eMedicine Specialties > Orthopedic Surgery > Knee

Tibial Nonunions

Minoo Patel, MBBS, MD, MS, FRACS, Senior Lecturer, Monash University; Consulting Adult/Pediatric Orthopedic Surgeon, Department of Orthopedic Surgery, Monash Medical Center, Australia
James J McCarthy, MD, FAAOS, FAAP, Associate Professor, Consulting Orthopedic Surgeon, Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health;; John Herzenberg, MD, FRCSC, Head of Pediatric Orthopedics, Co-director of International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore

Updated: Apr 9, 2009

Introduction

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

Tibial nonunions. Anteroposterior radiograph of pseudoarthrosis with nonunion.

Tibial nonunions. Patient with pseudoarthrosis after failure of internal fixation and bone stimulation.

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.

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

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.⁴ 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.⁵

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.⁵ Nonunion refers to a fracture that will not unite without additional surgical or nonsurgical intervention (usually by 6-9 mo).

Pathophysiology

The Weber-Cech classification is the one most widely used.⁶ 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.^7,8,9 Neurofibromatosis and fibrous dysplasia are predisposing factors, although some are idiopathic in nature. The pathology seems to lie in the periosteum.

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).¹⁰

Infected nonunions should be treated in an attempt to sterilize the nonunion site, but stability of the fracture site should not be sacrificed.¹¹

Treatment algorithm for tibial nonunions.

Relevant Anatomy

See Pathophysiology.

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.

Workup

Laboratory Studies

• The most critical step in the workup is to review the patient's prior history carefully, through evaluation of previous records, imaging studies, and discussion with the patient and previous treating physicians. Most often, the nonunion has occurred despite appropriate care, and rushing into treatment without a good understanding of why the nonunion occurred and how treatment will overcome these obstacles is a mistake.
• The role of the diagnostic workup is 3-fold. The first goal is to assess the patient to determine if he or she is able to undergo successful surgery. This obviously implies a routine preoperative assessment, but more specific laboratory tests may be indicated in an effort to determine if any systemic factors contribute to the failure of union. Laboratory assessment to determine the patient's nutritional status may be indicated. The total lymphocyte count and Rainey-MacDonald nutritional index may be helpful in identifying patients who may (or may not) develop infections after long-bone fractures.^12,13
• The second goal is to assess for any signs of infection. Evaluation with a routine complete blood cell count (CBC), sedimentation rate, and C-reactive protein (CRP) may be helpful. The CRP is the most accurate indicator of infection, but it is not necessarily specific for infection.¹⁴ Cultures may be helpful, but findings are often negative, especially if the patient has been treated with antibiotics.

Imaging Studies

• The third goal of the diagnostic workup is to assess fracture deformity. Plain radiography is typically the most helpful tool. The deformity must be assessed in both anteroposterior (AP) and lateral planes, with resolution of the plane and degree of maximum deformity. Any rotational component must be assessed either clinically or with CT scanning. Leg-length equality should be determined clinically or more accurately with scanography. Finally, fracture stability must be determined. Often, the fracture nonunion is difficult to assess on plain radiography; fluoroscopy, CT scanning, or tomography may be helpful. Assessment of the fibula is important to determine whether it is preventing tibial union.
• MRI is probably the most sensitive and specific study for osteomyelitis, with an accuracy of over 90%.¹⁵ It also provides additional information regarding the anatomy and location of infected bone, sinus tracks, and sequestrums. Unfortunately, MRI is less effective if residual hardware is present, and other studies may be more appropriate. Technetium-99m diphosphonate bone scanning has been used in an attempt to identify infections, but it is not specific for infection. However, combining this scan with indium-111–labeled leukocyte imaging increases the accuracy to 82%.¹⁶

Other Tests

• Vascular studies may be indicated if prior injury is a concern or if a free soft-tissue transfer is indicated. Consultation with a plastic surgeon may be warranted. Careful assessment and documentation of skin integrity and motor and sensory function are critical for surgical planning.

Histologic Findings

A histologic assessment may be helpful and has been shown to have a high sensitivity (87%) and specificity (100%) when assessing nonunion for the possibility of infection, especially when microbiologic findings are inconclusive.¹⁷

Treatment

Medical Therapy

Nonoperative methods

Nonoperative methods should always be considered, and although they are rarely considered the definitive treatment, they may be helpful as adjunctive therapy or as a temporizing option.

