Tibial Nonunions Treatment & Management

Updated: Oct 17, 2018
  • Author: Minoo Patel, MBBS, PhD, MS, FRACS; Chief Editor: Thomas M DeBerardino, MD  more...
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Treatment

Approach Considerations

Treatment of a tibial nonunion (see the image below) depends on 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.

Treatment algorithm for tibial nonunions. Treatment algorithm for tibial nonunions.

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) [23]  or autologous mesenchymal stem cells. [24] Infected nonunions should be treated in an attempt to sterilize the nonunion site, but stability of the fracture site should not be sacrificed. [25]

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.

The use of adjunctive treatment modalities continues to be the most controversial aspect of therapy, including the need and indication for electrical stimulation, ultrasound, various synthetic bone osteoconductive carriers, and osteoinductive bone growth factors (such as BMPs [23] ).

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Nonoperative Therapy

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

Functional cast bracing may be considered for selected cases. In a study by Sarmiento, this treatment was unsuccessful in fewer than 10% of patients, though the majority of patients also had fibular osteotomies and/or bone grafting. [26] This is especially common in patients at the extremes of age. Geriatric patients, especially those who are unfit 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 pseudarthrosis) generally result from open fractures with soft-tissue stripping and bone devascularization. Functional cast bracing is an effective method for achieving union.

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. [27, 28, 29]

Low-frequency ultrasound has been shown to decrease fracture healing time. [30] A meta-analysis that reviewed 138 articles (of which only six met the authors' rigorous inclusion criteria) reported that fracture healing occurred about 2 months sooner with the use of ultrasound therapy. [31]

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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, biologic stimulation 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, nine of 11 nonunions healed within 4-23 weeks, without further surgery. [32]

Sugaya et al evaluated the efficacy of percutaneous autologous concentrated bone marrow grafting in 17 cases of fracture nonunion (femur, 10 cases; tibia, five cases; humerus, one case; ulna, one case). [33] By 6 months after grafting, healing of the nonunion had occurred in 11 of the 17 patients; by 12 months, healing had occurred in 13 of the patients.

The use of BMPs and other osteoinductive agents has gained increased support experimentally and clinically. [23, 34, 35] With high costs and limited clinical applications, indications are still being determined. [36]

Surgical approaches

Surgical treatment typically incorporates 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 (see the images below). The use of a reamed intramedullary (IM) nail is an excellent method of treating noninfected nonunions, especially in the middle three fifths of the tibia. [37] 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 allows 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 ti Tibial nonunions. Anteroposterior radiograph of tibial fracture after provisional fixation.
Tibial nonunions. Oblique view of tibial fracture 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 fra Tibial nonunions. Lateral radiograph of tibial fracture after provisional fixation.

For patients with a history of infection, previous external fixation, very proximal or distal fractures, or significant malalignment, reamed IM nailing is less effective. This technique can also be difficult, and the surgeon must be experienced with IM nailing techniques. The use of end reaming (cutting) bits, fluoroscopy, and a femoral IM distracter may be helpful.

In a multicenter, blinded, randomized trial of 1226 patients with tibial shaft fractures who underwent reamed nailing (622 patients) and unreamed nailing (604 patients), study investigators found that there may be a possible benefit for the use of reamed IM nailing in patients with closed-end fractures. The authors found no difference for open fractures. They suggested that delaying reoperation for nonunion for at least 6 months may reduce the number of reoperations. [38]

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. [39] The patients demonstrated a 92% healing rate in a mean of 7 months with no further treatment.

Compression plating has the advantage of being applicable 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. The soft tissues must be handled in an atraumatic manner, and dissection and periosteal stripping must be kept 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. [40]

External fixation, especially small-wire and hybrid external fixation, is an excellent option for treatment of tibial nonunions, especially if the fracture is very proximal or distal (periarticular), if bone loss is significant, if deformity (including shortening) is significant, or if ongoing infection is present. External fixation allows concurrent treatment of multiple issues. It can provide stability to 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. [41]

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 (see the image below), 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 Tibial nonunions. Close-up view of antibiotic bone cement beads.

The use of external fixation is probably the best technique for patients with complex and significant angular deformities that require correction and are too great for acute correction. Although highly versatile, pin-site infections occur routinely, making subsequent conversion to an IM nail difficult. Specialized training or experience in these techniques is important.

In a 3-year prospective study, Tall et al surgically treated 50 patients for neglected diaphyseal nonunion (femur, 14 cases; tibia, 22 cases; humerus, eight cases; forearm bones, six cases) an average of 11 months after the fracture event. [42] The procedure consisted of osteoperiosteal decortication followed by repermeabilization of the medullary canal and then internal fixation. Nonunion of the middle third of the femur and tibia was treated with IM nailing.

In this study, patients were reviewed clinically and radiographically on postoperative days 21, 45, 90 and 120. [42] Bone union was obtained in less than 120 days for the lower-limb fractures. No additional grafting was needed. There were two cases of leg-length differences. The investigators concluded that osteoperiosteal decortication is a reliable technique that leads to predictable, satisfactory results.

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Complications

Most complications that occur in the treatment of nonunions are an extension of the existing condition, but all tibial nonunions should nevertheless be approached with great care to avoid making a bad situation worse.

Possibly the greatest concern is creating an infected nonunion from an aseptic nonunion. [43] In a 1994 study by Wu, a 13% rate of infection occurred, regardless of treatment technique (ie, compression plating vs IM nailing). [44] Conversion from external fixation to IM nailing should be avoided if possible. [45] 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.

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