Nonunion Site Research Articles

The treatment of nonunion of femoral shaft fractures after intramedullarynaildynamizationwith temporary compression using external fixator followed by relocking of the internal intramedullary nail

Objective To introduce the technique we invented to treat hypertrophic and oligotrophic nonunion of femoral shaft fracture after dynamization of intramedullary nail (IMN) and to report its preliminary results. Methods The data of 2 cases with hypertrophic nonunions of femoral shaft fracture and 1 case with oligotrophic nonunion following IMN dynamization who had been treated by the technique from March 2006 to July 2017 in Beijing Jishuitan hospital were retrospectively studied. There were 2 females and 1 male, aged 50, 66 and 24 years old. 2 parallel half pins were inserted from anterior to posterior at the trochanteric and condylar zones of the femur for antegrade intramedullary nailing patients, and from lateral to medial sides for retrograde intramedullary nailing patient respectively, then the pins were connected with monolateral limb reconstruction fixator. The fracture nonunion site was compressed by the fixator up to 10-15 mm. The holes at the end of intramedullary nail where their screws were removed for dynamization were locked again with 2 locking screws, and then the frame was removed. The patients are allowed to start their rehabilitation and fully bear their body weight 1 day after the operation. Results The three patients were followed up for 25, 22, and 7 months after the surgery, respectively. The X-ray films showed the fracture healed at 7 months in two case, and at 12 months in one. One patient got her nail removed 25 months after the operation, feeling good 37 months after the removal. Conclusion This technique is an option to manage the hypertrophic and oligotrophic fracture nonunion of the femur after dynamization of IMN. It is mini-invasive to the nonunion site, easy to practice and allows early rehabilitation. Key words: Femoral fractures; Fractures, ununited; Fracture fixation, intramedullary; External fixators

The role of vascularized flaps in the treatment of proximal pole avascular necrosis in scaphoid non-unions.

Objectives: The purpose of this study is to evaluate the clinical and radiological outcomes of scaphoid non unions surgically treated with bone graft versus medial condyle corticoperiosteal free flaps. Materials and Methods: 32 patients were divided in 2 groups. Group A (17 patients 12male, 5 females, mean age 35 years old) treated with bone grafts; Group B (15patients 11 male, 4 females, mean age 33 years old) treated with medial condyle cortico periosteal free flap. A radiological follow up was performed about every 30 days after surgery until the complete healing and at 12-month follow-up. The clinical follow up was performed at 6 and 12 months from surgery. Functional assessment was provided by Mayo wrist score and Visual Analogic Scale (VAS). Results: The average length of follow up was 12.52 months ± 1.36. In group A 60% of patients healed in 4.4 ± 1months with a reduction of 28.4% of healing times in group B (p<0.05). In Group B all nonunion sites healed primarily at an average time period of 3.2 ± 1 months. Statistical analysis showed a significant difference (p<0.001) about the preoperative and the postoperative VAS and Mayo Wrist Score evaluation in both groups at 6 and 12-month follow-up, moreover we recorded a statistical difference between groups at the 6-month and 12-month follow-up (p<0.05). Conclusion: The present study showed that the free flaps showed better clinical and radiographic results for the surgical treatment of scaphoid nonunions. In fact, despite the good results of the bone graft, the flaps seems to be preferable in the treatment of these nonunions. (www.actabiomedica.it)

Intercalary allograft reconstruction in a patient with large tibial defect: Case report

A fit 26 year-old-man presented to our Department with an open fracture of the left tibial shaft (AO 42-C3). The fracture was initially treated with an External Fixator, which was replaced by an intramedullary Grosse Kempf nail after 4 months. In the following year he developed an atrophic non-union and we witnessed the increasing bone resorption at the fracture site which led to the nail breakage. An accurate CT pre-operative planning was made and a revision surgery was successfully performed: the broken nail was removed and intercalary allograft reconstruction was made, using a compressible intramedullary nail. Whereas in literature it is well described how intercalary allografts can be used to fill the massive diaphyseal defects after tumor resections, we assumed it could also be an adequate technique to treat a large bone defect at a non-union site.