• Functional cast bracing may be considered for selective cases. In a study by Sarmiento, this treatment was unsuccessful in fewer than 10% of patients, although the majority of patients also had fibular osteotomies and/or bone grafting.¹⁸ This is especially common in patients at the extremes of age. Geriatric patients, especially those who are not fit for major surgery, can be treated successfully with a cast brace. Meticulous attention is required for the condition of the skin. Pediatric nonunions (not congenital pseudoarthrosis) generally result from open fractures with soft-tissue stripping and bone devascularization. Functional cast bracing is an effective method for achieving union.

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.

• Pulsed electromagnetic stimulation has been shown to be an effective modality, especially for hypertrophic nonunions, but it does not address issues of instability, deformity, or leg-length inequality.^19,20,21
• Low-frequency ultrasonography has been shown to decrease fracture healing time.²² A meta-analysis that reviewed 138 articles (of which only 6 met their rigorous inclusion criteria) reported that fracture healing was found to occur about 2 months sooner with the use of ultrasonography.²³

Surgical Therapy

Treatment principles and rationale

Hypertrophic nonunion

Hypertrophic nonunions display extensive callus formation. These vascular nonunions have excellent healing potential. They are best treated with rigid stabilization with or without compression. Additional biologic stimulation in the form of bone grafting is not required.

Atrophic nonunion

Atrophic nonunions are characterized by an absence of callus, deficient bone vascularity, and poor healing potential. Debridement of all necrotic tissue is necessary, with opposition of viable and vascular bone fragments. In addition, biologic stimulation is required. Historically, this has taken the form of bone grafting, preferably autograft, which is osteogenic, osteoconductive, and osteoinductive. The posterolateral approach usually is preferred to the anterolateral approach because greater space is available for bone grafting and an additional incision through the previous scar is avoided. The posterolateral approach should not be used in proximal-third tibial fractures because of the high risk of injury to the neurovascular structures.

Bone marrow injection has been shown to be an easy and effective treatment. This should be accomplished with the aid of fluoroscopy. Marrow is harvested from the iliac crest and injected directly into the posterior fracture site. In one study, 9 of 11 nonunions healed within 4-23 weeks, without further surgery.²⁴

The use of bone morphogenetic protein (BMP) and other osteoinductive agents has gained increased support experimentally and clinically.^10,25,26 With high costs and limited clinical applications, indications are still being determined.²⁷

Surgical treatment

Principles of surgical treatment include the incorporation of the following:

• Fibular osteotomy
• Removal of ineffective, broken, or infected hardware
• Use of biologic bone enhancement
• Bone stabilization
• Eradication of infection

A fibular osteotomy should be used if the fibula is felt to be inhibiting compression across the tibial nonunion site. This is usually performed in combination with other procedures and is used as an isolated procedure only if a stable noninfected hypertrophic nonunion with little or no deformity is present. Usually a small segment of bone is removed (1-2 cm).

Removal of necrotic or infected bone must be performed for a union to occur. This may involve the need for significant bone graft, shortening, or bone transport.

Bony alignment and stability are essential for satisfactory treatment of a tibial nonunion. The use of a reamed intramedullary (IM) nail is an excellent method of treatment of noninfected nonunions, especially in the middle three fifths of the tibia.²⁸ Conversion from a nonreamed nail or plate in closed and grade I or II open fractures with no evidence of infection is the primary indication. This technique has the advantage of early rehabilitation and maintenance of the alignment, and the reaming may act as a bone graft at the fracture site.

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, see Images 5 and 7 in Multimedia).

Tibial nonunions. Lateral radiograph of tibial fracture after provisional fixation.

Compression plating has also been shown to be effective for treating tibial nonunions. Wiss treated 49 patients with a tibial nonunion after initial external fixation.³⁰ The patients demonstrated a 92% healing rate in a mean of 7 months with no further treatment. Compression plating has the advantage of being applied anywhere along the tibia, and casting is usually unnecessary. However, it may contribute to difficulties with wound healing and can potentially devascularize a segment of bone. Handle the soft tissues in an atraumatic manner. Keep dissection and periosteal stripping to a minimum. Additionally, in patients with poor bone quality, the fixation is less secure. The use of a locking custom blade plate for periarticular nonunions has been described.³¹

The use of external fixation, especially small-wire and hybrid external fixation, is an excellent option for the treatment of tibial nonunions, especially if the fracture is very proximal or distal (periarticular), if significant bone loss occurred, if deformity (including shortening) is significant, or if ongoing infection is present. The use of external fixation allows for the treatment of multiple issues concurrently. External fixation can provide for stability of the fracture site, even in very proximal or distal fractures, with the use of fine-wire fixation. Large infected bone segments can be removed and grafted, or a shortening can be performed.³²

Limb-length equalization can be performed with bone transport or as an isolated procedure after union has occurred. Adjunctive therapy, such as the use of antibiotic bone cement or bone substitute beads, can easily be incorporated, and stabilization with external fixation usually provides for access if soft-tissue grafts are needed.

