Tibial Nonunions 

  • Author: Minoo Patel, MBBS, MS, FRACS; Chief Editor: Carlos J Lavernia, MD, FAAOS   more...
 
Updated: Feb 6, 2012
 

Background

Tibial fractures can now be treated successfully in the majority of patients, yet nonunions of the tibia are not uncommon (see images below). They may result in significant morbidity, require numerous operative procedures to treat, and leave the patient with functional deficits.

Tibial nonunions. Anteroposterior radiograph of psTibial nonunions. Anteroposterior radiograph of pseudoarthrosis with nonunion. Tibial nonunions. Patient with pseudoarthrosis aftTibial nonunions. Patient with pseudoarthrosis after failure of internal fixation and bone stimulation.

The subcutaneous position of the tibia results in a greater incidence of open fractures and provides less soft-tissue coverage, factors that produce a higher incidence of nonunion and infected nonunion. Although appropriate and prompt treatment is needed to treat tibial injuries successfully, the incidence of a nonunion is more closely related to the fracture characteristics than subsequent treatment. Establish realistic expectations of the outcome with the patient as early in the treatment course as possible, preferably prior to treatment intervention.[1]

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Epidemiology

Frequency

Tibial nonunions are estimated to constitute 2-10% of all tibial fractures. The incidence is greater with high-energy injuries and open fractures. The National Center for Health Statistics has reported that close to 500,000 tibia and fibula fractures occur each year in the United States.

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Etiology

The development of a tibial nonunion is related most often to the type and degree of injury, but several additional factors may predispose a patient to a tibial nonunion, such as the degree of fracture comminution and bone loss, whether the fracture is open, and the degree of soft-tissue injury. Subsequent complications, such as infection or compartment syndrome may play a role.[2]

In a prospective, observational study of 416 patients from 41 trauma centers operatively treated for tibial shaft fractures, delayed healing or nonunion occurred in 13%. Open fractures with injuries less than 5 cm were 3.6 times as likely to have delayed healing or nonunion as closed fractures; for open fractures greater than 5 cm, the likelihood of delayed healing or nonunion was 5.7 times greater than that for closed fractures. Healing problems were twice as great for distal shaft fractures and fractures with a postoperative diastasis.[3, 4]

The patient profile also contributes to the incidence of nonunion. Cigarette smoking is well documented to place the patient at a higher risk of delayed healing or nonunion.[5] The use of nonsteroidal anti-inflammatory medications may inhibit bone healing, as can the nutritional status of the patient and compliance with the postoperative regimen. Finally, prompt and appropriate treatment is needed because iatrogenic injury to the soft-tissue envelope (ie, excessive periosteal stripping), distraction across the fracture site, inadequate immobilization or fixation, and the splinting effect of an intact fibula may contribute to the development of a nonunion.

Historically, the definition of delayed union and nonunion have been based on time from the onset of injury. More recently, the exact time frames are considered to be less important. Fracture healing is a dynamic, progressive process, and intervention is warranted within 3-5 months after injury if monthly radiographic studies do not show progression of fracture healing.[6]

Typically, delayed union is a term used for a fracture that has not united within a period of time that would be considered adequate for bone healing. Delayed union suggests that union is slow but will eventually occur without additional surgical or nonsurgical intervention. The time frame is different for different fractures. Tibial diaphyseal fractures that do not show enough bridging callus to achieve clinical stability by 16 weeks are considered to be delayed union fractures.[6] Nonunion refers to a fracture that will not unite without additional surgical or nonsurgical intervention (usually by 6-9 mo).

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Pathophysiology

Classification

The Weber-Cech classification is the one most widely used.[7] Fractures are classified according to radiographic appearance, which correlates with the fracture biology, as follows:

  • Hypertrophic nonunions are tibial nonunions that show prolific callus formation. These nonunions are vascular and have excellent healing potential given the right environment. Hypertrophic nonunions result from inadequate immobilization of the fracture.
  • Atrophic nonunions are characterized by an absence of callus and atrophic bone ends, which may be tapered and osteopenic or sclerotic. Bone vascularity is deficient, and the bone has poor healing potential. A special subgroup of atrophic nonunions consists of those that form a fibrous capsule around a freely mobile nonunion. This cavity is filled with a viscous fluid, creating the appearance of a joint, and is referred to as a tibial pseudoarthrosis.
  • Normotrophic nonunions are nonunions that share the characteristics of both the atrophic and hypertrophic nonunions. The bone ends have moderate healing potential.

Determining whether evidence of infection is present at the nonunion site is critical.

Paley and Herzenberg classify nonunions according to clinical mobility as the following:

  1. Stiff (< 5º mobility)
  2. Partially mobile (5-20º mobility)
  3. Flail (>20 ºmobility)

The Paley-Herzenberg categories roughly correlate to the 3 Weber-Cech categories.

Congenital pseudoarthrosis of the tibia is a unique condition observed in children.[8, 9, 10] Neurofibromatosis and fibrous dysplasia are predisposing factors, although some are idiopathic in nature. The pathology seems to lie in the periosteum.

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Indications

Treatment principles and rationale

The treatment of a tibial nonunion depends of the fracture classification, location of the nonunion, lower extremity alignment, fracture stability, presence of infection, soft-tissue injury (including nerve deficits), and patient characteristics and possible concomitant injuries. A forthright discussion with the patient should be initiated, with the patient's wishes and the physician's experience taken into account.

In general, hypertrophic nonunions are treated with rigid stabilization with or without compression. Additional biologic stimulation in the form of bone grafting is not required.