\u201cRevision of subtrochanteric femoral nonunions after intramedullary nailing with dynamic condylar screw\u201d

BackgroundNonunions of the subtrochanteric region of the femur after previous intramedullary nailing can be difficult to address. Implant failure and bone defects around the implant significantly complicate the therapy, and complex surgical procedures with implant removal, extensive debridement of the nonunion site, bone grafting and reosteosynthesis usually become necessary. The purpose of this study was to evaluate the records of a series of patients with subtrochanteric femoral nonunions who were treated with dynamic condylar screws (DCS) regarding their healing rate, subsequent revision surgeries and implant-related complications.MethodsWe conducted a retrospective chart review of patients with aseptic femoral subtrochanteric nonunions after failed intramedullary nailing. Nonunion treatment consisted of nail removal, debridement of the nonunion, and restoration of the neck shaft angle (CCD), followed by DCS plating. Supplemental bone grafting was performed in all atrophic nonunions. All patients were followed for at least six months after DCS plating.ResultsBetween 2002 and 2017, we identified 40 patients with a mean age of 65.4 years (range 34–91 years) who met the inclusion criteria. At a mean follow-up period of 26.3 months (range 6–173), 37 of the 40 (92.5%) nonunions healed successfully (secondary procedures included). The mean healing time of the 37 patients was 11.63 months (± 12.4 months). A total of 13 of the 40 (32.5%) patients needed a secondary revision surgery; one patient had a persistent nonunion, nine patients had persistent nonunions leading to hardware failure, two patients had deep infections requiring revision surgery, and one patient had a peri-implant fracture due to low-energy trauma four days after the index surgery.ConclusionsThe results indicate that revision surgery of subtrochanteric femoral nonunions after intramedullary nailing with dynamic condylar screws is a reliable treatment option overall. However, secondary revision surgery may be indicated before final healing of the nonunion.

Treatment for proximal pole scaphoid nonunion with capsular-based vascularized distal radius graft.

We retrospectively reviewed the results of 89 patients with proximal pole scaphoid nonunion, 58 with avascular necrosis, treated with a capsular-based vascularized distal radius graft. Seventy-one male and eighteen female patients with symptomatic nonunion at the proximal pole of the scaphoid were included in this study. No patient had a humpback deformity. In all patients, the vascularized bone graft was harvested from the dorsum of the distal radius and was attached to a capsular flap of the dorsal wrist capsule. After fixation of the scaphoid with a small cannulated screw, the graft was inserted press-fit into the scaphoid trough in the nonunion site. Supplementary fixation of the graft with a microsuture anchor into the scaphoid was used in 66 patients. At a mean time of 12.3weeks (range 6-24) after surgery, solid union was achieved in 76 of 89 patients (49 of 58 with avascular necrosis). Eleven patients had persistent nonunion and two fibrous union as determined by CT scan. Sixty-six of the patients with solid bone union were completely pain free, and ten complained of slight pain with strenuous activities. No donor site morbidity was observed. The capsular-based vascularized bone graft from the distal radius is a reliable alternative technique for scaphoid nonunions. It is a simple and expedient harvesting technique without the need for a microsurgical anastomoses. The supplemental fixation with a microsuture anchor eliminates the risk of graft displacement.

