Nonunions of

Long Bones
Robert Probe, MD
Scott & White Memorial Hospital
Texas A&M University Health Science Center
Original Author: Matthew J. Weresh, MD; March 2004;
New Author: Robert Probe, MD; Revised January 2007

Outline
Treatment Principles
Definition
Epidemiology
Etiology
Evaluation
Classification

Stabilization
Biologic

Specific Bones

Clavicle
Humerus
Forearm
Femur
Tibia

Definition
FDA: 9 months elapsed time with no healing
progress for 3 months.
Problems
Subjective
Arbitrary

Pragmatic: A fracture that has no potential to heal

without further intervention

Incidence
Between 5% and 10% of long bone fractures
Relative Risk depends upon:

Injury
Bone
Patient
Treatment

Nonunion under conditions of

Absolute Stability
Fracture gaps that exceed the
allowable distances for
primary or gap healing
Construct instability that
prevents primary healing

Nonunion under Conditions

of Relative Stability
Sufficient stability is not
imparted at the soft callus
stage to allow for
mineralization of the
chondroid matrix.
Instability prevents bringing
bone formation despite
biologic activity

Local Risk Factors

Open Fractures
High energy fractures
with bone devitalization
Severe associated soft
tissue injury
Bone loss
Infection

Systemic Risk Factors

Malnutrition
Smoking
NSAIDs
Systemic Medical
Conditions

Smoking and Tibial Fractures

Smokers

Non-smokers

Healing Time

32 wk

28 wk

Bone Graft
Required

26%

18%

Exchange Nail
Required

38%

26%

Adams Injury 2001

Non-steroidals and Healing

32 femoral nonunions compared with 67 that
healed uneventfully
No difference:
Smoking
Reaming
Locking

NSAIDs
Significant to P< 0.000001
Giannoudis JBJS-B 2000

Iatrogenic
Poor Reduction
Unstable fixation
Bone Devitalization

Iatrogenic Stripping
Indiscriminate devitalization (1)
Leads to limited healing potential and implant failure
(2,3)
Occasionally requiring resection and reconstruction
prior to healing (4,5)
1

Diagnosis Suspected When:

Persistent Pain
Non physiologic motion
Progressive deformity
No radiographic evidence of healing
Failing implants

Clinical Exam
Limb Stability
Limb alignment and length
Condition of the soft-tissue
envelope
Neurovascular exam

Radiologic Evaluation
Standard radiographs are often
diagnostic
45 degree oblique films can
increase diagnostic accuracy
Despite additional projections,
the potential for false-positive
results for fracture healing
remains

Clinical diagnosis can be confirmed and

information about stability obtained with
stress radiographs.

Varus

Valgus

Computed Tomography
Clarity when implants or fracture obliquity produce
doubt

Classification
Is there infection?
Is there deformity?
Define the biologic
activity and stability

Infection
MRI can play a role in identifying soft tissue
component; however, bone edema is too
sensitive to be accurate
Reliance on clinical diagnosis augmented by
CRP
Low virulence infection may require aspirate
or operative culture for diagnosis
Indium scan carries only moderate sensitivity
and specificity

Determine Deviations in:

Angulation
Length
Rotation
translation

Define the Level of Osteogenesis along

the Spectrum of Biologic Activity
hypertrophic

oligotrophic

atrophic

Inherent Biology

Weber & Cech: Pseudarthosis, 1976

Nonoperative Treatment
Electromagnetic
Direct Current
Inductive coupling (PEMF, CMF)
Capacitive coupling

Ultrasound
mechanical energy in the form of low frequency
acoustic waves
30 mW/cm2

Role of Nonoperative Modalities

All have clinical evidence to support
effectiveness
Few comparative studies between modalities
Few comparative studies between nonoperative
and operative methods
Best suited for hypertrophic nonunions with good
inherent stability
Does nothing to correct deformity or provide
immediate stability

Surgical Treatment:
Algorithm
Cure infection if present
Correct Deformity if significant
Provide stability through
implants
Add biologic stimulus when
necessary

Infected Nonunions
Contaminated implants and devitalized
implants must be removed
Infection treated:
Temporary stabilization (external fixation)
Culture specific antibiotics
+/- local antibiotic delivery (antibiobic beads)

Secondary stabilization with augmentation of

osteogenesis (cancellous grafting)

24 year male with

continued distal
osteolysis after
debridement,
antibiotics and local
beads

Hardware removed and

Infected bone debrided.

Once the infection

Was resolved, bone
Graft was applied and
Healing ensued.