Tibial nonunions. Close-up view of antibiotic bone cement beads.

Complications

Most complications that occur in the treatment of nonunions are an extension of the existing condition, but approach all tibial nonunions with great care to avoid making a bad situation worse. Possibly the greatest concern is creating an infected nonunion from an aseptic nonunion. In a 1994 study by Wu, a 13% rate of infection occurred, regardless of treatment technique (ie, compression plating vs IM nailing).³³ The conversion from external fixation to IM nailing should be avoided if possible.³⁴ Malalignment, shortening, and continued nonunion may also occur, as well as graft-site morbidity (if autograft is used). Other complications, such as neurovascular injury, compartment syndrome, persistent nonunion, and ultimately amputation, may also result.

Outcome and Prognosis

Little documentation exists in the literature regarding the functional outcomes of patients treated for tibial nonunions.³⁵ Discussing the potential limitations in future functional abilities with the patient is critical. Fracture healing does not mean full function, and residual weakness, pain, and limitations in function are common, even in appropriately treated patients with clinically successful outcomes.

Future and Controversies

The use of adjunctive treatment modalities continues to be the most controversial topic, including the need and indication for electrical stimulation, ultrasonography, various synthetic bone osteoconductive carriers, and osteoinductive bone growth factors (such as bone morphogenetic proteins¹⁰ ).

Multimedia

Media file 1: Treatment algorithm for tibial nonunions.

Media file 2: Tibial nonunions. Anteroposterior radiograph of pseudoarthrosis with nonunion.

Media file 3: Tibial nonunions. Lateral radiograph of pseudoarthrosis with nonunion.

Media file 4: Tibial nonunions. Patient with pseudoarthrosis after failure of internal fixation and bone stimulation.

Media file 5: Tibial nonunions. Anteroposterior radiograph of tibial fracture after provisional fixation.

Media file 6: Tibial nonunions. Oblique view of tibial fracture after provisional fixation (note the fracture gap is not visible on the anteroposterior and lateral radiographs, see Images 5 and 7 in Multimedia).

Media file 7: Tibial nonunions. Lateral radiograph of tibial fracture after provisional fixation.

Media file 8: Tibial nonunions. Close-up view of antibiotic bone cement beads.

References

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Keywords

tibial nonunion, tibial delayed union, aseptic nonunion, infected nonunion, tibial fractures, fractures of the tibia, fractured tibia, nonunions of the tibia, broken leg, leg fracture, delayed healing, hypertrophic nonunions, atrophic nonunions, normotrophic nonunions, long bone fractures, bone morphogenic protein, bone morphogenetic protein, BMP

Contributor Information and Disclosures

Author

Minoo Patel, MBBS, MD, MS, FRACS, Senior Lecturer, Monash University; Consulting Adult/Pediatric Orthopedic Surgeon, Department of Orthopedic Surgery, Monash Medical Center, Australia
Minoo Patel, MBBS, MD, 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, Orthopaedic Research Society, Orthopaedics Overseas, Pediatric Orthopaedic Society of North America, and Royal Australasian College of Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

James J McCarthy, MD, FAAOS, FAAP, Associate Professor, Consulting Orthopedic Surgeon, Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health;
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: Nothing to disclose.

John Herzenberg, MD, FRCSC, Head of Pediatric Orthopedics, Co-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: Nothing to disclose.

Medical Editor

Charles T Mehlman, DO, MPH, Director, Musculoskeletal Outcomes Research, Associate Professor, Division of Pediatric Orthopedic Surgery, 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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Thomas M DeBerardino, MD, Director, John A Feagin, Jr, Sports Medicine Fellowship at West Point, Associate Professor of Orthopedic Surgery, Uniformed Services University of the Health Sciences and Keller Army Community Hospital
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 None; Arthrex, Inc. Honoraria Speaking and teaching; Genzyme Biosurgery. Inc. Grant/research funds Other; Musculoskeletal Transplant Foundation Grant/research funds Other; Histogenics Grant/research funds None

CME Editor

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, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of 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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