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Nonunions: Evaluation and Treatment Nonunions: Evaluation and Treatment
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Mark R. Brinker, M.D.
Fracture nonunion is a dreadful entity and is often the bane of the orthopaedic surgeons existence. Although fracture nonunions may represent a very small percentage of the traumatologists case load, they can account for a high percentage of a surgeons stress, anxiety, and frustration. Fracture nonunion is often anticipated after a severe traumatic injury, such as an open fracture with segmental bone loss, but it may also make an unanticipated appearance after treatment of a low-energy fracture that seemed destined to heal. A fracture nonunion represents a chronic medical condition associated with pain and with functional and psychosocial disability.135 Because of the wide variation in patient responses to various stresses133 and the impact it may have on a patients family (e.g., relationships, income), these cases are often difcult to manage. Between 90% and 95% of all fractures heal without problems.61, 189 Nonunions comprise the small percentage of cases in which the biologic process of fracture repair is unable to overcome the local biology and mechanics of the bony injury.
DEFINITIONS
criteria, their arbitrary use of a temporal limit is awed.81 For example, several months of observation should not be required to declare a tibial shaft fracture with 10 cm of segmental bone loss a nonunion. Conversely, how does the orthopaedic surgeon dene a slow-healing fracture that continues to consolidate but requires 12 months of observation to heal? At best, denitions of nonunion and delayed union in the literature are inconsistent, subjective, ambiguous, and arbitrary; therefore, there are no objective criteria. These limitations produce difculty in synthesizing the literature on series of nonunions. For clarity, I dene nonunion as a fracture that, in the opinion of the treating physician, has no possibility of healing without further intervention. I dene delayed union as a fracture that, in the opinion of the treating physician, shows slower progression to healing than was anticipated and is at substantial risk for becoming a nonunion without further intervention. To fully appreciate the biologic processes and clinical implications of fracture nonunion, an understanding of the normal fracture repair process is required. The following section discusses the local biology of fracture healing, requirements for fracture union, and types of normal fracture repair.
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz A fracture is said to have gone on to nonunion when the normal biologic healing processes of bone cease to the extent that solid healing cannot occur without further treatment intervention. The denition is largely subjective and imprecise because it calls for speculation (forecasting) of future events. The criteria are also not specic enough to result in low interobserver variability. The literature contains myriad denitions of nonunion. For the purposes of clinical investigations, the U.S. Food and Drug Administration denes a nonunion as a fracture that is at least 9 months old and has not shown any signs of progression to healing for 3 consecutive months.90, 237 Mullers158 denition of nonunion is failure of a fracture (tibia) to unite after 8 months of nonoperative treatment. Although these two denitions are the most widely used
FRACTURE REPAIR
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz Fracture repair is an astonishing process. The healing response involves spontaneous, structured regeneration of bony tissue that results in a return of mechanical stability to the skeletal system. At the moment of bony injury, a predetermined response occurs. The response involves proliferation of tissues that ultimately lead to healing at the site of fracture. The early biologic response at the fracture site is an inammatory response with bleeding and the formation of a fracture hematoma. In the presence of osteoprogenitor cells from the periosteum and endosteum and hematopoietic cells capable of secreting growth factors, the repair
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Copyright 2003 Elsevier Science (USA). All rights reserved.
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TABLE 201
SECTION I General Principles
Type of Fracture Healing Based on Type of Stabilization

Type of Stabilization Cast (closed treatment) Compression plate Intramedullary nail External xator Inadequate immobilization With adequate blood supply Without adequate blood supply Inadequate reduction with displacement at the fracture site Predominant Type of Healing
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When small gaps exist between apposing fracture fragments, gap healing occurs through appositional bone formation.
Periosteal bridging callus and interfragmentary enchondral ossication Primary cortical healing (cutting cone-type remodeling) Early: periosteal bridging callus Late: medullary callus Depends on extent of rigidity Less rigid: periosteal bridging callus More rigid: primary cortical healing Hypertrophic nonunion (failed enchondral ossication) Atrophic nonunion Oligotrophic nonunion
Indirect Bone Healing

Indirect bone healing occurs in fractures that have been stabilized with less than absolute rigidity. Examples of xation resulting in indirect bony healing include intramedullary nail xation, tension band wire techniques, cerclage wiring, external xation, and plate-and-screw xation applied suboptimally. Indirect healing involves coupled bone resorption and formation at the fracture site. Healing occurs by a combination of external callus formation and enchondral ossication.
CAUSES OF NONUNIONS
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response of bone occurs rapidly. After fracture healing, bony remodeling progresses according to Wolffs law.13, 14, 184, 206, 251 The process of fracture repair involves intramembranous and enchondral bone formation. The process requires mechanical stability, an adequate blood supply, and good bony contact. The specic biologic response is related to the type and extent of injury and to the type of treatment (Table 201).
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Predisposing Factors: Instability, Inadequate Vascularity, and Poor Bone Contact

The most basic requirements for fracture healing include mechanical stability, an adequate blood supply (i.e., bone vascularity), and bone-to-bone contact. The absence of one or more of these factors predisposes the fracture to development of a nonunion. The basic requirements for healing may be negatively affected by the severity of the injury, suboptimal surgical xation from a poor plan or a good plan carried out poorly, or a combination of injury severity and the suboptimal performance of the surgical procedure. INSTABILITY Mechanical instability can follow internal or external xation and results in excessive motion at the fracture site. Factors producing mechanical instability include inadequate xation with hardware (i.e., implants too small or too few), distraction at the fracture site with a gap between the fracture surfaces (recall that orthopaedic hardware is equally capable of holding bone apart as it is holding bone together), bone loss, and poor bone quality (i.e., poor purchase) (Fig. 201). If an adequate blood supply exists, excessive motion at the fracture site can result in abundant callus formation, widening of the fracture line, failure of brocartilage to mineralize and be replaced by bone, and failure of the fracture to unite. INADEQUATE VASCULARITY Loss of blood supply to the fracture surfaces may arise because of the severity of the injury or because of surgical dissection. Open fractures and high-energy closed injuries are associated with soft tissue stripping and damage to the periosteal blood supply. These injuries can also disrupt the nutrient vessels and impair the endosteal blood supply. Several studies have shown a relationship between the
Healing through Callus

Some fracture treatment methods, such as cast immobilization, lack absolute rigid xation of the fracture site. In the absence of rigid xation, stabilization of bony fragments occurs by periosteal and endosteal callus formation. If an adequate blood supply exists at the fracture site, callus formation proceeds and results in a substantial increase in the cross-sectional area at the fracture surface. The increased diameter at the fracture site caused by callus formation enhances fracture stability. Fracture stability is also provided by the formation of brocartilage, which replaces granulation tissue at the fracture site. A critical event in the fracture repair process is mineralization of brocartilage. Only after calcication of brocartilage can enchondral bone formation proceed, in which bone replaces cartilage.
Direct Bone Healing

Direct osteonal healing occurs without the formation of an external callus and is characterized by gradual disappearance of the fracture line. The biologic process requires an adequate blood supply and absolute rigidity at the fracture site, which is most commonly accomplished with a compression plate. In areas of direct bone-to-bone contact, fracture repair resembles cutting-conetype remodeling.
CHAPTER 20 Nonunions: Evaluation and Treatment
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extent of soft tissue injury and the rate of the fracture nonunion. Court-Brown and co-workers45 described 547 tibial shaft fractures treated with intramedullary nail xation. The rate of nonunion in closed fractures was 3.4%, compared with a nonunion rate of 16.5% for open fractures. Among the group of patients with open fractures, markedly higher rates of nonunion were seen in those with the most severe soft tissue damage. Chatziyiannakis and colleagues35 reported similar ndings for 71 tibial shaft fractures treated with unilateral external xation. Vessel injury in certain anatomic areas, such as the posterior tibial artery, may also predispose to development of a nonunion.24 The vascularity at the fracture site may also be compromised at the time of open reduction with excess stripping of the periosteum and damage to bone and the soft tissues during hardware insertion. Whatever the cause, inadequate vascularity at the fracture site results in necrotic bone at the ends of the fracture fragments, with or without large defects. These necrotic surfaces inhibit the
normal biology of fracture healing and often result in fracture nonunion. POOR BONE CONTACT Bone-to-bone contact is an important requirement for fracture repair. Poor bone-to-bone contact at the fracture site may result from soft tissue interposition, malposition or malalignment of the fracture fragments, bone loss, or distraction of the fracture fragments. Whatever the cause, poor bone-to-bone contact compromises mechanical stability and creates a defect that the fracture repair process must bridge. As these defects increase in size, the probability of fracture union decreases. The threshold value for rapid bridging of cortical defects through direct osteonal healing, the so-called osteoblastic jumping distance, is approximately 1 mm in rabbits,221 but the magnitude of this distance varies from species to species. Larger cortical defects may also heal, but they do so at a much slower rate and bridge by means of woven bone. The
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FIGURE 201. Mechanical instability at the fracture site can lead to nonunion and has several causes. A, Inadequate xation. A 33-year-old man presented with a femoral shaft nonunion 8 months after inadequate xation with exible intramedullary nails. B, Distraction. A 19-year-old man with a tibial fracture was treated with plate-and-screw xation. He is at risk for nonunion because of distraction at the fracture site. Illustration continued on following page
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FIGURE 201 Continued. C, Bone loss. A 57-year-old man presented with segmental bone loss after debridement of a high-energy, open tibial fracture. D, Poor bone quality. A 31-year-old woman presented 2 years after open reduction and internal xation for an ulnar shaft fracture. Loss of xation resulted from poor bone caused by chronic osteomyelitis.
critical defect represents the gap distance between fracture surfaces that cannot be bridged by bone without intervention. The magnitude of the critical defect depends on a variety of factors related to the injury and varies considerably among species. According to the theory of Perren and Cordey,183 small defects produce high strain at the fracture site. Osteoblasts, which do not tolerate a high-strain environment, are predominated by chondroblasts and broblasts, which thrive under high strain. In larger gaps and segmental defects, the strain is too low to promote osteoblastic activity. Perren and Cordey believe that osteoblasts ourishand thereby give rise to fracture healingonly under specic
strain conditions. When fracture-site strain is too high or too low, delayed union or nonunion ensues. The exact amount of strain that promotes fracture repair remains unknown.
Other Contributing Factors

In addition to mechanical instability, inadequate vascularity, and poor bone-to-bone contact, other factors may contribute to the occurrence of a nonunion. These factors, however, should not be considered direct causes of nonunion (Table 202).
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INFECTION Infection in the zone of fracture, including bone or the surrounding soft tissues, does not directly cause nonunion. However, an infection may create the same local environment that predisposes noninfected fractures to fail to unite. Infection may result in motion and instability at the fracture site as implants loosen in infected bone (i.e., poor bone quality). Necrotic bone at the fracture site (i.e., sequestrum), a common complication of infection, is avascular and discourages bony union. Infection also produces poor bony contact because osteolysis at the fracture site results from ingrowth of infected granulation tissue. NICOTINE CONSUMPTION AND CIGARETTE SMOKING Cigarette smoking adversely affects fracture healing. Experimental evidence suggests that nicotine inhibits vascular ingrowth and early revascularization of bone47, 195 and diminishes osteoblast function.54, 70, 191 Animal investigations have shown that cigarette smoking and nicotine impair bone healing in rabbits with fractures,190 rabbits undergoing spinal fusion,230, 259 and rabbits undergoing tibial lengthening.242, 243 Human studies have reported delayed fracture healing and higher nonunion rates in patients who smoke cigarettes. In a consecutive series of 146 closed and type I open tibial shaft fractures, Schmitz and associates224
reported a signicant delay in clinical and radiographic evidence of fracture healing in smokers treated with external xation and intramedullary nail xation. Similarly, Kyro and co-workers128 reported an association between the number of cigarettes smoked and delayed union of the tibia. Selznick and colleagues227 also reported higher rates of delayed union and nonunion in smokers with open tibial fractures treated with external xation and intramedullary nailing. Hak and associates87 reported a markedly higher rate of persistent nonunion in smokers compared with nonsmokers who underwent exchange reamed intramedullary nailing for femoral shaft nonunion or delayed union. Cobb and co-workers41 reported as high as a 16-fold increase in the risk of nonunion of ankle arthrodesis in smokers compared with nonsmokers. The rate of successful spinal fusion has also been reported to be lower in smokers.25 Although the exact mechanism remains to be fully elucidated, animal and human investigations show that nicotine consumption and cigarette smoking have a deleterious effect on fracture healing. Adverse effects on local vascularity and cellular function at the fracture site probably constitute part of the mechanism. Cigarette smoking is associated with osteoporosis and generalized bone loss,188 and mechanical instability due to poor bone quality for purchase may play a role in the production of nonunions in smokers undergoing surgical stabilization with orthopaedic hardware. CERTAIN MEDICATIONS
TABLE 202
Causes of Nonunions
PREDISPOSING FACTORS Mechanical instability Inadequate xation Distraction Bone loss Poor bone quality Inadequate vascularity Severe injury Excessive soft tissue stripping Vascular injury Poor bone contact Soft tissue interposition Malposition or malalignment Bone loss Distraction CONTRIBUTING FACTORS Infection Nicotine or cigarette smoking Certain medications Advanced age Systemic medical conditions Poor functional level Venous stasis Burns Radiation Obesity Alcohol abuse Metabolic bone disease Malnutrition Vitamin deciencies
Although numerous investigators have studied the effects of nonsteroidal anti-inammatory drugs (NSAIDs) on fracture healing, the literature does not provide a consensus opinion. Several animal studies have shown that NSAIDs have negative effects on the healing of experimentally induced fractures and osteotomies.4, 5, 66, 96, 115, 137, 200, 234 Other investigators, however, have reported no signicant alterations in the fracture repair process in animals administered NSAIDs.100, 154 Huo and co-workers100 were unable to show differences in fracture histology or biomechanics between rats given ibuprofen and controls, but they cautioned against extrapolating their ndings to humans. Three reports have documented delayed long bone fracture healing in human subjects taking oral NSAIDs.26, 79, 118 Giannoudis and colleagues79 showed a marked association between delayed fracture healing and NSAID use, as well as between fracture nonunion and NSAID use in fractures of the femoral diaphysis treated by intramedullary nailing. Butcher and Marsh26 reported similar ndings for tibial fractures, as did Khan118 for clavicle fractures. Although a body of literature exists implicating NSAIDs as a factor in delayed fracture healing, no true consensus exists. Even for those who believe the negative effects exist, the mechanism of action remains obscure (i.e., direct action at the fracture site vs. indirect action through hormonal effect). Whether all NSAIDs display similar effects and the dose-response characteristics of specic NSAIDs to produce delayed union or nonunion remains unknown. Other medications have been postulated to have an
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adverse effect on fracture healing. They include phenytoin,90 ciprooxacin,98 steroids, anticoagulants, and other agents. OTHER ISSUES Other issues may retard fracture healing or contribute to fracture nonunion but are not primary causes. These factors include advanced age,90, 128, 205 systemic medical conditions (e.g., diabetes),76, 182 poor functional level with an inability to bear weight, venous stasis, burns, irradiation, obesity,73 alcohol abuse,73, 76, 182 metabolic bone disease, malnutrition and cachexia, and vitamin deciencies.56 Animal studies (rats) have shown that deciency of albumin produces a fracture callus that has reduced strength and stiffness,187 although early fracture healing events proceed normally.62 Dietary supplementation of protein during fracture repair to achieve and maintain appropriate daily requirements reverses these effects and augments fracture healing,53, 62 although protein intake in excess of normal daily requirements has not been proven to be benecial.84, 187 Inadequate caloric intake, as occurs among the elderly, contributes to failure of fracture union.233
EVALUATION OF NONUNIONS
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz No two patients presenting with a fracture nonunion are identical. The evaluation process is perhaps the most critical step in the patients treatment pathway. It is here that the surgeon begins to form opinions about how to heal the nonunion. The goal of the evaluation is to discover the cause of the nonunion. Without a clear understanding of the cause, the treatment strategy cannot be based on knowledge of fracture biology. A worksheet for patients with nonunions is an excellent method of assimilating the various data (Fig. 202).
