, technically demanding and has a poor patient compliance, the Limb Reconstruction System (LRS) is a viable alternative. The aim of this study is to assess the functional and radiological outcome and the complications associated with the management of fracture non-union tibia treated with LRS. Method: A prospective case series was undertaken comprising of 20 patients. Both infected and non-infected shaft of tibia fractures were enrolled. Patients underwent debridement, implant removal and definitive fixation with LRS. Radiological and functional outcome were assessed using the ASAMI (Association for the Study and Application of the Method of Ilizarov Group) score. Results: In 90% cases the mechanism of injury was road traffic accident. Mean period of non-union before admission was 12.85 months, mean time for union was 9.30 months, with 95.0% cases successfully uniting. 55% cases underwent lengthening following Ilizarov’s principles. ASAMI Radiological outcome was Excellent in 80%, Good in 15% and Poor in 5% cases. ASAMI Functional outcome was Excellent in 40%, Good in 50% and Poor in 10% cases. Pin tract infection was the most common problem at 70.0% while ankle stiffness at 35% was the most common true complication. Conclusion: Thus by this study it can be expressed that LRS is a feasible alternative to ring fixators for the management of fracture non-union shaft of tibia.

Functional Evaluation of Long Bone Nonunion Managed by Limb Reconstruction System

Abstract Background: The management of infected nonunion of long bones is a demanding task for the treating surgeon. Various treatment options have been tried in the past with less than satisfactory outcome. The purpose of the study was to establish the efficacy of limb reconstruction system (LRS) in the treatment of nonunion of the tibia and the possibility of correcting any bone length discrepancy. Materials and Methods: A prospective cohort study was performed on 30 patients with infected nonunion of lower limb long bones, treated with LRS for 2 years between November 2018 and December 2020, in our institution. The outcome was evaluated on the basis of bone union and functional outcome using the Association for the Study and Application of the Method of Ilizarov (ASAMI) score. Results: According to the ASAMI score, results were excellent in 75% good in 10%, fair in 5%, and poor in 10% of patients. The average union time was 44 weeks and average fixation time was 46 weeks. Conclusion: LRS is a lightweight, patient-friendly device that does not interrupt patient’s day-today activities. It is useful for managing limb length discrepancies, allows early mobilization and better wound management, thus it is an effective and versatile treatment modality in infected nonunion of the tibia.

Acquired Spur-Like Bony Growth Over the Previous Fibulectomy Site Following the Management of Both Bone Leg Fracture Nonunion: A Case Report

Abstract Exophytic bony outgrowths have many differential diagnoses, with osteochondroma being the most common. The de novo development of a well-defined bony growth over the location of a previous surgery is a rare occurrence. Here, we describe a case of gradual development of a small bony exophytic lesion over the fibula diaphysis as a delayed complication of the previous fibulectomy. The index surgical procedure of fibulectomy was coupled with bone grafting at the tibial nonunion site following failed conservative management of the tibia fracture. The tibia fracture eventually united after the bone graft procedure. However, there was a gradual development of the aforementioned bony outgrowth noted in serial radiographs at the site of the previous fibulectomy. The growing lesion was also palpable on deep palpation over the corresponding site, and the excision of the lesion revealed a solid bony mass. Histopathology showed the lesion to be composed of mature bony tissue without any evidence of a cartilage cap. No recurrence or complication was noted in the fourteen-month follow-up. The diagnosis of an acquired exostosis was established based on clinical, radiological, and histopathological evaluation.

The Management of Aseptic Non-unions of Distal Femur Fractures with Anatomical Lateral Locking Plates.

Distal femoral non-unions are challenging, and frequently associated with short distal fragments, poor bone stock, and with issues from previous implants. A retrospective study of 31 patients admitted with distal femoral non-unions treated using anatomical lateral locking plates. Non-union scores were used. The Knee Society and Neer's scores were used for the comparison of results. The mean follow-up was 39.5 months (from 24 months to 60 months). Stable union was accomplished in all. There was a significant improvement in the average Neer's score (24 preoperative to 82 post-operatively at final follow-up), the Part 1 Knee Society score from an average of 46 preoperatively to 84 post-operatively, and Part 2 Knee Society score from 36 preoperatively to 80 post-operatively. Optimal stability, good compression at the non-union site (either by lag screws or a compression device or both), maintaining the axial alignment strictly, freshening of bone ends, using an adequate amount of cortico-cancellous bone graft, respecting the biology along with the correct choice of the implant (including the size) are essential to achieve union at the fracture site. Paying attention to the basic principles of management, good contact, stability and maintaining biology is essential in the treatment of non-union. Mukhopadhaya J, Ranjan R, Sinha AK, et al. The Management of Aseptic Non-unions of Distal Femur Fractures with Anatomical Lateral Locking Plates. Strategies Trauma Limb Reconstr 2022;17(3):137-143.