Lambeau osseux interosseux postérieur pour l’avant-bras pédiatrique

Posterior interosseous bone flap (PIBF) is a reliable vascularised bone graft in adults for treatment of forearm and elbow difficult nonunions. In our best knowledge there is no published experiments on this technique in children. We reviewed our patients and found 6 patients with PIBF for treatment of forearm nonunions and distal radius physeal arrest. From May 2015 to December 2017, six patients from 2 to 8 years old underwent PIBF from distal ulna. The indication of this treatment were, radius congenital pseudoarthrosis two patients, non-union due to chronic osteomyelitis one patient, radius traumatic non-union one patient, distal radius physeal arrest due to enchondroma two patients. In non-union cases, one half of diameter from 2–3 cm of distal ulnar metaphysis harvested on the base of posterior interosseous vessels and transferred to non-union site of the radius. For transfer of the physis whole distal 2 cm of ulna, including physis harvested on the base of these vessels and transferred to the distal radius after resecting damaged physis. All nonunions healed in 3 to 4.5 months. Ulnar fracture and radial head gradual dislocation occurred in one patent with congenital pseudoarthrosis. Non of physeal transfers ended to normal growth due to bony bridge. Non-union is rare in paediatric forearm but if it stablished it is difficult to be treated. Congenital pseudoarthrosis and chronic osteomyelitis are the examples of underlying disease, which make the treatment so difficult. Free fibular transfer is the treatment of choice, but it is a demanding technique and the donor site complications is frequent. Pedicle bone graft is a simple alternative for this procedure. In our patients PIBF worked with complete union in an acceptable time without sever complications. Distal radius physeal arrest especially in young children is a disabling condition. Lengthening over the time is a time consuming procedure. Free phseal transfer is an attractive idea. Unfortunately with PIBF technique transferred physis didn’t work, because of bony bridge around the physis. PIBF works in the paediatric difficult forearm nonunions. But because of smaller size of the ulna, more meticulous techniques should be done. Physeal transfer of distal ulna to radius is not successful with this technique and needs further investigations.

Treatment of Resistant and High-Risk Humeral Non-union Cases with rhBMP7

Introduction: Non-union of the humeral shaft is a rare condition. In these patients, more stable fixation with or without autograft results in nearly 95% union rate. The purpose of this study was to evaluate bone union following use of recombinant human bone morphogenetic protein-7 (rhBMP7) for treating humeral non-union.Material and methods: This was a prospective study of resistant non-union cases treated by repeated fixation and addition of rhBMP7. The case series consisted of 16 patients with an average age of 53.8 years (24-71). Patients presented with non-union of the humeral shaft and had experienced at least one failed attempt at surgical repair. Osigraft® (rhBMP7) was added to the non-union site after decortication, medullary canal reaming and fixation with one or two plates. The average time elapsed between the initial fracture and the second revision was 31 months (5-103). The patients had undergone an average of 2.3 procedures (1-6).Results: All patients were reviewed after at least 24 months of follow-up. No neurological complications were reported. One failure occurred in a non-compliant patient with septic non-union who had undergone four previous procedures. The other patients experienced bone union after an average of 12.4 months (6-14), with no further procedures required. The patients were able to return to their normal daily activities.Conclusion: Failure of the initial fracture treatment (unstable fixation, postoperative bone defect) is the primary cause of non-union. Although autograft is the gold standard treatment for non-union cases, the course of action to take if this primary strategy fails has not been defined. During secondary use (due to failed autograft procedure) and when there is no requirement for a structural graft (humerus can be shortened), providing stable fixation and adding a growth factor leads to bone union even in a septic environment.

Black pigmentation of both forearm bones after chronic minocycline antibiotic therapy for septic nonunion. A case report and literature review

We report the case of a 28-year-old man with a septic forearm non-union treated with minocycline for 3 months. At the time of reconstructive surgery, the radius and ulna were entirely black. Surgical debridement until bleeding of both bone extremities resulted in a 5-cm defect that was filled with a cement spacer. Histology confirmed poorly vascularized bone with focal areas of acute inflammatory infiltrate at the non-union sites (highly suggestive of infection) and normal structure of the remaining diaphyseal bones, although black in color. Reconstruction with free vascularized fibula transfer was successful leading to complete bone healing. An incidental finding of minocycline-induced black bone discoloration should not change the surgeon's decision because there is no evidence of adverse effects on bone healing in the literature. Surgery can be performed safely at sites of minocycline-induced black bone pigmentation.

Fractures in patients with osteopetrosis, insights from a single institution.