Patient History
The evaluation process begins with a thorough history, including the date of injury and mechanism of injury resulting in the initial fracture. Any preexisting medical problems (e.g., diabetes, malnutrition, metabolic bone disease), disabilities, or associated injuries that may have an impact on the treatment plan or expected outcome should be ascertained. The patient should be questioned regarding pain and functional limitations related to the nonunion. An exhaustive review of all prior surgeries to treat the fracture and fracture nonunion, including the specic details of each surgical procedure, must be obtained. These details are collected through discussions with the patient and family, with prior treating surgeons, and by a thorough review of all medical reports and records since the time of the initial fracture. Knowledge of all prior operative procedures is empowering and critical for designing the right treatment
plan for the patient. Conversely, ignorance of any prior surgical procedure can lead to needlessly repeating surgical procedures that have failed to promote bony union in the past. For example, a humeral shaft fracture initially treated with an intramedullary nail and subsequently treated with autologous bone graft on three separate occasions for nonunion is unlikely to heal with a fourth bone graft procedure. Worse, ignorance of prior surgical procedures can lead to the occurrence of avoidable complications. For example, knowledge of the prior use of external xation is important, particularly when the use of intramedullary nail xation for nonunion treatment is contemplated. The risk of serious infection after intramedullary nail xation for a nonunion in a patient whose injury was previously treated with external xation has been thoroughly described.16, 108, 140, 144, 149, 196, 260 In general, the risk of infection is greatest when external xation was in place for a long time (i.e., several months), the time from removal of external xation to placement of an intramedullary nail was short (i.e., days to weeks), and external xation wear was complicated by purulent pin-site infections (look for pin-site ring sequestra on current radiographs). A thorough review of all prior surgical procedures is of the utmost importance. The hospital records and operative reports from the time of the initial fracture may also be a useful source of information regarding the condition of the tissues in the zone of the injury (e.g., description of open wounds, contamination, crush injuries, periosteal stripping, devitalized bone fragments). The history of prior soft tissue coverage procedures can also be readily obtained from these sources. The history should also include details regarding prior wound infections. Culture reports should be sought in the medical records. Intravenous and oral antibiotic usage should be documented, particularly if the patient remains on antibiotics at the time of presentation. Problems with wound healing and prior episodes of soft tissue breakdown should be documented. Other previous perioperative complications (e.g., venous thrombosis, nerve or vessel injuries) that may affect the treatment plan should also be documented. A history should be sought for the use of adjuvant nonsurgical therapies, such as electromagnetic eld and ultrasound therapy. The patient should be questioned regarding other possible contributing factors for nonunion (see Table 202). The pack-year history of cigarette smoking should be documented. Active smokers should be offered a program (i.e., pharmaceutical or counseling or both) to halt the addiction. From a practical standpoint, it is unrealistic to delay treatment of a symptomatic nonunion until the patient stops smoking (you would grow old and gray, and your town would be overrun by oozing, limping hulks of human esh). A history for NSAID use should be obtained, and their usage should be discontinued. To summarize, the patient history is an important tool in reconstructing the factors leading to failure of the fracture to heal and is important in planning treatment.
GENERAL INFORMATION Patient Name: Referring Physician: Injury (description): Date of Injury: Mechanism of Injury: Occupation:
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Age: Height:
Gender: Weight:
Pain (0 to 10 VAS): Was Injury Work Related?:
PAST HISTORY Initial Fracture Treatment (Date): Total # of Surgeries for Nonunion: Surgery #1 (Date): Surgery #2 (Date): Surgery #3 (Date): Surgery #4 (Date): Surgery #5 (Date): Surgery #6 (Date): (Use backside of this sheet for other prior surgeries) Use of Electromagnetic or Ultrasound Stimulation? Cigarette Smoking # of packs per day # of years smoking History of Infection? (include culture results) History of Soft Tissue Problems? Print Graphic Medical Conditions: Medications: NSAID Use? Narcotic Use: Presentation Allergies: PHYSICAL EXAMINATION General: Extremity: Stiff Lax Nonunion: Adjacent Joints (ROM, compensatory deformities): Soft Tissues (defects, drainage): Neurovascular Exam: RADIOLOGIC EXAMINATION Comments OTHER PERTINENT INFORMATION
NONUNION TYPE Hypertrophic Oligotrophic Atrophic Infected Synovial Pseudarthrosis

FIGURE 202. Worksheet for patients with nonunions.
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Physical Examination
After obtaining a thorough history, a physical examination is performed. The general health and nutritional status of the patient should be assessed. Malnutrition and cachexia are factors that contribute to diminished fracture repair.64, 84, 187, 233 Measurement of arm muscle circumference is the best indicator of nutritional status. Obese patients with nonunions have unique management problems related to achieving mechanical stability in the face of high loads and dealing with large soft tissue envelopes.112 The fracture zone should be inspected for the status of the overlying skin and soft tissues. The presence of active drainage and sinus formation should be noted. The presence and description of deformity at the fracture site should be documented. The nonunion site should undergo manual stress testing to evaluate motion and pain. In general, nonunions that display little or no clinically apparent motion have callus formation to some degree and have good vascularity at the fracture surfaces. Nonunions that display more motion generally have poor callus formation, but they may have vascular or avascular fracture surfaces. Accurate assessment of motion at a nonunion site is difcult in the case of a limb with paired bones when one of the bones is intact. A neurovascular examination should be performed to rule out or document vascular insufciency and motor or sensory dysfunction. Active and passive motion of the joints proximal and distal to the nonunion should be
performed. Not uncommonly, motion at the nonunion site substitutes for an adjacent joint and thereby diminishes motion at that joint. For example, patients with a long-standing distal tibial nonunion often present with a xed equinus contracture and a limited arc of ankle motion (Fig. 203). Similarly, patients with supracondylar humeral nonunions commonly present with brous ankylosis of the elbow joint (Fig. 204). Such problems may alter the treatment plan and the expectations for the ultimate functional outcome. An interesting situation is the case of the stiff nonunion with an angular deformity. These patients may present having already developed a compensatory xed deformity at an adjacent joint. It is imperative that the xed deformity at the joint be recognized preoperatively and that the treatment plan include its correction. Realignment of a stiff nonunion with a deformity without addressing an adjacent compensatory joint deformity results in a straight long bone with a deformity at the joint, producing a disabled limb. For example, patients with a stiff distal tibial nonunion with a varus deformity often develop a compensatory valgus deformity at the subtalar joint to achieve a plantigrade foot for gait. On presentation and visual inspection, the distal limb segment paradoxically appears aligned. Radiographs, however, show the distal tibial varus deformity. To determine whether the compensatory valgus deformity through the subtalar joint is xed or mobile (reducible), the patient is asked to position the subtalar joint in varus (i.e., invert the foot). If the patient cannot achieve inversion through the subtalar joint, and the
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FIGURE 203. A 20-year-old woman presented with a distal tibial nonunion 22 months after a high-energy, open fracture. The clinical photograph (A) and lateral radiograph (B) show apex anterior angulation at the fracture site resulting in the clinical equivalent of a severe equinus contracture.
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FIGURE 204. A, The anteroposterior radiograph was obtained at presentation of a 32-year-old man with a supracondylar humeral nonunion. On physical examination, it can be difcult to differentiate motion at the nonunion site and the elbow joint. This patient had very limited range of motion at the elbow but gross motion at the nonunion site. Cineradiography can help evaluate the contribution of the adjacent joint and the nonunion site to the arc of motion. B, C, Cineradiography showing exion and extension of the elbow reveals that most of the motion is occurring through the nonunion site, not the elbow joint. This patient should be counseled preoperatively regarding elbow stiffness after stabilization of the nonunion.
examiner cannot passively invert the subtalar joint, the joint deformity is xed. Deformity correction is therefore required at the nonunion site and the subtalar joint. If the patient can achieve subtalar inversion, the deformity at the joint will resolve with realignment of the deformity at the nonunion. A patient with a distal tibial nonunion may also present with apex posterior angulation at the nonunion site. This patient may develop a compensatory plantar-exion deformity at the ankle joint to achieve a plantigrade foot for gait. The physical examination is performed to assess whether the deformity
is xed. Can the patient position the foot into the apex dorsal angulation of the tibia through ankle dorsiexion? If the patient cannot place the joint in question into the position that parallels the deformity at the nonunion site, the joint deformity is xed and requires correction. If the patient can achieve the position, the joint deformity will resolve with realignment of the long bone deformity (Fig. 205). If a bone grafting procedure is contemplated, the anterior and posterior iliac crests should be examined bilaterally for evidence (e.g., incisions) of prior surgical
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prior harvesting by plain radiographs or a computed tomography (CT) scan.
Radiologic Examination
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Diagnostic radiologic examinations are a critical part of the evaluation process, and the information gathered offers great insight into the causes of poor fracture healing.
PLAIN RADIOGRAPHS The radiologic examination begins with a review of the original fracture lms. This initial step offers tremendous insight into the character and severity of the initial bony injury. It also is instructive in regard to the progress or lack of progress toward healing compared with the most recent plain radiographs. In addition to the original injury radiographs, radiographs of the salient aspects of the previous treatments rendered should be reviewed. The prior radiographs always tell the story of the nonunion being seen for treatment, although the story may only reveal itself to an astute observer. The prior plain lms should be carefully
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FIGURE 205. Angular deformity at a nonunion site that is near a joint can result in a compensatory deformity through a neighboring joint. For example, coronal-plane deformities of the distal tibia can result in a compensatory coronal-plane deformity of the subtalar joint. A deformity of the subtalar joint is xed if the patients foot cannot be positioned into the deformity of the distal tibia (A) or exible if it can be positioned into the deformity of the distal tibia (B). Sagittal-plane deformities of the distal tibia can result in a sagittal-plane deformity of the ankle joint. A deformity of the ankle joint is xed if the patients foot cannot be positioned into the deformity of the distal tibia (C) or exible if it can be positioned into the deformity of the distal tibia (D).
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harvesting. In the case of a patient who has had prior spinal surgery with bone harvested through a midline posterior incision, it may be difcult to determine which posterior crest has already been harvested. In such a case, the left and right posterior iliac crests can be evaluated for
FIGURE 206. A nonunion is visualized better on small cassette views than on large cassette views; compare with Figure 207.
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involved bone (including the adjacent proximal and distal joints); AP, lateral, and two oblique views of the nonunion site itself (on small cassette lms that improve magnication and resolution of the nonunion site) (Fig. 206); AP and lateral 51-inch alignment radiographs of both limbs for lower extremity nonunions (useful for assessing leg-length discrepancies and deformities) (Fig. 207); and exion-extension lateral radiographs to determine the arc of motion and to assess the relative contributions of the joint and the nonunion site to the overall arc of motion. The current plain lms are used to assess several radiographic characteristics of a nonunion: anatomic location, healing effort, bone quality, surface characteristics, status of previously implanted hardware, and deformities.
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Anatomic Location The anatomic location of the nonunion is determined using plain radiographs. Diaphyseal nonunions involve primarily cortical bone, whereas metaphyseal and epiphyseal nonunions mostly involve cancellous bone. The presence or absence of intra-articular extension of the nonunion should also be assessed.
Presentation
Healing Effort and Bone Quality The radiographic healing effort and bone quality of a nonunion helps to dene the biologic and mechanical causes of the nonunion. The assessment of healing includes evaluating radiolucent lines and gaps and appraising callus formation. Assessment of bone quality includes observing sclerosis, atrophy, osteopenia, and bony defects. Radiolucent lines seen along fracture surfaces on plain radiographs suggest gaps devoid of bony healing. These gaps can be lled with a variety of tissue types depending on the cause of the nonunion. The simple presence of radiolucent lines on plain radiographs is not synonymous with fracture nonunion. Conversely, the fact that plain radiographs fail to display a clear radiolucent line does not conrm fracture union (Fig. 208). Callus formation occurs only in fractures and nonunions that have an adequate blood supply. The presence of callus, however, does not necessarily imply the bone is solidly uniting. AP, lateral, and oblique radiographs should be reviewed for callus bridging the zone of injury. The radiographs should be carefully checked for the presence of radiolucent lines so that a nonunion with abundant callus is not mistaken for a solidly united fracture. Weber and Cech252 classied nonunions based on healing effort and bone quality as seen radiographically into viable nonunions, which are capable of biologic activity, and nonviable nonunions, which are incapable of biologic activity.
FIGURE 207. A 60-year-old man presented with a tibial nonunion and an oblique-plane angular deformity as seen on the 51-inch, anteroposterior view (A) and the 51-inch, lateral view (B).
examined for the status of any orthopaedic hardware (e.g., loose, broken, or inadequate size or number of implants), including its removal or insertion on subsequent lms. The evolution of deformity at the nonunion site over time should be evaluated using the prior radiographs. Has this been a gradual process, or did the deformity occur in a single event? The presence of healed or nonhealed articular fragments, buttery fragments, and wedge fragments should also be conrmed. The time course of missing or removed bony fragments, added bone graft, and implanted bone stimulators should be reconstructed so that the subsequent fracture repair response can be evaluated. The next step is to carefully evaluate the nonunion with good-quality radiographs. They should include an anteroposterior (AP) and lateral radiograph of the
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(i.e., still hypertrophic but with less abundant callus formation). Oligotrophic nonunions possess an adequate blood supply to mount a healing response but display little or no callus formation. Oligotrophic nonunions arise from inadequate reduction with displacement at the fracture site. Nonviable nonunions do not display callus formation. Although some of the bony fragments in certain types of nonviable nonunions may possess a blood supply, these nonunions are incapable of biologic activity because their inadequate vascularity precludes the formation of periosteal and endosteal callus. A radiolucent gap is observable on plain radiographs. This gap is bridged with brous tissue that has no osteogenic capacity. Atrophic nonunion is the most advanced type of nonviable nonunion. The cause of an atrophic nonunion is not completely understood. The ends of the bony surfaces are avascular, perhaps because of the high-energy nature of the initial injury or soft tissue stripping at the time of one or more surgical procedures. Radiographically, the fracture surfaces appear partially absorbed and are usually osteopenic. In severe cases, large sclerotic, avascular bone segments or segmental bone loss may be observed. Surface Characteristics The surface characteristics (Fig. 2010) at the site of nonunion are an important prognostic factor in regard to its resistance to healing with various treatment strategies. Surface characteristics that should be evaluated on plain radiographs include the surface area of adjacent fragments, extent of current bony contact, orientation of the fracture lines (i.e., shape of the bone fragments), and stability to axial compression, which is a function of fracture surface area, orientation, and comminution. The nonunions that are easiest to treat have large, transversely oriented
FIGURE 208. A denitive decision cannot always be made about bony union based on plain radiographs. A, Anteroposterior (AP) and lateral radiographs show the fracture site of an 88-year-old woman 14 months after a distal tibial fracture that was treated elsewhere with external xation. Is this fracture healed, or is there a nonunion? Compare with Figure 2017. B, A 49-year-old man presented 13 months after open reduction and internal xation of a distal tibial fracture. AP and lateral radiographs were obtained. Is this fracture healed, or is there a nonunion? Compare with Figure 2017.
Viable nonunions include hypertrophic nonunions and oligotrophic nonunions. Hypertrophic nonunions possess adequate vascularity and display callus formation. They arise because of inadequate mechanical stability with persistent motion at the fracture surfaces. The fracture site is progressively resorbed with accumulation of unmineralized brocartilage and displays a progressively widening radiolucent gap with sclerotic edges. The reason persistent motion at the gap of a nonunion inhibits calcication of brocartilage remains obscure.183 Vascular invasion of capillaries and blood vessels occurs on both sides of the nonunion but are unable to penetrate the brocartilaginous tissue at the nonunion site (Fig. 209).193 As motion persists or increases at the nonunion site, endosteal callus may accumulate and seal off the medullary canal, resulting in increased production of hypertrophic periosteal callus. Hypertrophic nonunions may be subclassied as elephant foot type (i.e., abundant callus formation) or horse hoof type
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FIGURE 209. Microangiogram of a hypertrophic delayed union of a canine radius. Notice the tremendous increase in local vascularity. The capillaries, however, are unable to penetrate the interposed brocartilage (arrows). (From Rhinelander, F J Bone Joint Surg Am 50:78, 1968.) .W.
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Surface area
stability of the mechanical construct used to xate the bone. Loose or broken implants denote instability at the nonunion site (i.e., the race between bony union and hardware failure has been lost),158, 174, 201204, 209 and the injured bone requires further stabilization before union can occur. Radiographs are useful for planning what hardware needs to be removed for the next treatment plan to be carried out.
