Aim: Non-unions have been traditionally classified as atrophic, oligotrophic and hypertrophic and their management was primarily dictated by that. In our Unit, we have based our treatment rationale mainly on the stability of the metalwork and the presence of symptoms rather than the radiologic appearance of the non-union or the presence of infection. The aim was to present the treatment algorithm for lower limb long bone non-union following operative fixation.
Materials and methods: All patients treated for a femoral or tibial non-union following fixation between 2014 and 2020 in our unit and with a minimum follow-up of 2 years were included. Non-union was defined as having no evidence of fracture healing in any cortices six months after the index procedure. Union was defined as bridging callus in at least three cortices visualized on at least two orthogonal radiographs. Information retrieved included demographic and fracture characteristics, presence of infection, evidence of metalwork stability and treatment. Outcome measures included union rate, time to union and complications. Data were analysed with the Statistical Program for Social Sciences (SPSS) using contingency tables and linear regression. A p-value of less than 0.05 was considered statistically significant.
Results: Seventy-seven consecutive patients were included in the study. Union was achieved in 91% of the cases, while union was noted in all the patients treated non-operatively. The mean time to union was 14.49 months (9.98). Complications were encountered in 20 of the patients and the most common were docking site non-union and metalwork breakage. Infection was the only factor that affected time to union in a statistically significant manner (p = 0.006).
Conclusion: The results of our study suggest that in cases of long bone non-union following operative fixation using signs of metalwork instability and the presence of clinical symptoms as the main indication for surgical intervention provides a satisfactory outcome. This approach prevented operative management in a large proportion of patients.
Clinical significance: This article presents an algorithmic approach that could aid clinicians in their decision-making in long-bone non-union management.
Level of evidence: Therapeutic level III.
Mills LA, Simpson AHRW. The relative incidence of fracture non-union in the Scottish population (5.17 million): A 5-year epidemiological study. BMJ Open 2013;3(2):e002276. DOI: 10.1136/bmjopen-2012-002276.
Kanakaris NK, Giannoudis PV. The health economics of the treatment of long-bone non-unions. Injury 2007;38(Suppl. 2):S77–S84. DOI: 10.1016/s0020-1383(07)80012-x.
Stewart SK. Fracture non-union: A review of clinical challenges and future research needs. Malays Orthop J 2019;13:1–10. DOI: 10.5704/MOJ.1907.001.
Calori GM, Phillips M, Jeetle S, et al. Classification of non-union: Need for a new scoring system? Injury 2008;39(Suppl. 2):S59–S63. DOI: 10.1016/S0020-1383(08)70016-0.
Rupp M, Biehl C, Budak M, et al. Diaphyseal long bone nonunions: Types, aetiology, economics, and treatment recommendations. Int Orthop 2018;42(2):247–258. DOI: 10.1007/s00264-017-3734-5.
Schmal H, Brix M, Bue M, et al. Nonunion: Consensus from the 4th annual meeting of the Danish Orthopaedic Trauma Society. EFORT Open Rev 2020;5:46–57. DOI: 10.1302/2058-5241.5.190037.
Hlukha L, Alrabai HM, Sax O, et al. Mechanical failures in magnetic intramedullary lengthening nails. J Bone Joint Surg 2022;105(2):113–127. DOI: 10.2106/JBJS.22.00283.
Andrzejowski P, Giannoudis PV. The ‘diamond concept’ for long bone non-union management. J Orthop Traumatol 2019;20(1):21. DOI: 10.1186/s10195-019-0528-0.
Giannoudis PV, Gudipati S, Harwood P, et al. Long bone non-unions treated with the diamond concept: A case series of 64 patients. Injury 2015;46(Suppl. 8):S48–S54. DOI: 10.1016/S0020-1383(15)30055-3.
Haubruck P, Tanner MC, Vlachopoulos W, et al. Comparison of the clinical effectiveness of bone morphogenic protein (BMP)-2 and -7 in the adjunct treatment of lower limb nonunions. Orthop Traumatol Surg Res 2018;104(8):1241–1248. DOI: 10.1016/j.otsr.2018.08.008.
Moghaddam A, Zietzschmann S, Bruckner T, et al. Treatment of atrophic tibia non-unions according to ‘diamond concept’: Results of one- and two-step treatment. Injury 2015;46(Suppl. 4):S39–S50. DOI: 10.1016/S0020-1383(15)30017-6.
Ollivier M, Gay AM, Cellier A, et al. Can we achieve bone healing using the diamond concept without bone grafting for recalcitrant tibial nonunions? Injury 2015;46(7):1383–1388. DOI: 10.1016/j.injury.2015.03.036.
Bilgili F, Balci HI, Karaytug K, et al. Can normal fracture healing be achieved when the implant is retained on the basis of infection? An experimental animal model. Clin Orthop Relat Res 2015;473(10):3190–196. DOI: 10.1007/s11999-015-4331-9.
Croes M, van der Wal BCH, Vogely HC. Impact of bacterial infections on osteogenesis: Evidence from in vivo studies. J Orthop Res 2019;37(10):2067–2076. DOI: 10.1002/jor.24422.
Croes M, Boot W, Kruyt MC, et al. Inflammation-induced osteogenesis in a Rabbit Tibia Model. Tissue Eng Part C Methods 2017;23(11):673–685. DOI: 10.1089/ten.TEC.2017.0151.