Osteopetrosis is a hereditary skeletal disorder in which defective osteoclast function leads to abnormally hard and brittle bones. This study aims to describe the pattern of fractures occurring in this group of patients, possible complications, and strategies to avoid them. This is a case series of six osteopetrotic patients with a total of 12 fractures managed in our institution over a period of nineyears. Patient records were also reviewed for complications both intra- and post-operatively. The majority of the fractures involved the femur, with three of these being peri-implant in nature. Other bones involved include the tibia, humerus, patella, fifth metatarsal, and proximal phalanx of the toe. There was a high rate of complications while managing these patients: three patients had peri-implant stress fractures, three with retained broken screws, and one case each of delayed union, non-union, and surgical site infection. Osteopetrosis fractures present a unique challenge to the orthopedic surgeon. Careful pre-operative planning should be undertaken before proceeding with surgery in these cases.

Exchange nailing with open bone grafting for aseptic femoral diaphyseal nonunion with implant failure: A study of 13 cases

Introduction: In spite of vast advances in implants and operative techniques in the management of femoral diaphyseal fracture, treating a case of aseptic nonunion still poses a great challenge to treating surgeon. In India, the illiteracy of the patient and the false security of stable fixation with intramedullary rods often leads to premature weight bearing causing implant failure and nonunion. Material and methods: 13 patients aged 19 yrs - 52 yrs with aseptic femoral diaphyseal nonunion with implant failure were treated during Sept 2015 -Dec 2017. Twelve of them required opening nonunion site for implant removal, hence were treated by exchange nailing and autogenous bone grafts. One case treated by closed exchange nailing only.Results: 11 cases achieved solid osseous union with single procedure in an average of 5.3 months. One patient required dynamization in 4th post-operative month. A case of closed exchange nailing without bone grafting healed in 6 months.Conclusion: Exchange nailing with bone grafting is an excellent method for treating aseptic femoral diaphyseal nonunion with implant failure.

High prevalence of bacteria in clinically aseptic non-unions of the tibia and the femur in tissue biopsies

There are several hints that bacterial colonization might be an often overseen cause of non-union. Modern procedures like PCR have been reported to diagnose bacterial colonization with a high degree of accuracy. While PCR is not ubiquitously available, we hypothesize that biopsies from the non-union site are comparable to PCR results reported in the literature. Retrospective analysis of microbiological results of biopsies from non-unions (femoral or tibial, history of revision surgery, and/or open fracture) with stable osteosynthesis, no clinical signs of local infection were analysed. CRP and leucocyte count were taken on admission. Multiple tissue samples (soft tissue and bone) were from the non-union (1-4cm incision). Samples were cultivated for 2 weeks and tested following EUCAST protocols using VITEK® 2. 11 tibia- and 7 femur non-union (44 ± 23.9years), 11 open fractures (1 I°, 6 II°, 4 III° Gustillo Anderson), 0-5 revisions, and 4.1 (± 1.8) tissue samples were taken 8.5 (± 1.7) months after trauma. Cultures were positive in 8/18 (44,4%) (3/18 Propionibacterium acnes, 1/18 S. capitis, and 4/18 S. epidermidis). There was neither a correlation between number of biopsies taken and positive culture results (Pearson R: - 0.0503, R2 0.0025), nor between positive culture results and leucocytes counts (Pearson R: - 0.0245, R2 0.0006) or CRP concentration (Pearson R: 0.2823, R2 0.0797). The results confirm that the presence of bacteria in cases with no clinical signs of infection is a relevant issue. The prevalence of bacteria reported here is comparable that reported from cohorts tested with PCR or sonication. In most cases, there was only one positive biopsy, raising the question whether a contamination has been detected. Thus, to better understand the problem, it is necessary to gather more knowledge regarding the sensitivities and specificities of the different diagnostic procedures.