Poor
Good
Fair
Bone contact
B
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Fair
Poor
Fracture line orientation
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Horizontal
Intermediate
Vertical
Stability to axial compression
Most stable
Least stable
FIGURE 2010. Surface characteristics at the site of nonunion should be considered. A, Surface area. B, Bone contact. C, Orientation of the fracture line. D, Stability to axial compression, which is a function of fracture surface area, orientation, and comminution.
adjacent surfaces with good bony contact that are stable to axial compression. Status of Previously Implanted Hardware Plain radiographs are a useful means of evaluating the status of previously implanted hardware and therefore the
Deformities After assessment for clinical deformity with a physical examination, plain radiographs are used to more fully characterize all deformities associated with the fracture nonunion. All deformities are characterized by location (i.e., diaphyseal, metaphyseal, or epiphyseal), magnitude, and direction, including a description of the deformity in terms of length, angulation, rotation, and translation. Deformities involving length include shortening and overdistraction and are measured in centimeters on plain radiographs compared with the contralateral, normal extremity (an x-ray marker should be used to correct for x-ray magnication). Shortening may result from bone loss (i.e., injury or debridement) or overriding of the fracture fragments (i.e., malreduction). Overdistraction may arise because of a traction injury or improper positioning at the time of internal or external xation. Deformities involving angulation are characterized by their magnitude and the direction in which the apex of the angulation points. Pure sagittal- or coronal-plane deformities are easy to characterize. When coronal-plane angulation exists at a nonunion site in the lower extremity, the deformity commonly results in an abnormality to the mechanical axis of the lower extremity (i.e., mechanical axis deviation) (Fig. 2011). Varus deformities result in medial mechanical axis deviation, and valgus deformities result in lateral mechanical axis deviation. Oblique-plane angular deformities occur in a single plane that is neither the sagittal nor the coronal plane. The magnitude and direction of an oblique-plane angular deformity can be characterized using the trigonometric method or the graphic method.23, 95, 167, 168, 170, 171 Angulation at a diaphyseal nonunion is usually obvious on plain radiographs. The angulation results in divergence of the anatomic axes (i.e., mid-diaphyseal lines) of the proximal and distal fragments (see Fig. 2011). The magnitude and direction of angulation can be measured on plain radiographs by drawing the anatomic axes of the proximal and distal segments (see Fig. 2011). Angular deformities associated with nonunions of the metaphysis and epiphysis (i.e., juxta-articular deformities) may not be as obvious on the initial radiographic review. They are not as simple to evaluate as diaphyseal deformities, and the mid-diaphyseal line method cannot characterize a juxta-articular deformity. Recognition and characterization of a juxta-articular deformity require an analysis using the angle formed by the intersection of a joint orientation line and the anatomic or mechanical axis of the deformed bone (Fig. 2012). When the angle formed differs markedly from the contralateral normal extremity, a juxta-articular deformity is present. If the contralateral extremity is also abnormal (e.g., in patients with bilateral
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injuries), the known normal values described for the lower extremity are used23, 168, 171 (Table 203). The center of rotation of angulation (CORA) is the point at which the axis of the proximal segment intersects the axis of the distal segment (Fig. 2013). For diaphyseal deformities, the anatomic axes are quite convenient to use. For juxta-articular deformities, the axis line of the short segment is constructed using one of three methods: extension of the segment axis from the adjacent, intact bone if its anatomy is normal; comparing the joint orientation angle of the abnormal side with the opposite side if the latter is normal; or drawing a line that creates the
population normal angle formed by the intersection with the joint orientation line. The bisector is a line that passes through the CORA and bisects the angle formed by the proximal and distal axes (see Fig. 2013). Angular correction along the bisector results in complete deformity correction without the introduction of a translational deformity.23, 167, 168, 170, 171 Rotational deformities associated with a nonunion may be missed on physical and radiologic examinations because attention is focused on the more obvious problems (e.g., ununited bone, pain, infection). When the rotational deformity is recognized, accurate assessment of
MAD
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21
25
C
FIGURE 2011. A, Nonunion of the diaphysis of the tibia with a varus deformity results in medial mechanical axis deviation (MAD). Notice the divergence of the anatomic axis of the proximal and distal fragments of the tibia. B, In the close-up view of a section of a 51-inch anteroposterior (AP) radiograph of a 37-year-old woman with an 18-year history of a tibial nonunion, notice the 26-mm medial MAD. C, The AP and lateral radiographs show a 25 varus deformity and a 21 apex anterior angulation deformity, respectively.
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FIGURE 2011 Continued. D, The oblique-plane angular deformity is characterized using the trigonometric method. E, The oblique-plane angular deformity is characterized using the graphic method.
the magnitude of the deformity can be difcult on clinical examination, and plain radiographs offer little assistance. The best method of radiographic assessment of malrotation is through CT scanning. Like angular deformities, translational deformities associated with a nonunion are characterized by magnitude and direction. The magnitude of translation is measured as the perpendicular distance from the axis line of the proximal fragment to the axis line of the distal fragment. In instances of combined angulation and translation (in which the fragments are not parallel), translation is measured at the level of the proximal end of the distal fragment (Fig. 2014).168 When angular and translational deformities exist at a nonunion site, the CORA is seen at a different level on the AP and lateral radiographs (Fig. 2015). When the deformity involves pure angulation (without translation), the CORA is seen at the same level on the AP and lateral radiographs. In addition to assessing bony deformities related to malpositioned bony fragments, the radiographic evaluation should identify the presence or absence of compensatory deformities of the joints adjacent to the nonunion. In some cases, the compensatory deformities are clinically apparent on initial inspection, but this is not always true. Failure to recognize a compensatory deformity at an adjacent joint results in an incomplete treatment plan. The incomplete treatment plan (i.e., failure to correct the compensatory deformity at an adjacent joint) leads to a paradoxical outcome of apparent successful treatment without clinical benet: healed nonunion and straight bone but suboptimal functional improvement. Radiographic analysis should be performed at adjacent joints to identify a compensatory angular deformity when a deformity exists at the site of a nonunion. This is particularly important for a tibial nonunion with a coronal-plane angular deformity, because a compensatory deformity at the subtalar joint is common and commonly missed. Varus deformities of the tibia result in compensatory subtalar joint valgus deformities, and valgus deformities of the tibia result in compensatory subtalar joint varus deformities. Compensatory subtalar joint deformities are evaluated using the extended Harris view (Fig. 2016). Extended Harris views of bilateral lower extremities allow measurement of the orientation of the calcaneus relative to
94
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FIGURE 2012. Nonunion of the proximal tibia with a valgus deformity results in lateral mechanical axis deviation. The proximal medial tibial angle of 94 is abnormally high compared with the contralateral normal extremity and with the population normal values (see Table 203).
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TABLE 203
Normal Values Used to Assess Lower Extremity Metaphyseal and Epiphyseal Deformities (Juxta-articular Deformities) Associated with Nonunions
Anatomic Site of Deformity Proximal femur Plane Coronal Angle Neck shaft angle Anatomic medial proximal femoral angle Mechanical lateral proximal femoral angle Distal femur Coronal Anatomic lateral distal femoral angle Mechanical lateral distal femoral angle Sagittal Proximal tibia Coronal Sagittal Distal tibia Coronal Sagittal Anatomic posterior distal femoral angle Mechanical medial proximal tibial angle Anatomic posterior proximal tibial angle Mechanical lateral distal tibial angle Anatomic anterior distal tibial angle Description* Denes the relationship between the orientation of the femoral neck and the anatomic axis of the femur Denes the relationship between the anatomic axis of the femur and a line drawn from the tip of the greater trochanter to the center of the femoral head Denes the relationship between the mechanical axis of the femur and a line drawn from the tip of the greater trochanter to the center of the femoral head Denes the relationship between the distal femoral joint orientation line and the anatomic axis of the femur Denes the relationship between the distal femoral joint orientation line and the mechanical axis of the femur Denes the relationship between the sagittal distal femoral joint orientation line and the middiaphyseal line of the distal femur Denes the relationship between the proximal tibial joint orientation line and the mechanical axis of the tibia Denes the relationship between the sagittal proximal tibial joint orientation line and the middiaphyseal line of the tibia Denes the relationship between the distal tibial joint orientation line and the mechanical axis of the tibia Denes the relationship between the sagittal distal tibial joint orientation line and the middiaphyseal line of the tibia
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz
Normal Values 130 (range, 124136) 84 (range, 8089)
90 (range, 8595)
81 (range, 7983) 88 (range, 8590) 83 (range, 7987) 87 (range, 8590) 81 (range, 7784) 89 (range, 8892) 80 (range, 7882)
*Anatomic axes: femur, mid-diaphyseal line; tibia, mid-diaphyseal line. Mechanical axes: femur, dened by a line from the center of the femoral head to the center of the knee joint; tibia, dened by a line from the center of the knee joint to the center of the ankle joint; lower extremity, dened by a line from the center of the femoral head to the center of the ankle joint.
the tibial shaft in the coronal plane for normal and abnormal extremities (see Fig. 2016). COMPUTED AND PLAIN TOMOGRAPHY Plain radiographs do not always provide denitive information regarding the status of fracture healing. Sclerotic bone and orthopaedic hardware may obscure the fracture site and leave signicant doubt about whether the fracture is healed or a nonunion exists. This is particularly a problem in stiff nonunions or those well stabilized by hardware for which there may be little or no pain or evidence of motion at the fracture site. CT scans and plain tomography are useful in further evaluating such cases (Fig. 2017). CT scans are particularly helpful in estimating the percentage of the cross-sectional area that shows bridging bone (Fig. 2018). Nonunions typically show bone bridging less than 5% of the cross-sectional area at the fracture surfaces (see Fig. 2018). Healed or healing fracture nonunions typically show bone bridging greater than 25% of the cross-sectional area at the fracture surfaces. The cross-sectional area of bridging bone may be followed on serial CT scans to evaluate the progression of
fracture consolidation (see Fig. 2018). CT scans are also useful for assessing articular step-off, joint incongruity, and bony healing in cases of intra-articular nonunions. Plain tomography is particularly helpful in assessing the extent of bony union when CT images are compromised by hardware artifacts. Rotational deformities may be accurately quantied using CT. The relative orientations of the proximal and distal segments of the involved bone are compared with that of the contralateral normal bone. Although this technique has been most widely used for assessment of femoral malrotation,93, 97, 138 it may be used for any long bone. NUCLEAR IMAGING Nuclear imaging is a valuable tool for the study of fracture nonunions. A variety of studies are available, and when used in concert, they are useful for assessing for bone vascularity at the nonunion site, the presence of a synovial pseudarthrosis, and infection. Technetium 99m pyrophosphate complexes reect increased blood ow and bone metabolism and are
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absorbed onto hydroxyapatite crystals in areas of trauma, infection, and neoplasia. The technetium bone scan shows increased uptake in viable nonunions because there is a good vascular supply and osteoblastic activity at the fracture surfaces. Uptake may be particularly intense for viable nonunions with hypertrophic callus formation (Fig. 2019). Decreased tracer uptake is observed in nonviable nonunions in which blood supply and callus formation are poor (see Fig. 2019). Synovial pseudarthrosis (i.e., nearthrosis) is distinguished from a nonunion by the presence of a synovium-like xed pseudocapsule surrounding a uid-lled cavity. The medullary canals are sealed off, and motion occurs at this false joint.207, 252 Synovial pseudarthrosis may arise in sites
Translation = 26mm
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Axis of proximal segment
FIGURE 2014. The magnitude of a translational deformity is measured at the level of the proximal end of the distal fragment.
CORA Print Graphic
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Bisector Axis of distal segment
with hypertrophic vascular callus formation or in sites with poor callus formation and poor vascularity. The diagnosis of synovial pseudarthrosis is made by technetium 99m pyrophosphate bone scanning. Bone scans show a cold cleft at the nearthrosis between hot ends of ununited bone (see Fig. 2019).20, 67, 68, 207 Radiolabeled white blood cell scans (e.g., with indium 111 or technetium 99mhexamethylpropylene amine oxime [HMPAO]) are useful tools for the evaluation of acute infections of bone. Labeled polymorphonuclear leukocytes accumulate in areas of acute infections. Gallium scans are useful for the evaluation of chronic infections of bone. Gallium 67 citrate is localized in sites of chronic inammation. The combination of a gallium 67 citrate scan and a technetium 99msulfa colloid bone marrow scan can further clarify the diagnosis of chronic infection in cases of nonunion.
OTHER RADIOLOGIC STUDIES Fluoroscopy and cineradiography (see Fig. 204) are a helpful adjunct to plain exion-extension lateral radiographs for determining the relative contribution of a joint and an adjacent nonunion to the overall arc of motion. Fluoroscopy is also helpful for guided needle aspiration of a nonunion site in the workup for infection. Ultrasonography is useful for assessing the status of the bony regenerate (i.e., distraction osteogenesis) during bone transport or lengthening. Fluid-lled cysts delay
FIGURE 2013. This is the same case with a diaphyseal nonunion and deformity that is shown in Figure 2011. The center of rotation of angulation (CORA) and bisector are indicated.
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maturation of the regenerate and can be visualized and aspirated using ultrasound technology (Fig. 2020). Elimination of the cyst by aspiration helps shorten the time of regenerate maturation. Ultrasonography is also useful for conrming the presence of a uid-lled pseudocapsule in cases of suspected synovial pseudarthrosis by nuclear medicine study. Magnetic resonance imaging may occasionally be used to evaluate the soft tissues at the nonunion site or the cartilaginous and ligamentous structures of the adjacent joints. Sinograms may be used to image the course of a sinus tract in cases of infected nonunion. Angiography provides anatomic detail regarding the status of vessels as they course through a scarred and deformed limb. This study is unnecessary for most patients presenting with a fracture nonunion, but it is indicated if there is concern regarding the viability of the limb. Venous Doppler studies should be performed preoperatively to rule out a deep venous thrombosis in patients with a lower extremity nonunion who have been conned to a wheelchair or bedridden for an extended period. Intraoperative or postoperative recognition of a venous thrombus or an embolus in a patient who has not been screened preoperatively does not make for a happy patient, family, or orthopaedic surgeon.
Laboratory Studies
Routine laboratory tests, including electrolyte determinations and a complete blood cell count, are useful for screening general health. The sedimentation rate is a useful measure to follow in regard to the course of infection. If deemed appropriate, the nutritional status of the patient can be assessed by anergy panels, albumin levels, and transferrin levels. If a question exists regarding the patients wound healing potential, an albumin level (3.0 g/dL is preferred), and a total lymphocyte count (>1500 cells/ mm3 is preferred) can be obtained. In patients with a history of multiple blood transfusions, a hepatitis panel and a human immunodeciency virus (HIV) test may also be useful. In cases of suspected infection, the nonunion site may be aspirated or biopsied. This is most easily accomplished using uoroscopic guidance. The aspirated or biopsied material is sent for a cell count and Gram strain, and cultures are sent for identication of aerobic, anaerobic, fungal, and acid-fast bacillus organisms. To encourage the highest yield possible, all antibiotics should be discontinued at least 1 week before aspiration of the nonunion site.
Consultations
Patients with fracture nonunions rarely present with the isolated problem of an ununited bone. One or more conditions commonly accompany nonunion: soft tissue problems, infection, chronic pain, depression, motor or sensory dysfunction, joint stiffness, and unrelated medical problems. The complex nature of the problem necessitates the assemblage of a team of subspecialists to assist in the care of the patient with a nonunion. The consultants participate in the initial evaluation of the patient and play a vital role in the care of the patient throughout the course of treatment. Preoperative consultation with a plastic reconstructive surgeon may be necessary to assess the status of soft tissues, particularly when the need for coverage is anticipated after serial debridements of an infected non union. Consultation with a vascular surgeon may be necessary if there is any question regarding the viability (i.e., vascularity) of the limb. Consultation with an infectious disease specialist is helpful to prescribe the best antibiotic regimen to be used before, during, and after surgery. This is particularly important for the patient with a history of a long-standing infected nonunion. Many patients with nonunions present with dependency on oral narcotic pain medication. Referral to a pain management specialist is helpful in managing the patient through the course of treatment and ultimately detoxifying the patient so he or she is weaned off all narcotic pain medications.80, 218, 239 Depression is a common nding in patients with chronic medical conditions.58, 113, 114, 127 Patients with nonunions commonly present with signs of clinical
CORA
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CORA
CORA
AP view
Lateral view
FIGURE 2015. A, When the deformity at the nonunion site involves angulation without translation, the center of rotation of angulation (CORA) is seen at the same level on the anteroposterior (AP) and lateral radiographs. B, When the deformity at the nonunion site involves angulation and translation, the CORA is seen at a different level on the AP and lateral radiographs.
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FIGURE 2016. The extended Harris view shows the orientation of the hindfoot relative to the tibial shaft in the coronal plane. A, The patient is positioned lying supine on the x-ray table with the knee in full extension and the foot and ankle in maximal dorsiexion. The x-ray tube is aimed at the calcaneus at a 45 angle with a tube distance of 60 inches. B, An anteroposterior radiograph of the tibia shows a distal tibial nonunion with a valgus deformity. This patient had been treated with an external xator at an outside facility. In an effort to correct the distal tibial deformity, the hindfoot had been xed in varus through the subtalar joint. C, On clinical inspection, this situation is not always obvious and can be missed. Illustration continued on following page
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5 Hindfoot valgus
21 Hindfoot varus
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ne motor skills such as grooming, dressing, and use of hand tools. Occupational therapy may also be consulted if adaptive devices are required to complete activities of daily living during nonunion repair. Referral to physical or occupational therapy should be accompanied by a detailed diagnosis, specic precautions or contraindications, and weight-bearing status, if appropriate. The surgeons goal or purpose for referring a patient to rehabilitation should be made explicit to avoid miscommunication among the therapist, the patient, and the surgeon. A nutritionist may be consulted for patients who are malnourished or obese. Poor dietary intake of protein (albumin) or vitamins may contribute to delayed fracture union or nonunion.53, 6264, 84, 187, 233 A nutritionist may also counsel the severely obese patient about reducing body weight. The technical demands are high in caring for the obese patient with a nonunion, and a higher complication rate should be anticipated.112 Anesthesiologists and internists should be consulted early for the elderly patients or those with potentially serious medical conditions. Preoperative planning of special anesthetic and medical needs diminishes the likelihood of intraoperative and postoperative medical complications.