Persistent drainage
And gross motion after
Multiple attempts at
Surgical treatment

Treatment consisted
Of resection of
Infected bone, acute
Shortening and
External fixation

Followed by proximal
Corticotomy and
Distraction to restore
length

Methods of Adding Stability

Cast/Brace rarely sufficient in nonunions
External Fixation
Plates
Intramedullary Devices

External Fixation
Largest indication is a
temporary stabilization
following infection
debridement
Also useful in correction
of stiff deformity and
lengthening

Plate Stabilization
Plates provide a powerful reduction tool
Surgical technique should strive for absolute
stability
Locking plates have improved stability and
fixation strength
Other relative indications:
Absent medullary canal
Metaphyseal nonunions
When open reduction or removal of prior implants
is required

Plate Stabilization
Multiple Indications for plate
Broken implants require that
removal
Metaphyseal nonunion
Significant deformity

Technique
Blade properly positioned in the
distal fragment
Reduction obtained by bringing
plate to the shaft
Absolute stability with lag screw
Nonunion was not exposed

Broken
plate

Nail Stabilization
Ideal case Femur or tibia with an
existing canal and no prior implants
Exchange nailing provides a good
option for the tibia and femur
Special equipment is often necessary
to traverse sclerotic canals

Adding Biology
Often unnecessary in hypertrophic cases with sufficient
inherent biologic activity
Options

Aspirated stem cells (with or without expansion)

Demineralized Bone Matrix
Autogenous Cancellous Graft
Growth Factors
Platelet derived
Recombinant BMPs
Gene Therapy

Autogenous Cancellous Bone

Sites

Posterior Iliac Crest (20 cc)

Anterior Iliac Crest (10cc)
Proximal Tibia (7cc)
Distal Radius, Calcaneus, Olecronon (?)

All series suggest some incidence of donor

morbidity dependent upon harvest site and
volume required
Still considered by many to be the most
osteogenic graft material

Demineralized Bone Matrix

Osteoinduction has been experimentally
demonstrated*
Osteoinductive ability appears variable
between products and donors
A consecutive series with historic controls
has demonstrated effectiveness in humeral
shaft nonunions
Avoids the morbidity of iliac crest graft
As effective as iliac crest ????? (doubtful
in the authors opinion)
*Hierholzer et al J Bone Joint Surg 2006

Stem Cells
Aspirated iliac crest stem
cells has been shown to
enhance the activity of
osteoconductive grafts
Has been studied as an
isolated technique with
limited success
Role of expansion and
delayed implantation may
play a future role

Recombinant Bone Morphogenic

Proteins
BMP-2
Infuse
Demonstrated effective in acute open

tibial fractures
FDA approved in acute fractures

BMP-7
OP-1
Comparable to autograft in tibia

nonunions
FDA approved under HD exemption

BMP-2 for Open Tibial Fractures:

Prospective & Randomized with 450 Patients
Results
High dose BMP-2 treatment led to
44% reduction in risk of
nonunion/delayed union
Significantly fewer invasive interventions
Significantly faster fracture healing
Significantly fewer hardware failures and fewer
infections

BESTT Study Group, et al. J Bone Joint Surg 84A: 2123, 2002.

OP-1 in Tibial Nonunions

Prospective,

randomized study
122 patients with 124
tibial nonunions

Treatment
IM nail
70 % exchange nail
20 % new 1 nail
10 % maintained
prior nail
OP-1/collagen vs. ICBC
Clinical success:
81% BMP7
85% ICBG

Friedlaender GE et al, J Bone Joint Surg, 2001: 83A, Suppl 1; S1-151.

Ongoing Osteoinductive Research will

likely change the futureImproved understanding of
BMPs
Optimize BMP carriers
Explore role of expanded
stem cell lines
Role of gene therapy
Reduce the cost of
production of inductive
agents

DNA coding for growth factor released

growth factor
from cell

adenoviral
vector carrying
growth factor
gene

cell

making
ribosomes
growth factors
nucleus

Osteoinduction Summary
The diversity and limited numbers of nonunions make
Level 1 studies rare
Personal Opinion:

Nothing in hypertrophic or rodded nonunions

DBM in biologically friendly environments (humerus)
Autologous cancellous graft in challenging cases
BMP when ABG has failed or is not feasible

Specific Anatomic Sites

Clavicle
Humerus
Forearm
Femur
Tibia
Metaphyseal

Clavicle Nonunions
Middle 1/3 treated with
compression plating +/graft
Anterior or superior plate
position
95% union reported*
Lateral 1/3 treated with
ORIF or excision and
ligament reconstruction

*Ballmer J Shoulder Elbow Surg 1998

HUMERAL NONUNION
24 patients age 52-86yrs
(ave 72yrs)
Locking compression
plate with bone graft or
DBM
All healed 2 of the
DBM cases needed
secondary surgery for
bone grafting

Ring et al, CORR 425, 2004

Humeral Failed Intramedullary

Treatment
Avoid the temptation to
Perform exchange nailing
Union rates with exchange nailing
McKee
60%
Robinson
40%
Flinkkilla
46%
Recommended treatment is
rod removal and plating

Forearm
Compression plating for hypertrophic
nonunions
Critical attention to preservation of radial bow
and radio-ulnar relationship
Cancellous graft for atrophic nonunion or bone
loss