Исследование регионарной гемодинамики у пациентов с псевдоартрозами диафиза бедренной кости при лечении в условиях комбинированного чрескостного и интрамедуллярного остеосинтеза

Objective The purpose of the study was to explore peripheral hemodynamics in patients with femoral shaft nonunions treated with combined external fixation and intramedullary nail. Material and methods Two groups of patients were identified. Group I included 11 patients with a deformity at the apex of nonunion treated with consecutive combined osteosynthesis. Group II consisted of 15 patients with nonunions and femoral shortening treated with synchronous combined distraction-compression osteosynthesis. Methods of examination comprised duplex ultrasound of veins and paraosseous vessels at the regeneration site (HITACHI HI Vision Avius), USDG (ANGIO-PLUS, Moscow) and tetrapolar rheovasography (RVG) of lower limbs (Rheograph RGPA-6/12, Taganrog). Results and discussion Volumetric blood flow of the femur and tibia measured postoperatively with RVG showed no differences in the intact and operated limb whatever technique was applied. In all patients, major blood flow was recorded at stages of combined fixation and Ilizarov fixation, linear systolic velocity and pulsatility index were not significantly different from normal and intact limb values, hemodynamic criteria of vasoconstriction of major vessels were not identified. The steal syndrome of distal segments due to functional bypass was observed in patients with unstable metal constructs and did not aggravate after surgical treatment in Group I. Duplex ultrasound scan of the femoral shaft cortical bone showed expressed arterial and venous color map in all patients with high peripheral indices reflecting vascular tone and measuring PI = 12 ± 3.5; RI = 0.9 ± 0.1. Conclusion No significant hemodynamic changes were detected in major arteries during treatment of patients with femoral nonunions using combined techniques of external fixation and intramedullary nail. Vasodilatation of veins recorded during treatment of patients with femoral nonunions using combined techniques of external fixation and intramedullary nail was determined as a risk factor for venous thromboembolism. A local increase in the arterial and venous paraosseous blood flow was recorded at the cortical site of nonunion with combined intramedullary osteosynthesis.

Retrospective Comparative Outcomes Analysis of Arthroscopic Versus Open Bone Graft and Fixation for Unstable Scaphoid Nonunions

To compare union rates and clinical and radiologic outcomes after arthroscopic and open bone grafting and internal fixation for unstable scaphoid nonunions. Between March 2009 and November 2014, patients with unstable scaphoid nonunion underwent arthroscopic (group A) or open (group O) bone grafting and internal fixation. One senior surgeon alternatively performed either arthroscopic or open osteosynthesis for the same surgical indications. Visual analog scale score, grip strength, active range of motion, Mayo wrist score (MWS), and Disabilities of Arm, Shoulder, and Hand score were assessed preoperatively and postoperatively. Union was determined by computed tomography 8 to 10weeks postoperatively with bridging trabecula at the nonunion site. Scapholunate angle (SLA), radiolunate angle (RLA), and lateral intrascaphoid angle (LISA), plus height/length ratio (HLR) served to gauge carpal bone alignment in preoperative and postoperative radiographs. Those outcomes of patients with carpal collapse deformities, who met following conditions; (1) LISA of >45° or HLR of >0.65 on computed tomography images or (2) SLA of >60° or RLA of >10° on plain radiographs, were also compared. Overall, 62 patients qualified for study (group A, 28; group O, 34). Union rates did not differ by patient subset (group A, 96.4%; group O, 97.1%; P≒ 1); and visual analog scale score, grip strength, range of motion, Mayo Wrist Score, and Disabilities of Arm, Shoulder, and Hand scores were similar at last follow-up. In radiographic assessments, SLA, RLA, and LISA were similar, whereas scaphoid HLR excelled through open technique (group A, 0.59 ± 0.07; group O, 0.55 ± 0.05; P= .002). Subgroup analysis of patients with carpal collapse deformities (group A, 9; group O, 14) showed that all radiographic measures in group A (vsgroup O) reflected lesser correction (SLA, 56.7° ± 7.3° vs 49.2°±9.1° [P= .049]; RLA, 9.2° ± 2.0° vs 5.7° ± 3.0° [P=.005]; LISA, 34.8° ± 4.8° vs 25.6° ± 13.0° [P= .028]; HLR, 0.66 ± 0.04 vs 0.54 ± 0.07 [P < .001]). Arthroscopic and open bone grafting and internal fixation in treating unstable scaphoid nonunions, did not show any significant differences in clinical and radiologic outcomes at the minimum of 2years after operation. In scaphoid nonunions with carpal collapse deformities, open bone grafting restored better carpal alignment than arthroscopic bone grafting, although there were no differences in clinical outcomes between the 2 techniques. Level III, retrospective comparative study.