Normal (left)
Abnormal (right)
TREATMENT Objectives
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz
FIGURE 2016 Continued. D, The extended Harris view of the normal left side is compared with the abnormal right side. Notice the profound subtalar varus deformity of the right lower extremity. The distal tibial valgus deformity and the subtalar varus deformity must be corrected in this patient.
depression. Referral to a psychiatrist for treatment can be of great benet. A neurologist should evaluate patients presenting with motor or sensory dysfunction. Electromyography and nerve conduction studies are used to document the location and extent of neural compromise and to determine the need for nerve exploration and repair. A physical therapist should be consulted for preoperative and postoperative training. A few preoperative physical therapy visits can be used to educate the patient with respect to postoperative activity expectations and to instruct the patient in the use of expected assistive or adaptive devices. Immediate postoperative (inpatient) rehabilitation includes transfer training, gait training, range of motion exercises, and a simple strengthening program, with the goal of independent transfers and ambulation when possible. Outpatient physical therapy primarily addresses strength and range of motion of the surrounding joints but may include sterile or medicated whirlpool treatments to treat or prevent minor infections (e.g., pin-site irritation in patients treated with external xation). After the nonunion has united, more aggressive strengthening and return-to-work activities may be indicated, depending on the individual patients needs. Occupational therapy is also useful for activities of daily living and job-related tasks, particularly those involving
Before embarking on any method of treatment, the orthopaedist should be aware of the objectives in treating nonunions. Although treatment is directed at healing the fracture, this is not the only objective, because a nonfunctional, infected, deformed limb with pain and stiffness of the adjacent joints is an unsatisfactory outcome for most patients even if the nonunion heals solidly. Emphasis must be placed on returning the extremity and the patient to the fullest function possible during and after the treatment process. Treating a nonunion can be likened to a game of chess. It is difcult to predict the course until the process is under way. Some nonunions heal rapidly with a single intervention. Others require a lengthy treatment involving multiple surgeries. In general, viable nonunions are relatively easy to bring to union, whereas nonviable nonunions can be difcult to heal. Unfortunately, even the most benign-appearing nonunion may mount a terric battle against healing. Treatment must therefore be planned so that each step anticipates the possibility of failure and allows for additional treatment options without burning any bridges. The patients motivation, disability status, social problems, legal involvements, mental status, and desires should be carefully considered before treatment is begun. What does the patient expect from treatment? Are these expectations realistic? Obtaining informed consent is essential before any treatment. The patient must understand the uncertainty of nonunion healing, time course of treatment, and number of surgeries required. No guaran-
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tees or warranties should ever be given to the patient by the treating physician. If the patient is unable to tolerate a potentially lengthy treatment course or the uncertainties associated with the treatment and outcome, the option of amputation should be discussed. Although limb ablation has drawbacks, it does resolve the problem rapidly and may therefore be the preferred choice by certain patients.18, 40, 94, 210, 235 It is unwise to talk a patient into or out of any treatment option; this is particularly true for amputation. When feasible, eradication of infection and correction of unacceptable deformities are performed at the time of nonunion treatment. This, however, is not always practical or possible, and the treatment plan is then broken into several stages. To maximize function, the priorities of treatment should be as follows: 1. 2. 3. 4. Heal the bone. Eradicate infection. Correct deformities. Maximize joint range of motion and muscle strength.
with a deformity the rst priority is to heal the bone. This does not mean that the treatment cannot begin with a debridement in an effort to eliminate infection; it does mean that the overriding priority is to heal the bone. A residual infection or deformity can be addressed after successful bony union. Stiff brotic joints, associated especially with metaphyseal nonunions, are mobilized by arthrolysis, and contractures inhibiting joint motion are addressed in the treatment plan. Physical therapy is used to maintain or increase motion and muscle strength.
Strategies
After performing an in-depth evaluation using the history and physical examination results, radiologic examinations, laboratory studies, and consulting physicians opinions, an assessment of the overall situation is required. This assessment culminates in the design of a specic treatment strategy for the patients particular circumstances. The choice of treatment strategy is based on accurate assessment and classication of the nonunion (Table
It should be understood that the priorities of treatment do not necessarily denote the temporal sequencing of surgical procedures. For example, in an infected nonunion
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FIGURE 2017. A, The computed tomography (CT) scan of the 88-year-old woman shown in Figure 208A shows that this fracture is healed. B, The CT scan of the 49-year-old man shown in Figure 208B shows that the fracture has progressed to nonunion.
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204). Classication is based on one primary consideration and 13 treatment modiers (Table 205). PRIMARY CONSIDERATION: NONUNION TYPE The primary consideration for designing the treatment strategy is the nonunion type (Fig. 2021). The nonunion types include hypertrophic, oligotrophic, atrophic, infected, and synovial pseudarthrosis. By categorizing the nonunion into one of these ve types, orthopaedic surgeons are able to understand the mechanical and biologic requirements of fracture healing that have not
been met, and they are able to design a strategy to meet the healing requirements. Hypertrophic Nonunions Hypertrophic nonunions are viable. They possess an adequate blood supply193 and display abundant callus formation156; they simply lack mechanical stability. The requirement of a hypertrophic nonunion for healing is mechanical stability, and providing mechanical stability leads to a rapid biologic response (Fig. 2022). Rigid stabilization of a hypertrophic nonunion results in chondrocyte-mediated mineralization of brocartilage at
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FIGURE 2018. In addition to helping determine whether a fracture has united or has gone on to nonunion, computed tomography (CT) is useful for estimating the cross-sectional area of healing over time, as in this case of an infected midshaft tibial nonunion. A, Using the radiograph of the tibia 4 months after injury, it is difcult to say denitively whether the fracture is healing. B, The CT scan shows a clear gap without bony contact or bridging bone (0% cross-sectional area of healing). C, The radiograph was obtained 6 months later, after gradual compression across the nonunion site. D, The CT scan shows solid bony union (more than 50% cross-sectional area of healing).
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FIGURE 2019. Technetium bone scanning in three cases shows a viable nonunion (A), a nonviable nonunion (B), and a synovial pseudarthrosis (C); the arrow illustrates the cold cleft.
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FIGURE 2020. A, Radiograph shows a slowly maturing proximal tibial regenerate. B, Ultrasonography shows a uid-lled cyst (arrow). TABLE 204
Nonunion Types and Their Characteristics

Nonunion Type Hypertrophic Physical Examination
Plain Radiographs Abundant callus formation; radiolucent line (unmineralized brocartilage) at the nonunion site Little or no callus formation; diastasis at the fracture site Bony surfaces partially resorbed; no callus formation; osteopenia; sclerotic avascular bone segments; segmental bone loss Osteolysis; osteopenia; sclerotic avascular bone segments; segmental bone loss Nuclear Imaging Increased uptake at the nonunion site on technetium bone scan Increased uptake at the bone surfaces at the nonunion site on technetium bone scan Avascular segments appear cold (decreased uptake) on technetium bone scan. Increased uptake on technetium bone scan; increased uptake on indium scan for acute infections; increased uptake on gallium scan for chronic infections Laboratory Studies Unremarkable
Typically does not display gross motion; pain elicited on manual stress testing Variable (depends on the stability of the current hardware) Variable (depends on the stability of the current hardware)
Oligotrophic
Unremarkable
Atrophic
Unremarkable
Infected
Synovial pseudarthrosis
Depends on the specic nature of the infection: Active purulent drainage Active nondraining no drainage but the area is warm, erythematous, and painful Quiescentno drainage or local signs or symptoms of infection Variable
Variable appearance (hypertrophic, oligotrophic, or atrophic)
Technetium bone scan shows a cold cleft at the nonunion site surrounded by increased uptake at the ends of the united bone.
Elevated erythrocyte sedimentation rate and C-reactive protein; white blood cell count may be elevated in more severe and acute cases; blood cultures should be obtained in febrile patients; aspiration of uid from the nonunion site may be useful in the workup for infection Unremarkable
CHAPTER 20 Nonunions: Evaluation and Treatment TABLE 205
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Treatment Strategies for Nonunions Based on Classication
Treatment Strategy
Classication PRIMARY CONSIDERATION (NONUNION TYPE) Hypertrophic Oligotrophic Atrophic Infected
Biological
Mechanical
Synovial pseudarthrosis
Bone grafting for cases that have poor surface characteristics and no callus formation Biological stimulation via bone grafting or bone transport Debridement, antibiotic beads, dead space management, systemic antibiotic therapy, biological stimulation for bone healing (bone grafting or bone transport) Resect synovium and pseudarthrosis tissue, open medullary canals with drilling and reaming, bone grafting Treatment modiers are described in the text.
Augment stability Improve reduction (bone contact) Augment stability, compression Provide mechanical stability, compression Compression
TREATMENT MODIFIERS Anatomic location Epiphyseal Metaphyseal Diaphyseal Segmental bone defects Prior failed treatments Deformities Length Angulation Rotation Translation Surface characteristics Pain and function Osteopenia Mobility of the nonunion Stiff Lax Status of hardware Motor/sensory dysfunction Patients health and age Problems at adjacent joints Soft tissue problems
the interfragmentary gap. Mineralization of brocartilage may occur as early as 6 weeks after rigid stabilization and is accompanied by vascular ingrowth into the mineralized brocartilage.156, 222 By 8 weeks after stabilization, there is resorption of calcied brocartilage, which is arranged in columns and acts as a template for deposition of woven bone. Woven bone is subsequently remodeled into mature lamellar bone (see Fig. 2022).222 The treatment of a hypertrophic nonunion is simple from a conceptual standpoint: add mechanical stability. No bone grafting is required.49, 104, 156, 157, 202, 204, 208, 209, 250252 The nonunion site tissue need not be resected, and it should not be resected. These nonunions want to heal and are relatively easy to bring to union. They simply need a little push in the right direction (Fig. 2023). If the method of rigid stabilization involves exposing the nonunion site (e.g., compression plate stabilization), preparation of the nonunion site with decortication may accelerate the consolidation of bone. If the method of rigid stabilization does not involve exposure of the nonunion site (e.g., intramedullary nail xation, external xation), a surgical dissection should not be undertaken for the purpose of preparing the nonunion site because it is unnecessary. Oligotrophic Nonunions Oligotrophic nonunions are also viable. They possess an adequate blood supply but display little or no callus formation. The cause is typically an inadequate reduction that results in little or no contact at the bony surfaces (Fig. 2024). Treatment methods that result in union of oligotrophic nonunions include reduction of the bony fragments to improve bone contact, bone grafting to promote bridging of the ununited bony gaps, or a combination of reduction of the bony fragments and bone grafting. Reduction of the bony fragments to improve bony contact can be performed with internal or external xation. This method is particularly indicated for oligotrophic nonunions with friendly surface characteristics (e.g., large surface area without comminution) when compression can be applied at the nonunion site to promote union. Bone grafting can be performed using a variety of techniques (see the Treatment Methods section),
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including open and percutaneous methods, and serves to stimulate the local biology at the nonunion site. Atrophic Nonunions Atrophic nonunions are nonviable. Their blood supply is poor, and they are incapable of purposeful biologic activity (Fig. 2025). Although the primary problem is biologic, the atrophic nonunion requires a treatment strategy that employs biologic and mechanical techniques. Biologic stimulation is most commonly provided by autogenous cancellous graft laid onto a widely decorticated area at the nonunion site. When stabilized and stimulated, revascu-
Hypertrophic
Elephant foot
Horse hoof
Oligotrophic
Atrophic
larization occurs slowly over the course of several months. Revascularization is visualized radiographically by observing the progression of osteopenia as it moves through sclerotic nonviable fragments.201, 252 Small, free necrotic fragments are excised, and the resulting defect is bridged with bone graft. Several methods are available to treat larger bony defects and are discussed later in this chapter. Mechanical stability can be achieved using internal or external xation. Because atrophic nonunions are frequently associated with osteopenic bone, the method of xation must provide adequate purchase in poor-quality bone (see the Treatment Modiers section). Various opinions exist regarding the extent of bone excision that should be performed in uninfected atrophic nonunions. No consensus exists regarding whether large segments of sclerotic bone should be excised at the nonunion site. Those who favor plate-and-screw xation tend to retain large sclerotic fragments. Rigid plate stabilization, decortication, and bone grafting results in slow revascularization of sclerotic segments over several months and healing of the nonunion. Those who favor other treatment methods tend to excise large sclerotic fragments, resulting in a segmental bony defect that is then reconstructed using one of the several methods available. Both of these treatment strategies result in successful union in a high percentage of cases. My decision about which approach to take largely depends on the treatment modiers (discussed below). Infected Nonunions Infected nonunions pose a dual challenge because they are characterized by two of the most difcult orthopaedic entities to treat: bone infection and ununited fracture. The condition is further complicated by the fact that it is often accompanied by incapacitating pain (often with narcotic dependency), soft tissue problems, deformities, joint problems (e.g., contractures, deformities, limited range of motion), motor and sensory dysfunction, osteopenia, poor general health, depression, and myriad other problems. Of all nonunions, these are the most difcult to treat. The goals in treating infected nonunions are to obtain solid bony union, eradicate the infection, and maximize function of the extremity and the patient. Before embarking on a course of treatment, the length of time required, the number of operative procedures anticipated, and the intensity of the treatment plan must be discussed with the patient and the family. The course of treatment for nonunions is difcult to predict, especially for infected nonunions. The possibility of persistent infection and nonunion despite adequate treatment should be discussed, and the possibility of future amputation should be considered. The treatment strategy for infected nonunions depends on the specic nature of the infection (e.g., draining, active nondraining, quiescent)205 and involves biologic and mechanical approaches. Active Purulent Drainage. When purulent drainage is ongoing, the nonunion takes longer and is more difcult to heal (Fig. 2026). The actively draining infection necessitates serial radical debridements to eliminate the infection. The rst debridement should include obtaining deep cultures, including specimens of soft tissues and bone. No perioperative antibiotics should be given at least 1 week
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Synovial Pseudarthrosis
Sealed off medullary canal Synovial fluid Pseudocapsule
FIGURE 2021. Classication of nonunions.
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FIGURE 2022. A, The photomicrograph demonstrates unmineralized brocartilage in a canine hypertrophic nonunion (von Kassa stain). B, Six weeks after plate stabilization, chondrocyte-mediated mineralization of brocartilage is observed in this hypertrophic nonunion. C, The substance progresses to form woven bone. D, It remodels to compact cortical bone 16 to 24 weeks after stabilization. (From Schenk, R.K. Bull Swiss ASIF October, 1978.)
before obtaining deep intraoperative cultures. Excision of all necrotic soft tissues (e.g., fascia, muscle, abscess cavities, sinus tracts), bone, and foreign bodies (e.g., loose orthopaedic hardware, shrapnel) should be performed. Soft tissues are debrided using a scalpel and electrocautery. The sinus tract specimen should be sent for pathologic evaluation to rule out the possibility of carcinoma. Necrotic bone is debrided using osteotomes, curettes, rongeurs, and gouges. A power bur may be used to saucerize overhanging ledges of necrotic bone. Pulsatile irrigation with an antibiotic solution is an effective means of washing out the open cavity. After debridement of an actively draining infected nonunion, a dead space is commonly present. The initial treatment typically involves insertion of antibioticimpregnated polymethyl methacrylate beads, and a bead exchange is performed at the time of each serial debride ment. The dead space can subsequently be managed in a number of ways. The most widely used method involves lling the dead space with a rotational vascularized muscle pedicle ap (e.g., gastrocnemius, soleus184) or a microvascularized free ap (e.g., latissimus dorsi, rectus, others254, 255). Another method of managing the dead space involves open wound care with moist dressings, as in the
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FIGURE 2023. Plate-and-screw xation of this hypertrophic clavicle nonunion led to rapid bony union. A, The radiograph shows a hypertrophic nonunion 8 months after injury. B, A radiograph taken 15 weeks after open reduction and internal xation (without bone grafting) shows complete and solid bony union.
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and local erythema (see Fig. 2026). The history often includes episodes of fever. These nonunions are treated using principles similar to those described for actively draining, infected nonunions: debridement, intraoperative cultures, soft tissue management, mechanical stabilization, bone-healing stimulation, and systemic antibiotic therapy. These cases typically require incision and drainage of an abscess, and only small amounts of bone and soft tissue are excised. Nondraining, infected nonunions are frequently managed with primary closure after incision and drainage, or they may be managed with a closed suction-irrigation drainage system until the infection resolves or becomes quiescent. Quiescent. Nondraining, quiescent, infected nonunions are those in patients with a history of infection but without drainage or symptoms for 3 months or more205 or patients without a history of infection but with a positive
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FIGURE 2024. A patient with an oligotrophic nonunion of the femoral shaft was referred in 21 months following failed treatment of the initial fracture with plate-and-screw xation. Notice the absence of callus formation and poor contact at the bony surfaces.
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Papineau technique, until granulation occurs and skin grafting can be performed. Bony defects can be reconstructed using a variety of techniques, including bone grafting with cancellous autograft, bulk allograft, and vascularized grafts. These and other techniques are discussed in the section on Segmental Bone Defects. When possible, it is preferable to obtain coverage over bone graft with a vascularized muscle ap. Mechanical stability promotes bony healing in infected nonunions,78, 199 and a variety of techniques of xation are available. The Ilizarov method may be used to bridge large bone defects. Assuming that the infection has been eradicated after serial debridements and coverage, the nonunion may be treated as an atrophic nonunion with a bony defect. The consulting infectious disease specialist generally directs systemic antibiotic therapy. After procurement of deep surgical cultures, the patient is placed on broadspectrum intravenous antibiotics while the culture results are pending. Antibiotic coverage is later directed at the infecting organisms when the culture results are available. Active, Nondraining. Infected nonunions that are nondraining but active manifest with swelling, tenderness,
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FIGURE 2025. In this case of an atrophic nonunion of the proximal humerus, notice the lack of callus formation, the bony defect, and the avascular-appearing bony surfaces.
