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Tibial Non Unions

- 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 w/ no radiographic signs of progression toward healing for 3 months;
- pain on weight bearing is a classical symptom of nonunion
- final stage of a nonunited fracture is formation of pseudoarthrosis;
- ref: Any Cortical Bridging Predicts Healing of Tibial Shaft Fractures
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
- ref: Study finds 47% primary union rate in tibia patients with ‘critical-sized’ bone defects
tibial frx vascular supply
- references:
Delayed unions and nonunions of open tibial fractures. Correlation with arteriography results.
Fracture consolidation in a tibial nonunion after revascularization: a case report
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.

- right and left oblique xrays (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);
- classically, presence or absence of callus is described on each specific view (or callus seen on 4 cortices)
- ref: Any Cortical Bridging Predicts Healing of Tibial Shaft 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
- external bone stimulators:
Extracorporeal shock-wave therapy compared with surgery for hypertrophic long-bone nonunions
Low-intensity pulsed ultrasound for non-union treatment: a 14-case series evaluation
Indications and results for the Exogen™ ultrasound system in the management of non-union: a 59-case pilot study.

- Operative Treatment:   (treatment methods for tibial defects)
pre-operative planning:
- generally, operative intervention is warrented if there are no radiographic signs of healing by 3-5 months;
- compression of a non union w/ shortening of > 2 cm, may cause excess folding of soft tissues, vessels, and nerves;
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
- prior to any attempt at operative treatment of a non-union, first established that an infected non unions is not present;
- an infected delayed union requires débridement, soft-tissue coverage, bone stabilization and bone-grafting;
- ref: Exchange nailing for nonunion of diaphyseal fractures of the tibia: our results and an analysis of the risk factors for failure.
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;

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)
synthese reamer aspirator
Reamer-irrigator-aspirator bone graft and bi Masquelet technique for segmental bone defect nonunions: a review of 25 cases.
Treatment of large segmental bone defects with reamer-irrigator-aspirator bone graft: technique and case series
Treatment of recalcitrant, multiply operated tibial nonunions with the RIA graft and rh-BMP2 using intramedullary nails.
           - Masquelet technique:
           - decortication:
Treatment of tibial pseudarthrosis using Robert Judet's method of osteoperiosteal decortication
Deep decortication in nonunion of shaft fractures
Judet osteoperiosteal decortication for treatment of non-union: the Cornwall experience
Judet decortication and compression plate fixation of long bone non-union: Is bone graft necessary?
Tibia nonunion after intramedullar nailing for fracture: decortication and osteosynthesis by medial plating
Relevance of deep decortication and vascularization in a case of post-traumatic femoral non-union treated with grafts, platelet gel and bone marrow stromal cells.
Indications and outcomes of augmentation plating with decortication and bone grafting for femoral shaft nonunions
Treatment of nonunion in neglected long bone shaft fractures by osteoperiosteal decortication
Effect of decortications on union rate of tibial plating.
                     - Atrophic, aseptic, tibial nonunion: how effective is Judet’s osteoperiosteal decortication technique and buttress plating?
- 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 vs bone transport in management of tibial non-unions.
Management of nonunion of lower-extremity long bones using mono-lateral external fixator--report of 37 cases.
           - 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.
Augmentative locking compression plate fixation for the management of long bone nonunion after intramedullary nailing
Augmentation Plate Fixation for the Treatment of Femoral and Tibial Nonunion After Intramedullary Nailing
[Tibia nonunion after intramedullar nailing for fracture: decortication and osteosynthesis by medial plating
High success rate for augmentation compression plating leaving the nail in situ for aseptic diaphyseal tibial nonunions

- intramedullary nails for tibial fracture:
- exchange nailing:
tibial reaming 1 mm to 2 mm following which a broader intramedullary nail
- relative contraindications:
- bone loss of more than 2 cm and/or loss 50% of the bone diameter
infected non union
- 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 Wu CC, et al (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;
- 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;
- nonetheless, in cases of non infected non union, reaming followed by IM nailing may stimulate frx healing;
- ref: Exchange nailing for nonunion of diaphyseal fractures of the tibia: our results and an analysis of the risk factors for failure
                  - exchange nailing:
Exchange intramedullary nailing. Its use in aseptic tibial nonunion.
Exchange reamed intramedullary nailing for delayed union and nonunion of the tibia.
Results of a systematic approach to exchange nailing for the treatment of aseptic tibial nonunions.
Dynamizations and Exchanges: Success Rates and Indications.
Does Screw Configuration or Fibular Osteotomy Decrease Healing Time in Exchange Tibial Nailing?
Nail Dynamization for Delayed Union and Nonunion in Femur and Tibia Fractures.

- 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.
Treatment of tibial malunions and nonunions with reamed intramedullary nails.
Nonunions of the Distal Tibia Treated by Reamed Intramedullary Nailing.
Infected non-union of the tibial shaft treated by K�ntscher 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.
Treatment of femoral and tibial diaphyseal nonunions using reamed intramedullary nailing without bone graft.
Reconstruction of segmental bone defects due to chronic osteomyelitis with use of an external fixator and an intramedullary nail.

partial fibulectomy:
- if fibula is intact or has healed, resection of 1 inch of fibula may improve loading of the fracture site and stimulate union;
- some 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.

Successful Reconstruction for Complex Malunions and Nonunions of the Tibia and Femur

Low Complication Rate Associated With Raising Mature Flap for Tibial Nonunion Reconstruction.