Factors associated with development of re-nonunion after primary revision in femoral shaft nonunion subsequent to failed intramedullary nailing

BackgroundCurrently, there remains a lack of consensus regarding factors predictive of complication such as re-nonunion after primary revision in femoral shaft nonunion subsequent to failed intramedullary nailing (IMN). A better understanding of prognostic factors could potentially reduce the risk of re-nonunion happening and allow patients to maximize their recovery in the most expeditious manner. Our study aims to identify risk factors in the development of re-nonunion after primary revision inclusive of exchanging reamed nailing (ERN) and augmentative compression plating (ACP) with IMN in situ for femoral shaft nonunion subsequent to failed IMN.MethodsA retrospective study was performed for 63 cases (61 patients) of femoral shaft nonunion subsequent to failed IMN, who were made primary revision with either ERN or ACP from June 2007 to June 2015. The following set of variables was selected based on the speculation that they would contribute to the outcome: sex (male or female), age, body mass index(BMI), smoking, alcohol abuse, cause of injury, fracture type, type of IMN (antegrade or retrograde), use of IMN locking screws(dynamic or static), site of nonunion, primary nonunion time, pathological type of nonunion, bone defect (mm), primary revision method (ERN or ACP), and adjuvant autogenous bone grafting (ABG) (yes or no). Univariate analysis and multiple regression were used to identify risk factors in the development of re-nonunion after primary revision with either ERN or ACP for femoral shaft nonunion subsequent to failed IMN. The minimum follow-up time was 1.5 years (standard deviation [SD] = 1.2, range 1.5–8 years).ResultsOf 63 cases (61 patients) of femoral shaft nonunion subsequent to failed IMN, primary revision with ERN was performed in 33 (52.4%) cases and primary revision with ACP was performed in 30 (47.6%) cases. Adjuvant ABG procedure was undertaken in 39 (61.9%) cases during primary revisions. Re-nonunion was diagnosed as in 18 (28.6%) cases after primary revision with either ERN or ACP. There was a significant difference in time to union between patients treated with primary ERN and those with primary ACP (log-rank, p = 0.006). Furthermore, the difference was also statistically significant between patients with adjuvant ABG procedure and those without it (log-rank, p = 0.009). The relative risk factors included smoking, BMI, site of nonunion, bone defect, primary revision method, and adjuvant ABG procedure. However, primary revision method and adjuvant ABG procedure were shown to be two independent risk factors in multiple logistic regression analysis.ConclusionsPatients with excessive tobacco use, BMI ≥ 30 kg/m2, bone defect ≥ 5 mm, primary revision with ERN, and no adjuvant ABG procedure had a higher likelihood of developing re-nonunion. Of these risk factors, primary revision with ERN and no adjuvant ABG procedure were two strongest risk factors.