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FIGURE 2026. A, The clinical photograph shows an actively draining, infected tibial nonunion. B, Another photograph shows a nondraining, infected tibial nonunion. Notice the local swelling (there is also erythema) without purulent drainage. C, The radiograph shows a nondraining, quiescent, infected tibial nonunion. This patient had a history of multiple episodes of purulent drainage. Results of the gallium scan conrmed infection.
indium or gallium scan (see Fig. 2026). These cases may be treated like atrophic nonunions by using internal or external xation. If the nonunion is to be stabilized with plate-and-screw xation, the residual necrotic bone may be debrided at the time of surgical exposure. The bone is decorticated and stabilized. Bone grafting may also be performed. If external xation is the method of choice, the infection and nonunion may be successfully eliminated with compression without open debridement or bone grafting.225 Synovial Pseudarthrosis Synovial pseudarthroses are characterized by uid bounded by sealed medullary canals and a xed synovium-like pseudocapsule (Fig. 2027). Treatment entails biologic stimulation and augmentation of mechanical stability. The synovium and pseudarthrosis tissue are surgically excised, and the medullary canals of the proximal and distal fragments are opened with drilling followed by reaming. Gaps between the major fragments are closed by fashioning the bone ends to allow interfragmentary compression using internal or external xation.
Bone grafting and decortication at the nonunion site encourages more rapid healing. Professor Ilizarov described an alternative method of treatment for synovial pseudarthrosis.105, 225 According to him, slow, gradual compression across a synovial pseudarthrosis results in local necrosis and inammation, ultimately stimulating the healing process. I have had mixed results with this method and believe that resection at the nonunion followed by monofocal compression or bone transport more reliably achieves good results. TREATMENT MODIFIERS The treatment modiers (see Table 205) are important for arriving at a more specic classication of the nonunion. They help to ne tune the treatment plan. Treatment modiers include the anatomic location, segmental bone defects, prior failed treatments, deformities, surface characteristics, pain and function, osteopenia, mobility of the nonunion, status of hardware, motor or sensory dysfunction, health and age of patients, problems at adjacent joints, and soft tissue problems.
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FIGURE 2027. A plain radiograph demonstrates a tibial nonunion with a synovial pseudarthrosis.
Anatomic Location The bone involved and the specic region or regions that the nonunion traverses (e.g., epiphysis, metaphysis, diaphysis) dene the anatomic location of a nonunion. Because a discussion on a bone-by-bone basis is beyond the scope of this chapter, I address the inuence of anatomic region on the treatment of nonunions in general terms. Epiphyseal Nonunions. Epiphyseal nonunions are relatively uncommon. When they do occur, the most common cause is inadequate reduction that leaves a gap at the fracture site. These nonunions therefore commonly manifest with oligotrophic characteristics; the other types rarely occur. The important considerations when evaluat-
ing epiphyseal nonunions are reduction of the intraarticular components (e.g., step-off at the articular surface); juxta-articular deformities (e.g., length, angulation, rotation, translation); motion at the joint, which is typically limited by arthrobrosis; and compensatory deformities at adjacent joints. Epiphyseal nonunions are typically treated with interfragmentary compression using screw xation. This is best achieved using a cannulated lag screw technique (i.e., overdrilling a glide hole) with a washer beneath the screw head. Previously placed screws that are holding the nonunion site in a distracted position should be removed. Arthroscopy is a useful adjunctive treatment for epiphyseal nonunions (Fig. 2028). The articular step-off can be evaluated and usually reduced under arthroscopic visualization, and the lag screws can be placed percutaneously using a cannulated screw system and uoroscopy. It is possible to freshen the intra-articular component of the nonunion using an arthroscopic bur if deemed necessary, although it is typically unnecessary. Arthroscopy also facilitates lysis of intra-articular adhesions to promote improved range of motion at the joint. Occasionally, an open reduction is required to reduce an intra-articular or juxta-articular deformity. In such cases, the surgical approach may be extended to include an arthrotomy for lysis of adhesions. Metaphyseal Nonunions. Metaphyseal nonunions are relatively common. In general terms, the nonunion type (i.e., hypertrophic, oligotrophic, atrophic, infected, and synovial pseudarthrosis) determines the treatment strategy. A variety of methods are available to treat unstable metaphyseal nonunions, including internal and external xation. Plate-and-screw stabilization provides rigid xation and is performed in conjunction with bone grafting for all but hypertrophic types (Fig. 2029). Screw xation alone (without plating) should never be used for nonunions of the metaphysis. Intramedullary nail xation is another xation option for metaphyseal nonunions (see Fig. 2029). Because the medullary canal is larger at the metaphysis than at the diaphysis, this method of xation is predisposed to instability. Special considerations and techniques are therefore required to treat metaphyseal nonunions with nail xation and include assurance of good bone-to-bone contact at the nonunion site; placement of a minimum of two interlocking screws in the short segment (oblique [nonparallel] interlocking screws add stability; customdesigned nails can provide for multiple interlocking screws); and placement of blocking (Poller) screws125, 126 to provide added stability (see Fig. 2029). It is imperative to perform intraoperative manual stress testing under uoroscopy to ensure stable xation when treating a metaphyseal nonunion with an intramedullary nail. External xation may also be used to treat metaphyseal nonunions. Ilizarov external xation is the preferred method because it has signicant advantages over unilateral, bilateral, and hybrid external xation. The full-ring Ilizarov system offers enhanced stability (with early weight bearing for lower extremity nonunions), and its dynamic nature allows for gradual compression at the nonunion site (see Fig. 2029). Metaphyseal nonunions are particularly well suited for treatment with thin-wire external xation
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because of the predominance of cancellous bone. However, two specic anatomic sites where internal xation is generally preferable to external xation for the treatment of nonunions are the proximal humeral and proximal femoral metaphyses; in these sites, the proximity of the trunk makes frame application technically difcult. Stable metaphyseal nonunions are most often oligotrophic and typically unite rapidly when stimulated. Conventional cancellous bone grafting or a percutaneous bone marrow injection may provide biologic stimulation of an
oligotrophic metaphyseal nonunion. Although both methods have a high rate of success, percutaneous marrow injection provides all the benets of minimally invasive surgery. Infected metaphyseal nonunions are treated with the strategy that has been previously outlined: debridement, antibiotic beads, systemic antibiotics, dead space management and wound coverage, bone stabilization, and reconstruction of bony defects. The special considerations for metaphyseal nonunions
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FIGURE 2028. The preoperative radiograph (A) and preoperative computed tomography scan (B) show an epiphyseal nonunion (oligotrophic) of the distal femur in an 18-year-old patient who was referred in 5 months after the injury. Solid bony union (C) resulted after arthroscopically assisted closed reduction and percutaneous cannulated screw xation.
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are similar to those of epiphyseal nonunions and include juxta-articular deformities, motion at the adjacent joint, and compensatory deformities at the adjacent joints. These issues are addressed in a manner similar to epiphyseal nonunions and are discussed in greater detail later. Diaphyseal Nonunions. Diaphyseal nonunions traverse cortical bone and therefore may take longer to heal and may be more resistant to union than metaphyseal and epiphyseal nonunions, which traverse primarily cancellous bone. However, by virtue of their more central location, diaphyseal nonunions are friendly to the widest array of xation methods using orthopaedic hardware (Fig. 20 30). Primarily, the nonunion type determines the treatment strategy, but the other treatment modiers must also be considered. Nonunions That Traverse More Than One Anatomic Region. Nonunions that traverse more than one
anatomic region are more complex. These nonunions require a strategy plan for each region. In some cases, the treatment can be performed using the same strategy for each region, whereas a combination of strategies must be used in others. For example, a nonunion of the proximal tibial metaphysis with diaphyseal extension could be treated with a single method. In such a case, a reamed intramedullary nail with proximal and distal interlocking screws provides mechanical stability and biologic stimulation (reaming) to both nonunions with a single treatment strategy. In another example, a nonunion of the distal tibial epiphysis with proximal extension into the metaphysis and diaphysis could be treated using a combination of strategies: cannulated screw xation (compression) of the epiphysis, percutaneous marrow injection of the metaphysis, and Ilizarov external xation stabilizing all three anatomic regions.
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FIGURE 2029. Metaphyseal nonunions can be successfully treated using a variety of methods. A, Preoperative and nal radiographs show an atrophic distal tibial nonunion treated with plate-and-screw xation and autologous cancellous bone grafting. B, Preoperative and nal radiographs show an oligotrophic distal tibial nonunion treated with exchange nailing. Notice the use of Poller screws in the short distal fragment to enhance stability. C, Preoperative and nal radiographs and the nal clinical photograph show a proximal metaphyseal humeral nonunion treated with intramedullary nail stabilization and autogenous bone grafting. D, Radiographs were obtained preoperatively, during treatment, and after treatment of a distal tibial nonunion treated using Ilizarov external xation.
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surface characteristics (e.g., increased surface area, potential for enhanced bony contact, horizontal orientation of the fracture nonunion line, enhanced stability to axial compression). Segmental bone defects associated with nonunions may have partial (incomplete) bone loss or circumferential (complete) bone loss (Fig. 2031). These defects may be managed using a variety of treatments. Treatment ts into three broad categories: static methods, acute compression methods, and gradual compression methods. Static Treatment Methods. Static treatment methods for bone defects are designed to ll the defect between the bone ends. When using static methods, the proximal and distal ends of the nonunion do not move, but instead remain statically xed using orthopaedic hardware (i.e., internal or external xation). When using a static method, it is important to ensure that the bone to be treated is at its appropriate length (i.e., not foreshortened or overdistracted). Static methods for treating bone defects include the use of autogenous cancellous bone graft, autogenous cortical bone graft, vascularized autograft, bulk cortical allograft, strut cortical allograft, mesh cagebone graft constructs, and synostosis techniques. Autogenous cancellous bone graft may be used to treat partial or circumferential defects. The other methods are typically used to treat circumferential segmental defects. These methods are discussed in the Treatment Methods section. Acute Compression Methods. Acute compression methods are designed to obtain immediate bone-to-bone contact at the nonunion site. These methods achieve immediate bone-to-bone contact by acutely shortening the extremity. The extent of acute shortening that is possible is limited by the soft tissues (i.e., soft tissue compliance, surgical or open wounds, and neurovascular structures). Some investigators82, 106, 225 have suggested that more than 2 to 2.5 cm of acute shortening at the nonunion site may lead to soft tissue problems such as wound closure difculties or kinking of blood vessels and lymphatic channels. In my experience, up to 4 cm of acute shortening at the nonunion site is well tolerated by the soft tissues in many patients (Fig. 2032). In a study
FIGURE 2030. Diaphyseal nonunions can be successfully treated using a variety of methods. A, Preoperative and nal radiographs show a left humeral shaft nonunion treated with plate-and-screw xation and autologous cancellous bone grafting. B, Preoperative and nal radiographs demonstrate a left humeral shaft nonunion treated with intramedullary nail xation. C, Radiographs were obtained preoperatively, during treatment, and after treatment of an infected humeral shaft nonunion treated using Ilizarov external xation.
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Segmental Bone Defects Segmental bone defects associated with nonunions result from high-energy open fractures in which bone is left at the scene of the accident; surgical debridement of devitalized bone fragments that are devoid of all soft tissue attachments after a high-energy open fracture; surgical debridement of an infected nonunion; surgical excision of necrotic bone associated with an atrophic nonunion; and surgical trimming at a nonunion site to improve the
Partial (incomplete) segmental bone defect
Circumferental (complete) segmental bone defect
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FIGURE 2031. Segmental bone defects may be associated with partial (incomplete) bone loss or circumferential (complete) bone loss.
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comparing acute shortening with subsequent relengthening versus bone transport for tibial bone defects, Paley and co-workers169 reported that acute shortening is appropriate for defects up to 7 cm long. Longitudinal incisions tend to bunch up with redundant tissues when acute shortening is performed. An experienced plastic reconstructive surgeon is invaluable for the closure of these wounds. Transverse incisions tend to bunch up less when acute shortening is performed at the nonunion site and therefore are less difcult to close. In limbs with paired bones, it is necessary to partially excise the unaffected bone to allow for compression across the ununited bone. For example, partial excision of the bula shaft (when the bula is intact) is necessary to allow compression and shortening of the tibia. Acute compression methods offer the advantage of immediate bone-to-bone contact at the nonunion site.
Immediate contact with compression across the segmental defect begins the process of healing as early as possible. The bone ends should be fashioned to create a docking site with bone surfaces that are as parallel as possible. Flat cuts with an oscillating saw improve bone-to-bone contact but probably damage the bony tissues at the docking site. Osteotomes, rasps, and rongeurs create less local damage to the bony tissues but are less effective in creating at bony cuts. No consensus opinion exists about which method of fashioning the bone ends is best. I prefer to use a wide, at oscillating saw (using intermittent short bursts of cutting) under constant irrigation to cool the saw blade and bone. Another advantage of acute compression with shortening is the ability to bone graft the docking site immediately. Cancellous bone graft packed around the acute docking site (which has been decorticated) promotes healing of the nonunion.
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FIGURE 2032. A, A circumferential (complete) segmental bone defect was noted in a 66-year-old woman with an infected distal tibial nonunion who was on high-dose steroids for severe rheumatoid arthritis. B, The radiograph was obtained during treatment following acute compression (2.5 cm) using an Ilizarov external xator and bone grafting at the nonunion site. C, The nal radiograph shows a healed distal tibial nonunion and restoration of length from concomitant lengthening at a proximal tibial corticotomy site.
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FIGURE 2033. Oblique, parallel, at cuts allow enhanced interfragmentary compression through lag screw xation when a segmental defect is treated with acute compression and plate stabilization.
A disadvantage of acute compression at segmental defects is the resulting functional consequences from foreshortening of the extremity. In the upper extremity, 3 to 4 cm of foreshortening is well tolerated. In the lower extremity, up to 2 cm of foreshortening may be treated with a shoe lift. Many patients poorly tolerate a shoe lift for 2 to 4 cm of shortening, and most do not tolerate more than 4 cm of foreshortening. Many patients undergoing acute shortening with compression across the segmental defect require a lengthening procedure of the ipsilateral extremity or a foreshortening procedure of the contralateral extremity (see Fig. 2032). These limb-length equalization procedures can be performed concurrently with or sequentially after the acute compression (shortening) procedure to treat the nonunion. Acute compression across the nonunion site is typically used to treat circumferential segmental defects and can be accomplished using a variety of treatment methods. When using internal xation devices, acute compression is most effectively applied by the intraoperative use of a femoral distractor or a spanning external xator. When using plate-and-screw xation, an articulating tension device may be used to gain further interfragmentary compression. Dynamic compression plates (DCP, Synthes, Paoli, PA) provide rigid xation and may be used to provide further interfragmentary compression. Oblique, parallel at cuts allow for enhanced interfragmentary compression through lag screw xation (Fig. 2033) and promote bony union when plate-and-screw xation is used. When using intramedullary nail xation, acute compression across the segmental defect can also be applied intraoperatively using a femoral distractor or a spanning external xator (Fig. 2034). Compression can be applied using these temporary devices before nail insertion or after nail insertion but before static interlocking of the nail. In either case, the medullary canal should be overreamed a minimum of 1.5 mm larger than the diameter of the nail. Overreaming permits nail passage without distraction at the nonunion site when the nail is placed after compression (shortening). Likewise, overreaming allows the proximal and distal fragments to slide over the nail and compress without jamming on the nail when compression with the external device is performed after nail insertion. Before intraoperative removal of the temporary compression device, care must be taken to ensure that the nail is statically locked
proximal and distal to the nonunion site. Some intramedullary devices, such as the Biomet Ankle Arthrodesis Nail (Warsaw, IN), have been designed to allow for the application of acute compression across the fracture or nonunion site during the operative procedure (Fig. 2035). In my experience, nails that allow for acute compression, when available, are preferable to conventional nails for this specic type of treatment. Acute compression can also be applied using an external xator as the denitive mode of treatment. Transverse, parallel at cuts allow for enhanced axial compression and minimize shear moments at the nonunion site. Because of its biomechanical and biologic advantages, which are discussed later in the chapter, I favor the use of Ilizarov external xation when using external xation for acute compression across a segmental defect. The Ilizarov frame can also be used in these cases for restoring length using a corticotomy with lengthening at another site of the bone (i.e., bifocal treatment). Gradual Compression Methods. Gradual compression methods to treat a nonunion with a circumferential segmental defect include simple monofocal gradual compression (i.e., shortening) or bone transport. Both methods are most commonly accomplished through external xation; I favor the Ilizarov device. Neither gradual compression nor bone transport is associated with the potentially severe soft tissue and wound problems associated with acute compression. On the other hand, both monofocal compression and bone transport are associated with malalignment at the docking site (the most extreme case being when the proximal and distal fragments completely miss each other), whereas acute compression is not. When the chosen method of treatment is monofocal, gradual compression, the external xator frame is constructed to allow for compression in increments of 0.25 mm (Fig. 2036). Slow compression at a rate of 0.25 to 1.0 mm per day is applied in one or four increments, respectively. When a large defect exists, compression is applied at a rate of 1.0 mm per day; at or near bony touchdown, the rate is slowed to 0.25 to 0.5 mm per day. Compression in limbs with paired bones necessitates partial excision of the intact unaffected bone. When the chosen method is bone transport, the frame is constructed to allow bone transport at a rate ranging from 0.25 mm every other day to 1.5 mm per day (Fig. 2037). The transport is typically started at the rate of 0.5 mm or 0.75 mm per day in two or three increments, respectively. The rate is often adjusted (increased or decreased) based on the quality of the bony regenerate as viewed on serial plain radiographs (see Fig. 2037). For both methods, favorable surface characteristics at the nonunion site greatly improve the chances of rapid healing at the docking site. When poor surface characteristics are present, open trimming of the nonunion site is recommended. When open trimming is performed at the time of the initial procedure, the docking site can be bone grafted if the anticipated time to docking is approximately 2 months or less (e.g., a 6-cm defect treated with gradual shortening or bone transport at a rate of 1.0 mm per day). If the time to docking is signicantly greater than 2 months (e.g., for larger defects), two options exist. In the rst, gradual
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FIGURE 2034. Acute compression of a tibial nonunion with a segmental defect was accomplished with a temporary (intraoperative only) external xator. Denitive xation was achieved using an intramedullary nail. Notice the use of Poller screws in the proximal fragment for enhanced stability. A, Radiograph on presentation. B, Intraoperative radiographs. C, Final result.