Forearm Nonunion with Bone Loss

35 patients, both bones 8,
ulna 11, radius 16
All with segmental defects
Treatment

Grafted defect

3.5 plates, autologous

cancellous bone graft
All nonunions healed
Improved function
Ring et al. JBJS 86A 2004

Femoral Nonunions
Low incidence with
good primary surgery
Stabilization may be
performed with either
plate or rod
Despite the rarity, cases
can become challenging
as evidenced by this
case
Dynamization
Plating
Revision
failed
plating
failed
to
work
to
work
Primary
surgery.
A short
Femoral
nailing
and
Failed
tohas
work
Nail Grafting
was
chosen
because
failed to
of intertrochanteric
work fracture.

Exchange Nailing
12 series in English
Literature between 1975 and
2006 (462 pts)
Success Rates
Average succcess of 89%
Range of 53%-100%

Necessary to change from

retrograde to antegrade?

Retrograde
nail

Antegrade
exchage

Healed

Plate to Nail
Jackson, 2001 - 13/14 (93%)
healed
Wu et al., Arch Ortho Trauma
Surg 1999
21 nailings after failed plating
21 / 21 healed

Plating of Femoral Nonunion

10 English series
between 1969 and 2006
(195 patients)
Success Rate
Average 89%
Range 63% to 100%

PLATING FEMORAL
NONUNIONS AFTER FAILED
NAILING
23 NONUNIONS
BLADE PLATE
4.5 LCDCP
BONE GRAFT
21 HEALED BY 12
WEEKS
2 REQUIRED REVISION
Bellabarba et al.J Ortho Trauma 2001; 254-63

All Paths are Reasonable under

Clinical Circumstances

Plate

Plate

Nail

Nail

Femoral Nonunion Guidelines

ORIF and bone graft
Deformity
Absent medullary canal
Atrophic

Exchange nailing
well aligned
Hypertrophic
Limited concern over infection

Tibial Intramedullary Nailing

for Nonunion
Indications:
Correctable alignment
Demonstrated biology
Reconstructable canal

Relative Contraindications
Previous infected pin sites
History of infection

Exchange Nailing for Tibial Nonunion

Indicated for isthmic
fractures that are not
infected
Increase nail diameter by
2mm
95% success rate*
Bone loss >50
circumference is a relative
contraindication
*Zelle et al J Trauma 2004

Addition of Posterolateral ICBG when

there is Substantial Bone Loss
2 years post fracture

Exchange nail with ICBG

Healed

Plating Tibial Nonunions

Indications

No canal
Stiff deformity
Prior external fixation
Need for graft

Relative
Contraindications
Poor soft-tissues

Note the plate used as a

reduction tool in this
case

Compression Plating for Tibial

Nonunions
50 patients with nonunion
following external fixation
External fixation averaged 8
weeks
Injury to plating averaged 8
months
Average deformity of 15 degrees
Post-op
92% union
4 deg angulation
Wiss JBJS-A 1992

Unique Challenges
of Metaphyseal Nonunions
Small articular segments
Joint contracture
Post-traumatic chondral changes
Residua from prior surgery

Devitalized bone
Infection
Fractured implants
Implant tracts

This implant is
failing under the
high bending
forces in the
subtrochanteric zone.

An intramedullary
implant was chosen
because of the reduced
bending moment.

Hypertrophic nonunion
With 30 degree sagital
deformity

Correction of
Deformity with
Absolute stability.
No graft was used
In this hypertrophic
case

Articular nonunions
present challenges
of arthrofibrosis and
small fragments

however, they
may be successfully
reconstructed if
satisfactory cartilage
remains.

Metaphyseal nonunion
with significant
chondral loss

Both the postTraumatic arthritis

And nonunion treated
simultaneously

In certain nonunions,
a deleterious
mechanical environment
may lead to nonunion

In this case of femoral

neck nonunion, shear
forces are converted
into compressive ones
by closing wedge
osteotomy.

In other instances, bone

loss and osteopenia may
make prosthetic replacement
a preferable option. This is
particularly true in the
proximal femur

..and increasingly
in other joints as
prosthetic replacements
continue to improve.

Traumatic Bone Loss

Reconstructive planning
and intervention should
begin prior to meeting
the time requirements
for nonunions
Options
Distraction osteogenesis
Iliac crest bone grafting
BMP reconstruction

Tibial Bone Defects Tx with

Ilizarov Techniques
27 tibial defects ave size 8.3 cm
Docking grafting in 25
Acute shortening in 10
Ave time of fixation was 8 months
Bone union in all cases

Song International Orthopaedics 1998

Diaphyseal Nonunion Summary

Careful assessment
Infection
Deformity
Biologic activity

Create viable bone and soft tissue

Correct the deformity
Provide stability
Osteoinduction when necessary
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