Correlation of CT imaging and histology to guide bone graft selection in scaphoid non-union surgery

IntroductionFor the treatment of scaphoid non-unions (SNU), different surgical techniques, including vascularized and non-vascularized bone grafts, are applied. Besides stability, vascularity, and the biological situation at the non-union site are important for healing and the appropriate choice of treatment. We assessed the healing potential of SNUs by histological parameters and compared it to CT parameters of bone structure and fracture location. Based on the results, we developed a CT classification and a treatment algorithm to impact graft selection in SNU surgery.Patients and methodsPreoperative 2D-CT reformations of 29 patients were analyzed for trabecular structure, sclerosis, and fragmentation of the proximal fragment. The fracture location was assessed on 3D-CT reconstructions and grouped in three zones depending on the potential blood supply. Samples were taken during surgery for histological evaluation. Histological parameters of bone healing were defined and a bone healing capacity score (BHC), reflecting histological bone viability, was calculated. CT findings were compared to BHC, age of SNU, and time to union.ResultsCases with trabecular structure and without fragmentation showed a statistically significant higher BHC. Time to union was significantly faster if trabecular structure was present and sclerosis was absent. In intraarticular proximal pole non-unions, where no blood supply is assumed, the BHC was statistically significantly lower and time to union was longer compared to SNUs of the other locations. A statistically significant correlation between BHC and time to union was found in the proximal and distal fragment with higher BHC associated with faster healing.ConclusionsCT parameters of bone structure and fracture location can reflect histological healing capacity of SNUs. This can guide bone graft selection in SNU surgery.

Assessment of radiological outcomes in gap non-union of long bones using non-vascularised fibular strut graft augmented with corticocancellous graft

Background: A prospective study was conducted in the department of Orthopaedics & Traumatology in Dr. D.Y Patil Hospital, Navi Mumbai from January 2015 to June 2017 to assess radiological outcomes in traumatic gap non-union of long bones after primary plate fixation failure using non-vascularised fibular strut graft augmented with corticocancellous graft. Methods: A total of 20 patients were included in study presenting with non-union of humerus. In 13 males and 7 females, age between 18-65 years (average 41 years), were operated using non-vascularized fibular strut graft taken from ipsilateral site augmented with auto corticocancellous graft. All the patients were operated by same surgeon with removal of previous plate and fixing with re-plating and intramedullary fibular grafting. The mean follow-up was 9 months (range 6-12 months). The patients were assessed for functional range of motion along with x-ray. Union was achieved after confirming on x-ray. Observations & Results: In study 20 patients there were 13 males and 7 females with average age being 41.35 yrs, average length of fibular graft was 6.3 cm and mean duration of union 21.15 weeks.1 patient was lost in follow up and none of patients showed non union or secondary intervention thus ensuring Bony union in all 20 patients treated with graft and plating Conclusion: This procedure successfully showed that union at nonunion site with adequate vascularity and good soft tissue coverage can be achieved with proper patient selection and using fibular graft in addition to traditional plating and CC graft technique. Even though procedure is lengthy but it’s simplicity, reproducibility and non expensive and patient compliant outcomes makes it a valid option to achieve union in nonunion.

High Rate of Union for Aseptic Distal Tibial Nonunions in Adults Treated With Slow Gradual Compression via Circular External Fixation.

To evaluate the healing rate of aseptic nonunions of the distal third of the tibia treated with Ilizarov slow gradual compression and deformity correction. Retrospective cohort study. Tertiary referral center. Ninety-four consecutive adult patients with 94 distal third tibial aseptic nonunions. Ilizarov external fixation and slow gradual compression; most patients also underwent bone grafting, deformity correction, or both before the initiation of compression. Rate of bony union. Eighty-seven of 94 cases (92.6%) healed after slow gradual compression across the nonunion site with a circular external fixator. Four of the 7 patients who failed treatment healed after additional operative treatment, and the remaining 3 refused further care. Circular external fixation with slow gradual compression was successful in treating aseptic nonunions of the distal third of the tibia in 92.6% of cases. Careful selection of patients for this treatment method can lead to a high success rate with a relatively low rate of major complications. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Non-union after plate fixation