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FIGURE 2035. Some intramedullary nails allow for acute compression across a fracture site or a nonunion site. This example, the Biomet Ankle Arthrodesis Nail (Warsaw, IN) is designed to allow acute compression at the time of the operative procedure. A, Before compression. B, Acute compression being applied across the ankle joint using the compression device.
who fail to demonstrate radiographic evidence of progression to healing despite 4 months of continued compression after bony touch-down, for patients at greatly increased risk of persistent nonunion at the docking site (who have several contributing factors for nonunion), and for those with poor surface contact at the docking site (who require trimming of the bone ends to improve the surface characteristics). By virtue of their architecture (i.e., point-to-point contact), nonunions with partial segmental defects are not readily amenable to many of the treatment strategies that have been discussed. These defects are most commonly treated with a static method, such as autologous cancellous bone grafting and internal or external xation. An unusual situation is a nonunion with a large (>6-cm) segment of partial (incomplete) bone loss. As the segment of partial bone loss increases in length, the chances for successful bony union using conventional bone grafting techniques decreases. In these cases, the treatment options are splinter (sliver) bone transport (Fig. 2038), surgical trimming of the bone ends to enhance surface characteristics followed by an acute or gradual compression method, or strut cortical allogenic bone grafting. The choice of treatment strategy for nonunions associated with segmental bone defects is complex and depends on a variety of factors. The diverse nature of the patients makes synthesis of the literature quite difcult. The recommendations for treatment of complete segmental bone defects by various surgeons are shown in Table 206. My preferred treatment methods for various situations are shown in Table 207. Prior Failed Treatments The prior failed treatments are always important to consider when evaluating a fracture nonunion. Why did the prior treatments fail? Were the treatment plans appropriate for the patients condition? Were there problems with the technical aspects of prior treatments? Each of these questions must be answered so that the cycle of treatment failure can be broken. A careful analysis of prior failed treatments can provide great insight into the character of the nonunion in terms of its response (or lack thereof) to various treatment modalities. Were there any positive biologic responses to any of the prior treatments? Did any treatment improve the patients condition in terms of pain and function? Did mechanical instability contribute to the prior failures? A prior treatment that has failed to provide any clinical or radiographic evidence of progression to healing should not be repeated. However, if the treating physician believes that improvements in the technical aspects of the treatment may lead to bony union, repeating the procedure may be warranted. Repeating a prior failed procedure may be considered if it demonstrated a measurable clinical or radiographic improvement in the nonunion. For example, repeat exchange nailing of the femur is an effective nonunion strategy in certain groups of patients87 but relatively ineffective in others.257 Those who heal after serial exchange nailings tend to show improvement after each successive procedure. Those whose nonunions persist tend to show little or no clinical and radiographic response to each of the nail exchanges,
compression or transport can be continued even after bony touchdown at the docking site is seen on plain radiographs. Continued compression at a rate ranging from 0.25 mm per week to 0.25 mm per day at the docking site is seen clinically and radiographically as bending of the xation wires, indicating that the rings are moving more than the proximal and distal bone fragments. In the second option, the docking site can be opened before bone contact (usually when the defect is approximately 1 to 2 cm), the proximal and distal surfaces can be freshened, and the defect can be bone grafted. Gradual compression or transport then proceeds into the graft material. In my experience, compression at the docking site without open bone grafting and surface freshening leads to successful bony union in many patients. Others believe that bone grafting the docking site signicantly decreases the time to healing. The literature is not helpful in clarifying this issue. A useful alternative to open bone grafting is percutaneous marrow injection at the docking site. This technique is minimally invasive and quite effective. I use the technique at the docking site of patients who I believe are at increased risk for persistent nonunion at the docking site; these patients usually have one or more contributing factors for nonunion (see Table 202). I reserve open bone grafting of the docking site for patients
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FIGURE 2036. An example of an infected nonunion treated with gradual, monofocal compression. A, The presenting radiograph shows the proximal tibial nonunion in a 79-year-old woman with a history of multiple failed procedures and chronic osteomyelitis. B, The intraoperative radiographs after bone excision and Ilizarov application show a segmental defect. C, Radiographs show gradual compression at the nonunion site over the course of several weeks. D, The radiograph shows the nal result with solid bony union.
and it is unlikely that these patients will ever heal with this technique (Fig. 2039). The nonunion specialist must be part surgeon, part detective, and part historian. History has a way of repeating itself. Without a clear understanding and appreciation of why the prior treatments have failed, the learning curve becomes a circle. Deformities The priority for a patient with a fracture nonunion and a deformity is healing the ununited bone. Although every effort should be made to heal the bone and correct the deformity at the same time, it is not always possible. When planning a treatment strategy for these patients, I ask
whether the effort to correct the deformity at the time of initial treatment will signicantly increase the risk of persistent nonunion. If the answer is yes, the treatment is planned to rst address the nonunion and later address the deformity in the healed bone (i.e., sequential approach). If the answer is no, both problems are treated concurrently. In my experience, most nonunions with associated deformities benet from concurrent treatment. Deformity correction most commonly improves bone contact at the nonunion site and therefore promotes bony union. Certain cases, however, are better treated with a sequential approach. Examples include cases in which it is unlikely that the deformity will ultimately limit function after successful bony union, cases in which adequate bony contact is
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best achieved by leaving the fragments in the deformed position, and cases in which soft tissue restrictions make the concurrent approach more complex than the sequential approach. Deformity correction at the nonunion site can be performed acutely or gradually. Acute correction is generally easily performed in lax nonunions, particularly when there is a segmental bone defect. In such cases, accurate, acute correction simplies the overall treatment plan and allows the treating physician to focus on healing the bone, which is without deformity after correction. Deformity correction of the stiff nonunion is more challenging. Acute correction typically requires surgical takedown of the nonunion site or an osteotomy at the nonunion site. Both approaches are effective in deformity correction but result in local damage at the nonunion site that may impair bony healing. When a large deformity exists, the fate of the surrounding soft tissues and neighboring neurovascular structures must be considered when acute deformity correction is contemplated. Gradual correction of a deformity in a stiff nonunion may be accomplished using Ilizarov external xation. Correction
of length, angulation, rotation, and translation may be performed in conjunction with compression, distraction, or both at the nonunion site. Introduction of the Taylor Spatial Frame (Smith & Nephew, Inc., Memphis, TN) in 1997 greatly simplied frame construction and expanded the combinations of deformity components that can be solved simultaneously (Figs. 2040 to 2043). The extent of deformity (i.e., length, angulation, rotation, and translation) that can be accepted without correction varies by anatomic location and from patient to patient. Generally, when it is anticipated that the deformity will limit function after successful bony union, correction should be strongly considered. Surface Characteristics The surface characteristics at the nonunion site are an important predictor of its resistance to healing with various treatment strategies. Nonunions that have large, transversely oriented adjacent surfaces with good bony contact are generally stable to axial compression and are therefore relatively easy to bring to successful bony union. In contrast, those with small, vertically oriented surfaces
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FIGURE 2037. A, The radiograph was obtained at presentation of the patient 8 months after a high-energy, open tibial fracture that was treated elsewhere using an external xator. B, A clinical photograph at presentation shows an open draining sinus tract. Illustration continued on following page
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FIGURE 2037 Continued. C, D, Bone transport progresses at a rate of 1.0 mm per day (0.25 mm four times per day). E, The nal radiograph shows solid union at the docking site, with mature bony regenerate at the proximal corticotomy site. Slow, gradual compression without bone grafting at the docking site resulted in solid bony union.
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with poor bony contact usually are more difcult to bring to bony union (Fig. 2044). Simple compression using internal or external xation generally leads to bony union in nonunions in which the opposing fragments have a large surface area. When the surface area is small, trimming of the ends of the bone may be necessary to improve the surface area for bony contact (Fig. 2045). Similarly, transversely oriented nonunions respond well to compression. Oblique or vertically oriented nonunions have some component of shear (with the bones sliding past each other) when subjected to axial compression. These shear moments can be minimized using interfragmentary screws when using plate-and-screw xation or steerage pins when using external xation (Fig. 2046; see also Fig. 2033).
FIGURE 2038. A, The nonunion has a large partial (incomplete) segmental defect. B, Splinter (sliver) bone transport can be used to span this defect.
Pain and Function Some patients with nonunions may have little or no pain and fairly good function. The painless nonunion
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TABLE 206
Review of the Recent Literature on Segmental Bone Defects

Author May et al, 1989 Patient Population
Findings/Conclusions The authors recommended treatment options for segmental bone defects are as follows: Tibial defects 6 cm or less with an intact bulaopen bone grafting vs. Ilizarov reconstruction Tibial defects greater than 6 cm with an intact bulatibiobula synostosis techniques vs. free vascularized bone graft vs. nonvascularized autogenous cortical bone graft vs. cortical allograft vs. Ilizarov reconstruction Tibial defects greater than 6 cm without a usable intact bulacontralateral vascularized bula vs. Ilizarov reconstruction Bony union rates for the three groups were as follows: Papineau technique = 49% Posterolateral bone grafting = 78% Soft tissue transfer = 70%
Current Concepts Review based on the authors experience treating more than 250 patients with post-traumatic osteomyelitis of the tibia.
Esterhai et al, 1990
Cierny and Zorn, 1994
42 patients with infected tibial nonunions and segmental defects. The average tibial defect was 2.5 cm (range, 0 10 cm); three treatment strategies were employed. All patients underwent debridement and stabilization and received parenteral antibiotics; following this protocol 23 underwent open cancellous bone grafting (Papineau technique), 10 underwent posterolateral bone grafting, and 9 underwent a soft tissue transfer prior to cancellous bone grafting. 44 patients with segmental infected tibial defects; 23 patients were treated with conventional methods (massive cancellous bone grafts, tissue transfers, and combinations of internal and external xation); 21 patients were treated using the methods of Ilizarov.
Green, 1994
32 patients with segmental skeletal defects; 15 were treated with an open bone graft technique; 17 were treated with Ilizarov bone transport 25 infected tibial nonunions with segmental bone loss greater than or equal to 2.5 cm; 15 patients were treated with debridement, external xation, bone grafting, and soft tissue coverage; 10 were treated with resection and bone transport using a monolateral external xator 37 cases of infected nonunion of the tibial shaft treated with open cancellous bone grafting (Papineau technique) stabilized via external xation; 15 nonunions had partial contact at the nonunion site, 22 had a complete segmental defect ranging from 1.5 to 3 cm in length. 32 patients with infected tibial nonunions with bone defects less than 3 cm; all were stabilized with external xation and were grafted with autogenous iliac crest bone at a mean of 8 weeks following soft tissue coverage.
Marsh et al, 1994
Emami et al, 1995
The nal results in the two treatment groups were similar. The Ilizarov method was faster, safer in B-host (compromised) patients, less expensive, and easier to perform. Conventional therapy is recommended when any one distraction site is anticipated to exceed 6 cm in length in a patient with poor physiologic or support group status. When conditions permit either conventional or Ilizarov treatment methods, the authors recommend Ilizarov reconstruction for defects of 2 to 12 cm. The authors recommendations are as follows: Defects up to 5 cmcancellous bone grafting vs. bone transport Defects greater than 5 cmbone transport vs. free composite tissue transfer The two treatment groups were equivalent in terms of rate of healing, eradication of infection, treatment time, number of complications, total number of operative procedures, and angular deformities after treatment. Limb-length discrepancy was signicantly less in the group treated with bone transport. All nonunions united at an average of 11 months following bone grafting. The authors recommend cancellous bone grafting for complete segmental defects up to 3 cm in length. Union was reported in 91% of patients (29 of 32) at a mean of 5.5 months following the bone graft procedure; union was achieved in the remaining 3 patients following posterolateral bone grafting.
Patzakis et al, 1995
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TABLE 207
Authors Recommendations for Treatment Options for Complete Segmental Bone Defects
Bone Clavicle Clavicle Humerus Humerus Humerus Humerus Humerus Radius or ulna Radius or ulna Radius or ulna Radius or ulna Radius or ulna Femur Femur Femur Femur Femur Femur Femur Tibia Tibia Tibia Tibia Tibia Tibia Tibia Tibia Host Healthy or compromised Healthy or compromised Healthy Healthy Compromised Compromised Compromised Healthy Healthy Compromised Compromised Compromised Healthy Healthy Healthy Healthy Compromised Compromised Compromised Healthy Healthy Healthy Healthy Compromised Compromised Compromised Compromised Segmental Defect <1.5 cm 1.5 cm <3 cm 3 cm <3 cm 36 cm >6 cm <3 cm 3 cm <3 cm 36 cm >6 cm <3 cm 36 cm 615 cm >15 cm <3 cm 36 cm >6 cm <3 cm 36 cm 615 cm >15 cm <3 cm 36 cm 615 cm >15 cm
Recommended Treatment Options Cancellous autograft bone grafting; skeletal stabilization Tricortical autogenous iliac crest bone grafting; skeletal stabilization Cancellous autograft bone grafting vs. shortening; skeletal stabilization Bulk cortical allograft vs. vascularized cortical autograft vs. bone transport; skeletal stabilization Cancellous autograft bone grafting vs. shortening; skeletal stabilization Bulk cortical allograft vs. vascularized cortical autograft vs. bone transport; skeletal stabilization Bulk cortical allograft vs. vascularized cortical autograft; skeletal stabilization Cancellous autograft bone grafting vs. tricortical autogenous iliac crest bone grafting vs. shortening; skeletal stabilization Bulk cortical allograft vs. vascularized cortical autograft vs. bone transport vs. synostosis; skeletal stabilization Cancellous autograft bone grafting vs. tricortical autogenous iliac crest bone grafting vs. shortening; skeletal stabilization Bulk cortical allograft vs. vascularized cortical autograft vs. bone transport vs. synostosis; skeletal stabilization Bulk cortical allograft vs. vascularized cortical autograft vs. synostosis; skeletal stabilization Cancellous autograft bone grafting vs. bone transport vs. bifocal shortening and lengthening; skeletal stabilization Bone transport vs. bifocal shortening and lengthening; skeletal stabilization Bone transport vs. bulk cortical allograft; skeletal stabilization Bulk cortical allograft; skeletal stabilization Cancellous autograft bone grafting vs. bone transport vs. bifocal shortening and lengthening; skeletal stabilization Bone transport vs. bifocal shortening and lengthening vs. bulk cortical allograft; skeletal stabilization Bulk cortical allograft with skeletal stabilization vs. bracing vs. amputation Cancellous autograft bone grafting vs. bone transport vs. bifocal shortening and lengthening; skeletal stabilization Bone transport vs. bifocal shortening and lengthening; skeletal stabilization Bone transport vs. bulk cortical allograft; skeletal stabilization Bone transport vs. bulk cortical allograft vs. synostosis; skeletal stabilization Cancellous autograft bone grafting vs. bone transport vs. bifocal shortening and lengthening; skeletal stabilization Bone transport vs. bifocal shortening and lengthening; skeletal stabilization Bone transport vs. bulk cortical allograft vs. synostosis; skeletal stabilization Bulk cortical allograft with skeletal stabilization vs. synostosis with skeletal stabilization vs. bracing vs. amputation
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FIGURE 2039. This 51-year-old woman has a femoral nonunion and was referred in after failing three prior exchange nailing procedures.
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FIGURE 2040. The Taylor Spatial Frame (Smith & Nephew, Inc., Memphis, TN) allows simultaneous correction of deformities involving length, angulation, rotation, and translation. A, Saw bone demonstration of a tibial nonunion with a profound deformity. Notice how the Taylor Spatial Frame mimics the deformity. B, The deformity has been corrected by adjusting the Taylor Spatial Frame struts. The strut lengths are calculated using a computer software program provided by the manufacturer.