Atrophic nonunions require augmentation to stimulate bone formation. This may require bone grafting, soft-tissue coverage, or other forms of biologic stimulation, such as bone morphogenetic proteins (BMPs).[11]

Infected nonunions should be treated in an attempt to sterilize the nonunion site, but stability of the fracture site should not be sacrificed.[12]

A treatment algorithm for tibial nonunions can be seen in the image below.

Treatment algorithm for tibial nonunions. Treatment algorithm for tibial nonunions.
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Relevant Anatomy

See Pathophysiology.

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Contraindications

Contraindications for operative management depend on a number of factors, all of which must be weighed carefully in the decision-making process. The overall health of the patient is critical to the decision-making process. If the patient is critically ill or has undergone multiple previous procedures without success, further treatment may not be possible or may be ill advised. Active infection modifies how and even whether the nonunion is treated. An injury to the neurovascular structures such that the foot is insensate may discourage heroic attempts for treatment of the nonunion. Amputation usually results in a quick return to activities, but it may result in overgrowth at the amputation site in children.

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Contributor Information and Disclosures
Author

Minoo Patel, MBBS, MS, FRACS  Senior Lecturer, Monash University; Director, Centre for Limb Reconstruction and Deformities, Epworth Centre, Melbourne, Australia; Orthopaedic Adult/Pediatric Surgeon, Epworth Hospital, Melbourne, Australia; Consulting Adult/Pediatric Orthopedic Surgeon, Department of Orthopedic Surgery, Monash Medical Center, Australia

Minoo Patel, MBBS, MS, FRACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, AO Foundation, Australian Association of Surgeons, Australian Medical Association, Australian Orthopaedic Association, Bombay Orthopedic Society, Indian Orthopedic Association, Orthopaedic Research Society, Orthopaedics Overseas, and Royal Australasian College of Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

James J McCarthy, MD, FAAOS, FAAP  Director, Division of Orthopedic Surgery, Cincinnati Children's Hospital; Professor, Department of Orthopedic Surgery, University of Cincinnati College of Medicine

James J McCarthy, MD, FAAOS, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Orthopaedic Surgeons, American Academy of Pediatrics, American Orthopaedic Association, Limb Lengthening and Reconstruction Society ASAMI-North America, Orthopaedics Overseas, Pediatric Orthopaedic Society of North America, Pennsylvania Medical Society, Pennsylvania Orthopaedic Society, and Philadelphia County Medical Society

Disclosure: Fixes-4-kids Ownership interest Consulting; Lippincott Williams and WIcins Royalty Editing textbook; OERHOPEDICS Royalty Editor

John Herzenberg, MD, FRCSC  Head of Pediatric Orthopedics, Director of International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore

John Herzenberg, MD, FRCSC is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Orthopaedic Surgeons, Limb Lengthening and Reconstruction Society ASAMI-North America, and Pediatric Orthopaedic Society of North America

Disclosure: Smith and Nephew, EBI, Orthofix Educational Grant None

Specialty Editor Board

Charles T Mehlman, DO, MPH  Professor of Pediatrics and Pediatric Orthopedic Surgery, Division of Pediatric Orthopedic Surgery, Director, Musculoskeletal Outcomes Research, Cincinnati Children's Hospital Medical Center

Charles T Mehlman, DO, MPH is a member of the following medical societies: American Academy of Pediatrics, American Fracture Association, American Medical Association, American Orthopaedic Foot and Ankle Society, American Osteopathic Association, Arthroscopy Association of North America, North American Spine Society, Ohio State Medical Association, Pediatric Orthopaedic Society of North America, and Scoliosis Research Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Thomas M DeBerardino, MD  Associate Professor, Department of Orthopedic Surgery, Consulting Surgeon, Sports Medicine, Arthroscopy and Reconstruction of the Knee, Hip and Shoulder, Team Physician, Orthopedic Consultant to UConn Department of Athletics, University of Connecticut Health Center

Thomas M DeBerardino, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, and American Orthopaedic Society for Sports Medicine

Disclosure: Arthrex, Inc. Grant/research funds Other; Arthrex, Inc. Consulting fee Speaking and teaching; Genzyme Biosurgery. Inc. Grant/research funds Other; Musculoskeletal Transplant Foundation Grant/research funds Other; Histogenics Grant/research funds None

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Carlos J Lavernia, MD, FAAOS  Adjunct Clinical Professor, Department of Orthopedic Surgery, University of Miami School of Medicine; Medical Director, Orthopedic Institute at Mercy Hospital

Carlos J Lavernia, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Hip and Knee Surgeons, Arthritis Foundation, Biomedical Engineering Society, Florida Orthopaedic Society, and Orthopaedic Research Society

Disclosure: Zimmer Stock Implant Designer

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Treatment algorithm for tibial nonunions.
Tibial nonunions. Anteroposterior radiograph of pseudoarthrosis with nonunion.
Tibial nonunions. Lateral radiograph of pseudoarthrosis with nonunion.
Tibial nonunions. Patient with pseudoarthrosis after failure of internal fixation and bone stimulation.
Tibial nonunions. Anteroposterior radiograph of tibial fracture after provisional fixation.
Tibial nonunions. Oblique view of tibial fracture after provisional fixation (note the fracture gap is not visible on the anteroposterior and lateral radiographs).
Tibial nonunions. Lateral radiograph of tibial fracture after provisional fixation.
Tibial nonunions. Close-up view of antibiotic bone cement beads.
 
 
 
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