Approximately a third of patients presenting with long-bone non-union have undergone plate fixation as their primary procedure. In the assessment of a potential fracture non-union it is critical to understand the plating technique that the surgeon was intending to achieve at the primary procedure, i.e. whether it was direct or indirect fracture repair. The distinction between delayed union and non-union is a diagnostic dilemma especially in plated fractures, healing by primary bone repair. The distinction is important as nonunions are not necessarily part of the same spectrum as delayed unions. The etiology of a fracture non-union is usually multifactorial and the factors can be broadly categorized into mechanical factors, biological (local and systemic) factors, and infection. Infection is present in ~40% of fracture non-unions, often after open fractures or impaired wound healing, but in 5% of all non-unions infection is present without any clinical or serological suspicion. Methods to improve the sensitivity of investigation in the search of infection include the use of; sonication of implants, direct inoculation of theatre specimens into broth, and histological examination of non-union site tissue. Awareness should be given to the potential anti-osteogenic effect of bisphosphonates (in primary fracture repair) and certain classes of antibiotics. Early cases of delayed/non-union with sufficient mechanical stability and biologically active bone can be managed by stimulation of fracture healing. Late presenting non-union typically requires revision of the fixation construct and stimulation of the callus to induce fracture union.

Study of outcome of treatment for nonunion of femoral shaft fractures: A case series

Introduction: Nonunion of femoral shaft fractures continues to hinder the successful outcome femur fracture treatment in spite of increased understanding of biomechanics and improvements of implant design. Nonunion of femur fracture presents a difficult treatment challenge for the surgeon and a disastrous personal and economic hardship for the patient. Method and Material: 20 consecutive cases of fractures shaft of femur non-union were admitted to the Orthopaedics Department, Dhiraj Hospital, Waghodia were included in this study. All patients underwent revision surgery in form of exchange nailing with autologous cancellous bone graft with plate augmentation in required cases. Results: Out of 20 patients maximum belonged to the age group of 31-40(8). 13 (65%) patient had hypertrophic non-union and 7 (35%) had atrophic non-union. Average follow up of patients was upto 14 months post operatively. Out of 20 patients, 14 (70%) patient achieved union at their last follow up. Radiological signs of bone union was observed at a average of 7.5 months (5.5 to 11 months). Discussion and Conclusion: The use of plate augmentation and bone grafting for the treatment of femoral shaft nonunion, along with exchange interlocking intramedullary nail, to remove the rotational instability of the nonunion site increased the chances of union. Bone grafting performed simultaneously filled the bony defect and stimulated healing.

Minimally invasive plate osteosynthesis in humerus nonunion after intramedullary nailing.

The purpose of this study was to evaluate the results achieved after the use of lateral minimally invasive plate osteosynthesis (MIPO) in oligotrophic humerus nonunions resulting from failed intramedullary nailing (IM). We evaluated nine patients with humerus nonunion after failed locked intramedullary nailing, all treated using 3.5-mm locked compression plates (LCP) placed through lateral minimally invasive approaches, between 2010 and 2016. Patient's age averaged 39.7years. All nonunions were diaphyseal and oligotrophic. All nonunions had previous surgical treatment with static locked nails (seven antegrade and two retrograde). The IM nails were all well inserted in the humerus (none of them protruded or had rotator cuff lesions associated). Pre-operative Disabilities of the Arm, Shoulder and Hand (DASH) score averaged 25.5 points. Pre-operative Constant's score averaged 80.2. Pre-operative visual analog scale of pain averaged 2.4 points. Follow-up averaged 17.7months. Time between initial surgery and revision procedure averaged 11.7months. Union was achieved in all cases, after an average of 4.8months. DASH score at last follow-up averaged 5.1 points, and final Constant's score averaged 93.7 points. The analog scale of pain averaged 0.7 points. Time from definitive surgery to work return averaged 3.9months. Long 3.5-mm LCPs were used (plate length averaged 16.9 screw holes). In two cases, a third 4-cm incision at the nonunion site was performed and cancellous autologous iliac crest bone graft was associated. In our series of nine patients, we achieved union and good objective and subjective results, with high patient satisfaction, using a lateral MIPO technique and placing long 3.5-mm LCPs in selected oligotrophic humerus nonunions after failed IM nailing.