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is seen in three cases: patients with hypertrophic nonunions, elderly patients, and patients with Charcot neuropathy. Some hypertrophic nonunions may have relative stability and may therefore not cause symptoms during normal daily activities. The patient may have some discomfort when the fracture nonunion site is placed under stress, such as running, jumping, lifting, or pushing. These painless hypertrophic nonunions occur most often in the clavicle, humerus, ulna, tibia, and bula. They are often identied when, after apparent healing seen on a radiograph, an overexposed radiograph reveals a ne line of cartilage at a hypertrophic fracture site. Subsequent tomograms or CT scans conrm the nonunion (Fig. 2047). Painless nonunions are also seen in elderly patients. Typically, the nonunion involves the humerus, but it can also occur in the proximal ulna, the femur, and, less frequently, the tibia or lower bula. Nonsurgical treatment can be acceptable as long as day-to-day function is not affected. In particular, this treatment course should be considered in the elderly patient with multiple medical co-morbidities that increase the risk of perioperative complications. In such cases, immobilization in a brace or cast, possibly including ultrasonic or electrical stimulation of the fracture site, may be warranted (Fig. 2048). Operative stabilization may be necessary if instability and symptoms at the fracture site impair the patients routine daily activities or if there is concern that the overlying soft tissues will be compromised over time (Fig. 2049). Fracture nonunion in the presence of Charcot neuropathy can produce severely deformed and injured bones and joints that are relatively painless. These cases are usually treated with bracing and avoidance of surgery unless the overlying soft tissues are in jeopardy (see Fig. 2049). In all cases of painless fracture nonunion, the medical history, physical examination results, and imaging studies should be carefully considered when determining the treatment strategy. Surgical intervention does not always improve the patients condition or complaints, and in many cases, it can result in serious problems that reduce the patients quality of life. Simple, nonsurgical treatment may be all that is needed to control the patients symptoms and maintain or restore function, leading to a satisfactory outcome.
Osteopenia
FIGURE 2041. A, The preoperative photograph shows frame tting in the ofce. The anteroposterior (AP) and lateral radiographs show a distal tibial nonunion with deformity in a 58-year-old woman referred in 14 months after a high-energy, open fracture. B, The clinical photograph and AP radiograph were obtained during correction using the Taylor Spatial Frame (Smith & Nephew, Inc., Memphis, TN). C, The radiographs show the nal result.
Nonunions in patients with osteopenic bone represent an especially challenging management problem. The osteopenia may be isolated to the involved bone, as in an atrophic or infected nonunion, or it may be a preexisting condition that involves many areas of the skeleton, as in cases of osteoporosis or metabolic bone disease. Metabolic bone disease should be suspected in patients with nonunions in locations that do not typically have healing problems (Fig. 2050), in long-standing cases that have failed to unite
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FIGURE 2042. A, The preoperative radiograph demonstrates a distal femoral nonunion with deformity in a 60-year-old man who was referred in 6 months after open reduction and internal xation. B, The radiograph was obtained during correction using the Taylor Spatial Frame (Smith & Nephew, Inc., Memphis, TN). C, The radiograph shows the nal result.
despite adequate treatment, and in cases with loss of xation of hardware in the absence of technical deciencies. A workup for metabolic bone disease should be undertaken in suspected cases. Intramedullary nail xation is an exceptionally good technique in patients with osteopenic bone. Intramedullary nails function as internal splints, with contact between the implant and bone along the medullary canal. These devices also benet by their load-sharing characteristics. Interlocking screws proximal and distal to the fracture site help maintain rotational and axial stability. Specially designed interlocking screws for purchase in poor bone stock are available from several manufacturers. When rigid xation is desired, an intramedullary plate construct can be achieved with a custom-manufactured intramedullary nail with multiple interlocking screw capability (Fig. 2051). Plate-and-screw devices depend on xation at the screw-bone junction and are prone to loosening in patients with osteopenic bone where purchase may be poor. Weber and Cech252 described a method of reinforcing the screw holes with polymethyl methacrylate (PMMA) bone cement (Fig. 2052). Using this technique, loose screws are removed, except for those adjacent to or crossing the nonunion and those at the proximal and distal ends of the
plate. Slow-setting PMMA is mixed for 1 minute and then poured into a 20-mL syringe. The syringe has an attached nipple, needle, or catheter that is used for injecting PMMA into the screw holes. Each hole is injected with 1 to 2 mL of liquid cement, and the screws are rapidly reinserted into their correct holes. During injection, excess cement may come out through an adjacent empty screw hole. After reinsertion of the screws, all excess cement should be cleaned from around the screws, the plate, and the opposite side of the bone. No cement should enter the nonunion surfaces or gap. After approximately 10 minutes to allow cement hardening, the screws are tightened and checked for stability. If the end screws are essential for xation and are also loose, they are removed at this point, and another batch of cement is similarly mixed and injected. The end screws are then reinserted by following the same process. The bone cement technique is especially useful for nonunions of an osteopenic metaphysis. External xation using the thin-wire Ilizarov technique provides surprisingly good purchase in osteopenic bone. The stability of the construct can be improved by the use of olive wires, which discourage translational moments at the wirebone interface. The use of a washer at the olive wirebone interface helps to distribute the load and to prevent erosion of the olive wire into the bone.
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Mobility of the Nonunion Based on the results of manual stress testing, a nonunion may be described as stiff or lax. These terms are most applicable when the treatment method involves Ilizarov external xation. A stiff nonunion has an arc of mobility of 7 or less. A lax nonunion has an arc of mobility greater than 7.106, 225 Accurate assessment of motion at a nonunion site is difcult in the case of a limb with paired bones where one of the bones is intact. Stiff hypertrophic nonunions may be treated using compression, distraction, or sequential monofocal compression-distraction. Lax nonunions may be hypertrophic, oligotrophic, infected, or a synovial pseudarthrosis. Lax hypertrophic and oligotrophic nonunions may be treated with gradual compression. Although some surgeons225 have recommended 2 to 3 weeks of compression followed by gradual distraction, I have not found it necessary to distract in most cases (Fig. 2053). Other
surgeons166 have recommended sequential monofocal distraction-compression in the treatment of hypertrophic nonunions. Lax, infected nonunions and synovial pseudarthroses are treated in the manner previously described. Further details of the Ilizarov method are given later in this chapter. Status of Hardware The status of previously placed hardware directly affects treatment strategy design for a nonunion. One consideration is whether performance of the contemplated plan necessitates removal of the existing hardware. For example, a humeral shaft nonunion that was initially treated with intramedullary nail xation would likely require removal of the nail if the contemplated plan is plate-andscrew xation with bone grafting. Alternatively, the patient could be treated with Ilizarov thin-wire external xation with gradual compression, and the nail could be retained
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FIGURE 2043. A, The preoperative anteroposterior (AP) radiograph shows a distal radius nonunion with a xed (irreducible) deformity in a 73-year-old woman who was referred in 9 months after injury. B, This AP radiograph was obtained during deformity correction using the Taylor Spatial Frame (Smith & Nephew, Inc., Memphis, TN).
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FIGURE 2043 Continued. C, The postoperative radiograph was obtained soon after deformity correction and plate-and-screw xation with bone grafting for a wrist arthrodesis.
FIGURE 2044. The lateral radiograph demonstrates a tibial nonunion in a 59-year-old man who was referred in 6 months after the initial fracture. Treating nonunions such as this with vertically oriented surfaces and poor bony contact can be challenging.
(using slow compression over a nail using external xation [SCONE], as described in the Treatment Methods section). Removing previously placed hardware is considered when it is associated with an infected nonunion, when it interferes with the contemplated treatment plan, or when broken or loose hardware causes symptoms. The previously placed hardware may be retained when it augments the contemplated treatment plan (e.g., SCONE). Surgical dissection to remove the hardware may not be desirable in some cases (i.e., obesity, previous infections, or multiple prior soft tissue reconstructions overlying the hardware) and when the hardware does not interfere with the contemplated treatment plan. Removal may be used as the denitive treatment by repositioning the bone fragments,
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FIGURE 2045. Trimming the ends of the bone at a nonunion site may be used to improve the surface area for bony contact.
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improvement of sensation or motor function after reconstructive procedures. If neural reconstruction cannot restore purposeful limb function and other techniques such as tendon transfers or bracing are not thought to be of potential benet, amputation may be considered. Although ablation of the limb has disadvantages, it is more rapid, less costly, and less traumatizing than prolonged, multiple-staged reconstructions that often do little to improve the status of an insensate or accid limb or to increase the patients quality of life.
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FIGURE 2046. Steerage pins (arrow) enhance skeletal stabilization.
as in an oligotrophic nonunion with a statically locked nail in which the bone fragments are distracted. In such a case, the interlocking screws may be removed proximally or distally, the nonunion site can be acutely compressed using an externally applied device, and the interlocking screws can be inserted in their new position. Motor and Sensory Dysfunction Severe motor or sensory decits in a limb that has a fracture nonunion present special challenges. Many compensatory and adaptive strategies are available to address substantial motor or sensory decits associated with a nonunion. Supportive treatments such as bracing, exercise therapy to strengthen the intact muscles in the region, and the use of assistive devices for ambulation or other daily activities may allow preservation or restoration of function and support a plan for retaining the limb. For example, if anterior compartment motor function of the leg is impaired, ambulation can be improved after successful nonunion treatment by applying an ankle-foot orthosis or by performing a tendon transfer. Some factors to consider when designing a treatment plan for a patient with a nonunion associated with neural dysfunction include the quality and extent of plantar or palmar sensation, which are integral to ambulation and hand function, respectively; the location and extent of other sensory decits; the magnitude, location, and extent of motor loss (e.g., partial loss of motor function of the extensor hallucis longus versus complete loss of all motor function of the foot and ankle); and the potential for
Health and Age of Patients The patients health and age often inuence the design of the treatment plan. Advanced age and chronic illnesses result in diminished biologic activity at the site of fracture nonunion and may make a successful outcome more difcult to achieve. Patients who have multiple or serious medical conditions may be poor candidates for surgical intervention. Although age itself is not a contraindication to surgical treatment of a nonunion, elderly patients are more likely to have concomitant medical conditions that may render surgery inadvisable. Elderly patients who have been nonambulatory for an extended period, who have substantially impaired cognitive status, or who are conned to a long-term care facility often do not benet from reconstructive surgery for nonunions. The functional status of these patients is not likely to improve with surgery, and lack of compliance with postoperative instructions may become a signicant issue that produces further complications. In such cases, conservative treatment such as bracing is appropriate and engenders greater compliance than complicated postoperative care protocols. When the health of the patient is such that survival takes precedence over healing the nonunion, amputation may be considered. On the other hand, elderly patients with a nonunion who have chronic illness need to maintain or increase their functional status as quickly as possible to decrease the likelihood of medical complications such as pneumonia
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FIGURE 2047. A, The anteroposterior radiograph shows the clavicle fracture of a 17-year-old boy who presented 6 months after the injury. He had been told by his former physician that his clavicle was solidly healed, and he had no pain. He was brought in by his mother, who was concerned about the bump on his collarbone. B, A computed tomography scan conrms the diagnosis of nonunion.
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FIGURE 2048. A, The anteroposterior radiograph demonstrates a left humeral shaft nonunion in a 71-year-old, right-hand-dominant woman with multiple medical problems who presented 27 months after the initial injury. B, Results of the clinical examination are consistent with a lax (ail) nonunion that is not associated with pain. This patient is an excellent candidate for nonoperative treatment with functional bracing.
and thromboembolism. These patients often benet from a treatment strategy that allows immediate weight bearing and functional activity (Fig. 2054). Problems at Adjacent Joints Stiffness or deformity of the joints adjacent to the nonunion can limit outcome if they are not identied and addressed. Treatment of the stiff or deformed joints can be operative or nonoperative. Physical therapies, such as joint mobilization and passive range of motion exercises, are commonly prescribed preoperatively to prepare for postoperative activity or postoperatively while restoring general limb function after successful nonunion treatment. Alternatively, joint stiffness or deformity can be treated with arthrotomy or arthroscopy, concomitantly with the procedure for the nonunion to maximize postoperative function quickly or as a subsequent, staged surgical procedure if postoperative physical therapy does not restore joint motion. Compensatory deformities accompanying nonunion constitute a problem that demands careful
consideration. Treatment options for a compensatory deformity adjacent to a nonunion (e.g., subtalar valgus deformity in a patient with a distal tibial nonunion associated with a varus deformity) include joint mobilization through physical therapy, joint mobilization by surgical lysis of adhesions at the time of surgery for the fracture nonunion, joint mobilization by surgical lysis of adhesions after the nonunion has solidly united in a reduced anatomic position, arthrodesis of the involved joint with acute correction of the compensatory deformity at the time of surgery for the fracture nonunion, and arthrodesis of the involved joint with acute correction of the compensatory deformity after the nonunion has solidly united in a reduced anatomic position. Soft Tissue Problems Patients with nonunions often present with substantial overlying soft tissue damage from the initial injury, multiple surgical procedures, or both causes. It is advisable to consult a plastic reconstructive surgeon specializing in
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B
FIGURE 2049. A, The radiograph shows a humeral shaft nonunion in an asymptomatic 82-year-old woman with Charcot neuropathy (and a Charcot shoulder) of the left upper extremity from a large syrinx. The patient had been managed nonoperatively using a functional brace by the previous physician. B, The patient was referred in for skeletal stabilization when a bony spike at the nonunion site eroded through her tenuous soft tissue envelope. C, Denitive plate-and-screw stabilization after irrigation and debridement led to bony union.
post-traumatic soft tissue procedures. The decision of whether to approach a nonunion through previous incisions or by elevating a soft tissue ap versus a surgical approach through virgin tissues is difcult and should be handled on a case-by-case basis. Extremities with nonunion and extensive soft tissue damage or scarring may benet from less invasive methods of treatment such as Ilizarov external xation and percutaneous marrow grafting. Nonunions associated with soft tissue defects, open wounds, or infection may require a rotational or free ap coverage procedure as part of the treatment strategy. Occasionally, local soft tissue advancement with wound
closure is facilitated by creating a deformity at the nonunion site that places the edges of the soft tissue defect in proximity (Fig. 2055). This technique is particularly useful for elderly patients, immunocompromised patients, those with signicant vascular disease, and patients with severe medical problems who are not good candidates for extensive operative soft tissue reconstructions. Between 3 and 4 weeks after wound closure, the deformity at the nonunion site is slowly corrected. In selected patients, this technique obviates the need for rotational or free ap coverage. The technique is best applied using Ilizarov external xation.
FIGURE 2050. The anteroposterior radiograph shows the pelvis of a 50-year-old woman who presented 16 months after a superior and inferior pubic rami fracture. The endocrine assessment of this patient with a nonunion in an unusual location revealed an underlying metabolic bone disease.
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FIGURE 2051. Custom-manufactured intramedullary nails with multiple interlocking screw capability augment the rigidity of xation and function as an intramedullary plate. I have used this type of construct with great success in elderly patients with symptomatic humeral shaft nonunions with large medullary canals and osteopenic bone. A, The preoperative radiograph was obtained for an 80-year-old woman with a painful humeral nonunion 14 months after fracture. B, An early postoperative radiograph was obtained after percutaneously performed intramedullary plating using a custom humeral nail.
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FIGURE 2052. Using polymethyl methacrylate cement is an effective, multistep method for obtaining screw purchase in osteoporotic bone. A, The loose screws are removed. B, Liquid cement is injected into the screw holes using a syringe. C, The screws are rapidly reinserted into the cement in the holes. The screws are tightened only after the cement has hardened. The cement should not be allowed to enter the fracture site or go around the bone. (Adapted from Weber, B.G; Cech, O. Pseudarthrosis. Bern, Hans Huber, 1976.)
Treatment Methods
Many treatment methods can be used in the care of patients with fracture nonunions, including those that augment mechanical stability, those that provide biologic stimulation, and those that both augment mechanical stability and provide biologic stimulation. These treatment methods are summarized in Table 208. Some nonunions may be successfully treated using a single method. For example, a hypertrophic nonunion of the humeral shaft may be brought to union using a single mechanical method, such as compression plate xation. Other nonunions may require several methods used in concert. For example, an atrophic nonunion of the humeral shaft may be addressed using plate-and-screw xation, decortication at the nonunion site, and cancellous autogenous bone grafting. MECHANICAL METHODS Mechanical methods promote bony union by providing stability and, in some cases, bone-to-bone contact. These methods may be used alone or in concert with other methods. Weight Bearing Weight bearing is a treatment method used for nonunions of the lower extremity, most commonly nonunions involving the tibia. Weight bearing is most commonly used in conjunction with an external supportive device (e.g., casts, braces, cast braces), dynamization, or excision of bone (Fig. 2056).
External Supportive Devices: Casting, Bracing, and Cast Bracing Casting, bracing, and cast bracing may be used to augment the mechanical stability at the site of nonunion. In certain instances, especially hypertrophic nonunions, the increased stability from the external supportive device may result in bony union. External supportive devices are most effective when used in conjunction with weight bearing for lower extremity nonunions. Functional cast bracing with weight bearing as a treatment for nonunion has been advocated by Sarmiento,217 particularly for nonunions of the tibia. Casting, bracing, and cast bracing are advantageous because they are noninvasive and particularly useful for patients with severe medical conditions who are not candidates for operative reconstruction. Disadvantages of these methods are that they do not provide the same degree of stability as operative methods of xation and are generally less effective treatment methods; do not allow for concurrent deformity correction; may create or worsen deformities; or may result in break down of the soft tissues in lax nonunions (see Fig. 2049). Nonunion treatment with an external supportive device is most effective for stiff hypertrophic nonunions of the lower extremity. Oligotrophic nonunions that are not rigidly xed in a distracted position at the nonunion site may also benet from casting or bracing and weight bearing. Unless severe medical conditions prohibit surgery, external supportive devices have no role in the treatment of atrophic nonunions, infected nonunions, or synovial pseudarthrosis.
