Non-union

Definition
- a fracture in which all reparative processes have ceased without bony healing. Union
cannot be achieved without further intervention.
- Unless there is bone loss, non-union is defined as condition in which fracture has not
healed within nine months post-operatively and there is no visible progress of healing in
the last 3 months. (US FDA)
- Delayed union is defined as a fracture that takes longer than expected to unite. Fracture
that is progressing more slowly toward healing than would normally be expected;
however, achieving union remains possible.
-
Factors predisposing to non-union

Patient related Factors Injury related Treatment related

1. Metabolic and nutritional 1. Open Fracture - Insecure fixation
status 2. Infection - Insufficient
2. General health 3. Segmental Fracture immobilization
3. Activity level 4. Communition - Distraction
4. Vitamin D deficiency 5. Location: NOF, - ORIF
5. Smoking scaphoid - Irradiation
6. Obesity -
7. NSAIDs

Classification
1. Nonunions are classified based on location, presence or absence of infection, and etiology
a. Epiphyseal, metaphyseal or diaphyseal
b. Septic or aseptic
c. Hypertrophic or atrophic
d. Pseudoarthrosis - involves sealed medullary canals with an associated
pseudomembrane containing fluid. Bone scan – “cloud cleft” between areas of
increased activity

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Hypertrophic non-union
- have adequate vascularity, display abundant callus, and lack stability.
- Types
1. Elephant foot: rich in callus; d/t insecure fixation, early mobilization and
premature weight bearing
2. Horse hoof: poor in callus; due to moderately unstable fixation with plates and
screws
3. Oligotrophic: vascular but absent callus, after major displacement of fractures
and distraction of fragments
Avascular non-union: lack adequate vascularity and display no callus
1. Torsion-wedge
2. Communited
3. Defect
4. Atrophic
Torsion-wedge
- Intermediate fragment has decreased or absent blood supply
- This fragment is healed to one fragment but not to other
- E.g., tibial fracture treated with plates and screws
Communited
- One or more intermediate fragments are necrotic
- E.g., breakage of plate
Defect
- Loss of fragments of the diaphysis of bone
- After open fractures, sequesterectomy, resection of tumours
Atrophic
- Fracture fragments atrophic and osteoporotic
- Intermediate fragments missing
- Scar tissue lacking osteogenic potential in place
Classification of non-union of tibia by Paley et.al. [Dorr Paley]
- Type A: non-union less than 1 cm
- Type B: non-union more than 1 cm
1. B1: bone defect
2. B2: loss of bone length
3. B3: both
- Type A1: mobile
- A2: stiff

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 1. A 2-1: stiff non-union without deformity
2. A 2-2: stiff non-union with fixed deformity
- Both of these classification modified by presence or absence of infection

On the basis of bone end:

a. Cynlindrical
b. Rhomboidal
c. Pencil like
d. Trapezoidal
e. Marginal
Management
1. Pre-operative workup
a) History, physical examination, radiographic examination and laboratory
evaluation
2. History
a) Mechanism of injury
b) Prior surgical and non-surgical interventions

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 c) Previous treatment and time frame
d) Signs and symptoms consistent with current or previous infection
e) Presence or absence of pain
3. Physical examination
a) Detailed neuro vascular assessment
b) Status of soft tissue envelope, prior incisions, flaps, area of compromised
skin
c) Assessment of the stability or stiffness of non-union
d) Evaluation of deformity, limb-length discrepancy, joint range of motion,
compensatory contractures, erythema, drainage
4. Radiographic
a) Orthogonal radiographs to assess union, monitor progress towards union,
determining etiology, evaluating integrity of implants and checking for
infection
b) Comparision views of contralateral limb
c) CT scan and MRI needed occasionally
5. Laboratory evaluation
a) CBC, ESR, CRP and 25-hydroxy vitamin D
6. Treatment Options –
a) Non-invasive – casting or bracing, LIPUS, electric or electromagnetic
stimulation, ESWT
b) Invasive – bone grafting (or alternatives) and stabilization
c) Operations should be undertaken only after nonunion has been shown
clinically and radiographically or when union is extremely unlikely or
impossible without change in current treatment
d) Requirements of successful nonunion
 Biomechanical stability and biological viability of bone

e) Hypertrophic non-union
 Since the non-union has adequate biology, surgery must provide
appropriate stability. Stability can be provided by plates and
screws, locked intramedullary nailing, ringed external fixators
 Take down of non-union is often unnecessary, except to correct
associated deformity
f) Oligotrophic non-union
 Require biologic stimulus with bone grafting
g) Atrophic nonunions
 Resection of avascular bone required to achieve apposition of
healthy viable bone
 Provision of biologic stimulus through autologous bone grafting
h) Pseudoarthrosis

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  Complete surgical takedown with excision of atrophic bone ends,
followed by treatment according to same principles as that of
atrophic nonunions
i) Infected nonunion
 Treatment goals
a) Removal of all infected and divitalized bone and soft tissue
b) Sterilization of local environment with local wound
management techniques (antibiotic beads, VAC)
c) Creation of healthy bone ends with a well vascularized soft
tissue envelope
d) Stable fixation
 Achieving these goals often requires staged approach with multiple
surgeries
 If substantial bone loss is present, bone transport or later limb
lengthening using the Ilizarov method is often beneficial
 If soft tissue envelope is already scarred or becomes deficient after
treatment, free muscle or fasciocutaneous flap can be essential
Management of infected non-union (Campbell)
1. Conventional or classic treatment
2. Active treatment
3. Ilizarov method
- One or other methods can be performed wholly or in part, depending upon the
circumstances of the patient and judgement of surgeon
- Gold standard for diagnosis of infection is the multiple direct cultures of the fracture site
(not skin or sinus tract)
Conventional treatment
- Convert an infected and draining nonunion into one that has not drained for several
months and to promote healing of the nonunion by bone grafting
- Debridement is performed with removal of all foreign, infected, or devitalized materials
to provide a vascular bed.
- Bone grafting is deferred till soft tissues are completely healed and stabilized
- In tibia, anterior aspect is avoided, because draining sinuses and poor skin are usually
located here.
- The posterior aspect of the tibia (or the tibia and fibula) is decorticated proximal and
distal to the nonunion. The entire area is grafted with autogenous cancellous iliac crest
Active Treatment
- Obtain bony union early and shorten the period of convalescence and preserve motion in
adjacent joints.
- External fixation, debridement and bone graft followed by internal fixation after the
infection has healed and finally skin grafting if necessary.
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