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Dynamization Dynamization entails the creation of a construct that allows axial loading of bone fragments to obtain bony union. When possible, the construct is designed to allow axial loading while discouraging rotational, translational, and shear moments. Dynamization is most commonly used as an adjunctive treatment method in patients with a nonunion of the lower extremity that is being treated with intramedullary nail xation or external xation. Removal of the interlocking screws of a previously statically locked intramedullary nail allows the bone fragments to slide toward one another over the nail during weight bearing. This results in improved bone contact and compression at the nonunion site. In most cases, it is necessary to remove the interlocking screws only on one side of the nonunion (proximal or distal). Generally, the interlocking screws that are at the greatest distance from
the nonunion site are removed (Fig. 2057). When dynamization of an intramedullary nail is contemplated, axial stability and anticipated shortening must be considered. If shortening is anticipated to the extent that the intramedullary nail will penetrate the joint proximal or distal to the nonunion, treatment methods other than dynamization should be employed. Nail dynamization is advantageous because it is minimally invasive and allows for immediate return to weight-bearing activities. Disadvantages include resulting axial instability (which may result in shortening) and rotational instability, although some implant manufacturers have designed intramedullary nails with oblong interlocking screw holes that allow dynamization without the loss of rotational stability (see Fig. 2057). The technique may be useful for hypertrophic and oligotrophic nonunions involving the long bones of the
FIGURE 2053. A, The radiograph demonstrates a midshaft oligotrophic (lax) tibial nonunion in a 53-year-old man referred in 10 months after unilateral external xator stabilization for an open tibial fracture. Because of a history of recurrent pin tract infections and because the external xator had been removed 3 weeks before presentation, intramedullary nail xation was not thought to be an entirely safe treatment option for this patient. The patient was treated with gradual compression using an Ilizarov external xator. B, A radiograph obtained during treatment shows gradual dissolution of the nonunion site with gradual compression. Illustration continued on following page
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at the nonunion site promotes further bony union. Increasing pain at the nonunion site after dynamization is diagnostic of motion and suggests that bony union has not progressed to the extent presumed by the treating physician. Excision of Bone Excision of bone as a method of treatment of a nonunion can be used in three distinct ways. Using one method of excision, pain associated with the mechanical rubbing of the bone fragments at the nonunion site can be eliminated by excising one or more of the fragments. The excised bone fragment must be in an anatomic location that does not disrupt function. Anatomic locations in which excision of bone alleviates pain without impairing function include nonunions of the bula shaft (assuming the syndesmotic soft tissue structures are competent) and the ulna styloid. Partial excision of ununited fragments of the olecranon and patella may also be indicated in certain cases. Partial excision of the clavicle as a treatment for nonunion has been reported by Patel and Adenwalla176 and by Middleton and associates.150 Having had excellent results with plate xation, I am unable to recommend this technique for clavicle nonunions. In cases of high-energy trauma producing multiple bony injuries, articular injuries, or injury to the surrounding soft tissues, it is not always easy to predict pain relief after simple excision of bone at the nonunion site. Injection of local anesthetic into the nonunion site may help clarify the extent of pain relief anticipated after bone excision (Fig. 2058). The second method of bone excision is used in limbs with paired bones when one bone is intact and one has a nonunion. Excision of bone is performed on the intact bone to allow compression across the ununited bone. This technique is most commonly used in the leg in conjunction with external xation or intramedullary nail xation. Partial excision of the bula allows compression across an ununited tibia (Fig. 2059). The third method of bone excision is used to improve the surface characteristics at a nonunion site. Trimming and debridement are performed to improve the surface area, bone contact, and bone quality at the nonunion site. This technique of excision is most commonly used for atrophic and infected nonunions and for synovial pseudarthroses. Screws Interfragmentary lag screw xation is an effective method of treatment for epiphyseal nonunions (see Fig. 2028). Successful healing has also been reported after screw xation of patella nonunions122 (Fig. 2060) and olecranon nonunions.173 Interfragmentary lag screw xation may be used in conjunction with other forms of internal or external xation for metaphyseal nonunions. Screw xation alone is not recommended for nonunions of the metaphysis or diaphysis. Cables and Wires Periprosthetic fracture nonunions are particularly challenging by virtue of their neighboring hardware. A periprosthetic bone fragment that contains an intramedul-
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FIGURE 2053 Continued. C, The radiograph shows the nal result.
lower extremity. Unfortunately, no literature exists to strongly support or refute the use of nail dynamization in the treatment of nonunions. Atrophic and infected nonunions and synovial pseudarthroses are best treated using other methods. Dynamization of an external xator involves removal, loosening, or exchange of the external struts that span the nonunion. The method is most effective for lower extremity cases and is commonly used only after the treating physician believes that bony incorporation at the nonunion site is under way. In its preferred form, dynamization allows axial loading at the nonunion site during weight bearing in the external xator but discourages rotational, translational, and shear instability. Dynamizing an external xator is therapeutic and diagnostic. It is therapeutic to the extent that axial loading
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FIGURE 2054. A, The radiograph was obtained at presentation of a 73-year-old woman who was referred in with a distal tibial nonunion 14 months after her initial injury. B, Ilizarov external xation allows immediate weight bearing and improvement in functional activities, which is crucial in elderly patients for decreasing the risk of medical complications. C, The radiograph shows the nal result.
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FIGURE 2055. In certain cases, creating a deformity at the site of a nonunion facilitates wound closure. This is a particularly useful technique in elderly patients, immunocompromised persons, those with signicant vascular disease, or patients with severe medical problems who are not good candidates for extensive operative soft tissue reconstructions. A, In this example, the distal tibial nonunion with an open medial wound cannot be closed primarily because of retraction of the soft tissues. B, Creating a varus deformity at the nonunion site places the soft tissue edges in approximation and allows primary closure. The deformity at the nonunion site may be corrected later after healing of the soft tissues.
lary implant can be stabilized with cables or a cable-plate system, which obviates the need for implants traversing the (occupied) medullary canal. This type of reconstruction is commonly performed in concert with autogenous cancellous bone grafting with or without structural allograft bone struts (Fig. 2061). Tension band and cerclage wire techniques may be used to treat nonunions of the olecranon and patella,122 although I prefer more rigid xation techniques. Plate-and-Screw Fixation The modern era of nonunion management with internal xation can be traced to the establishment of the Swiss AO (Arbeitsgemeinschaft fur Osteosynthesefragen) by Muller, Allgower, Willenegger, and Schneider in 1958. Building from the foundation of the pioneers who had preceded them34, 49, 60, 110, 111, 117, 129, 130, 180 and using the metallurgic skills of the Swiss watch making and instrument industries and a research institute in Davos, the AO Group
developed a system of implants and instruments that remain in use today. The AO Group is responsible for the development of the most widely used modern concepts of nonunion treatment: stable internal xation under compression, decortication, bone grafting in nonunions associated with gaps or poor vascularity, leaving the nonunion tissue undisturbed for hypertrophic nonunions, and early return to function. Advantages of plate-and-screw xation include its rigidity of xation; versatility for various anatomic locations (Fig. 2062), especially periarticular and intraarticular nonunions, and situations such as periprosthetic nonunions; facilitation of correction of angular, rotational, and translational deformities (under direct visualization); safety after failed or temporary external xation. Disadvantages of the method include the requirement for extensive soft tissue dissection and the potential for associated complications; load-bearing nature of the implants that limit early weight bearing for lower extremity applications; and an inability to correct signicant foreshortening from bone loss. Stabilization with plate-andscrew xation is applicable for all types of nonunion. In cases of long bone nonunions with large segmental defects, other methods of skeletal stabilization should be considered. Published reports by many surgeons have documented success using plate-and-screw xation for the treatment of nonunions of the intertrochanteric femoral region,216 femur,241, 244 proximal tibia,27, 29, 261 tibia,92 clavicle,19, 51, 59, 165, 269 proximal humerus,91 humeral shaft,207, 265 distal humerus,145, 215 olecranon,50 and distal radius.71 A variety of plate types and techniques are available for specic nonunion applications. This information is beyond the scope of this chapter and is provided in each chapter that covers a specic anatomic region. Intramedullary Nail Fixation Intramedullary nailing is an excellent method of providing mechanical stability to a fracture nonunion. The method is useful for nonunions of the long bones whose injuries have previously been treated by a method other than an intramedullary nail; if the injury was most recently treated by a nail, placement of a new nail would be classied as an
TABLE 208
Treatment Methods for Nonunions
Mechanical Methods Weight-bearing External supportive devices Dynamization Excision of bone Screws Cables and wires Plate-and-screw xation Intramedullary nail xation Osteotomy External xation Biologic Methods Nonstructural bone grafts Decortication Electromagnetic, ultrasound, and shock wave stimulation Methods That Are Both Mechanical and Biologic Structural bone grafts Exchange nailing Synostosis techniques Ilizarov method Arthroplasty Arthrodesis Amputation
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FIGURE 2056. A, The radiograph was obtained for a 44-year-old man 8 months after a tibial shaft fracture. The patient did not want any operative intervention and his painful hypertrophic tibial nonunion was treated with weight bearing in a functional brace. B, The radiograph obtained 5 months after presentation shows the resulting solid bony union.
exchange nailing, which is a different technique that is discussed later. Intramedullary nail xation is particularly useful for lower extremity nonunions because of the ultimate strength and load-sharing characteristics of intramedullary nails. Intramedullary implants are an excellent treatment option for patients with osteopenic states in whom bone purchase may be poor. Intramedullary nail xation as a treatment for nonunion is commonly combined with a biologic method such as open grafting, intramedullary grafting, or intramedullary reaming. These techniques are used to stimulate the local biologic activity at the nonunion site, but the intramedullary nail itself is strictly a mechanical treatment method. Hypertrophic, oligotrophic, and atrophic nonunions, as well as synovial pseudarthroses, may be treated with intramedullary nail xation. The use of this method of xation in cases with active infection has been reported by several investigators,123, 124, 147, 228 but it remains controversial. Because of the potential risk associated with the technique in patients with infection (i.e., seeding the medullary canal) and because a variety of safer options exist, I and others142 generally recommend against the use of intramedullary nail xation in cases of active or prior deep infection. The use of exchange nailing in the face of infection is a different situation entirely because the medullary canal has already been seeded, and it is advocated in selected patients. Differing opinions exist regarding the use of intramed-
ullary nail xation in patients previously treated with external xation.16, 108, 140, 144, 149, 196, 260 The risk of infection after intramedullary nailing in a patient with prior external xation is generally accepted to be related to the duration of external xation, the period from removal of external xation to intramedullary nailing, and history of pin-site infection. Other factors affecting the risk of infection are related to the details of the application of the external xator: implant type (i.e., tensioned wires versus half pins), surgical technique (i.e., intermittent low-speed drilling under constant irrigation decreases thermal necrosis of bone when placing half pins and wires), and implant location (i.e., implants that traverse less soft tissue create less local irritation). The decision to use intramedullary nail xation in a patient whose injury has previously been treated with external xation should be made only after careful deliberation. I proceed with intramedullary nail xation in a patient who has had an external xator only when I believe that the benets outweigh the risks associated with this technique. A variety of other factors must be considered when treating long bone nonunions with intramedullary nail xation. First, the alignment (i.e., angulation and translation) of the proximal and distal fragments should be assessed on AP and lateral radiographs to determine if closed passage of a guide wire is possible. Second, plain radiographs and, when necessary, CT scans should be
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FIGURE 2057. A, Radiographs were obtained at presentation of a 40-year-old man 31 months after a closed femur fracture. The patient had failed multiple prior procedures, including exchange nailing and open bone grafting. The patient refused to have any type of major surgical reconstruction and was treated with nail dynamization by removing the proximal interlocking screws. B, Radiographs show solid bony union 14 months after dynamization. C, Intramedullary nails designed with oblong, interlocking screw holes allow dynamization without loss of rotational stability.
studied to determine whether the medullary canal is open or sealed off at the nonunion site and whether it allows passage of a guide wire and reamers. T-handle reamers or a pseudarthrosis chisel (or both) may be useful for closed recanalization, but they are effective only when the proximal and distal fragments are relatively well aligned. If these methods fail, a percutaneously performed osteotomy without a wide exposure of the nonunion site or percutaneous drilling of the medullary canals of the proximal and distal fragments or both (using uoroscopic imaging) may facilitate passage of the guide wire and nail (Fig. 2063). After the percutaneously performed osteotomy, deformity correction may be facilitated by the use of a femoral distractor or a temporary external xator.
Third, the xation strategy using interlocking screws must be considered. The choices include static interlocking, dynamic interlocking, and no interlocking. This decision is based on a number of factors, including the type of nonunion, the surface characteristics of the nonunion, the location and geometry of the nonunion, and the importance of rotational stability as judged by the treating physician. Fourth, loading and bone contact at the nonunion site can be optimized using a few special techniques. When static locking is to be performed, distant locking followed by backslapping the nail (as if to attempt to extract it) may improve contact at the nonunion site; this maneuver is followed by proximate locking. Some intramedullary nails have been designed to
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allow application of acute compression at the nonunion site during the operative procedure. A femoral distractor or a temporary external xator may aid in compression, deformity correction, or both at a nonunion site being stabilized with intramedullary nail xation (see Fig. 2034). For tibial nonunions, partial excision of the bula facilitates compression at the nonunion site during nail insertion and later during weight-bearing ambulation. Osteotomy or partial excision of the bula also facilitates acute correction of tibial deformities associated with a nonunion. Operative exposure of the nonunion site at the time of intramedullary nail xation has been recommended124, 147, 149, 175, 211, 228, 249, 264 for open bone grafting, hardware removal, deformity correction, resection of infected or necrotic bone, recanalization of the medullary canal for an injury that has failed closed technique, and soft tissue release. Some surgeons175, 228, 263, 264 have advocated routine exposure and open bone grafting for all nonunions being treated with intramedullary nail xation. Other investigators have recommended open exposure of the nonunion site only in cases requiring hardware removal,147, 149 deformity correction,147, 149, 211 nonunion takedown,124 open
recanalization of the medullary canal,142 or soft tissue release.147 Still others,3, 142, 260 as do I, discourage routine open bone grafting of nonunion sites being treated with intramedullary nail xation. Closed nailing without exposure of the nonunion site is advantageous because it does not damage the periosteal blood supply, the infection rate is lower, and it does not disrupt the tissues that have osteogenic potential at the nonunion site. In cases requiring a wide exposure of the nonunion site for open bone grafting, resection of bone, deformity correction, or hardware removal, I tend to use alternate methods of xation such as plate and screws or external xation. In general, I prefer to avoid treatment methods that impair the endosteal and periosteal blood supply, as do intramedullary nailing and open exposure of the nonunion site, respectively. I may somewhat reluctantly combine these methods for some exceptions: 1. Nonviable nonunions in patients with poor bone quality when bone grafting is needed to stimulate the local biology of the nonunion and nail xation is mechanically advantageous 2. Segmental nonunions with bone defects when I do not believe reaming will result in union and think nailing is
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FIGURE 2058. A, The radiograph was obtained at presentation of a 70-year-old man who was referred in 28 months after a high-energy pilon fracture. The patients primary complaint was pain over the bular nonunion. Injection in this area with local anesthetic resulted in complete relief of the patients pain. B, The radiograph shows the results after treatment of the bular nonunion by partial excision. The procedure resulted in complete pain relief.
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the best method to stabilize the segmental bone fragments 3. Nonunions associated with deformities in noncompliant or cognitively impaired individuals when the biomechanical advantages of intramedullary nail xation (over plate xation) are required and external xation is a poor option 4. Nonunions with large segmental defects when bulk cortical allograft and intramedullary nail xation are the chosen treatment (Fig. 2064) A technique that may be used in conjunction with nail xation to treat diaphyseal defects is closed intramedullary bone grafting. This technique was described by Chapman32 for use in recent fractures of the femoral shaft with segmental bone loss. I have used this technique to treat nonunions of the femur and tibia with excellent results (Fig. 2065). Grafting by means of intramedullary reaming
is an excellent method of treatment and is discussed in the section on Exchange Nailing. Intramedullary nail xation as a treatment for nonunion is most commonly used in the tibia. Reported healing rates for nonunions have been 92% to 100%.3, 116, 142, 147, 149, 153, 211, 228, 232, 248, 260 With the development of specialized nails and the availability of custom-designed nails, the anatomic zone of the tibia that can be treated with intramedullary nail xation has expanded from that recommended by Mayo and Benirschke142 in 1990. I do not favor an algorithmic approach regarding anatomic zones and nailing tibial nonunions. Instead, each tibial nonunion should be evaluated on a case-by-case basis, with templating performed when nail xation is contemplated for proximal or distal diametaphyseal or metaphyseal nonunions. A situation worth noting is the case of a slow or arrested proximal tibial regenerate (a nonunion of sorts) after an Ilizarov length-
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FIGURE 2059. A, The radiograph was obtained at presentation of a 42-year-old man who was referred in 5 months after a distal tibial fracture. B, The patient was treated with deformity correction and slow, gradual compression using an Ilizarov external xator. This approach required partial excision of the bula (arrow).
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able.33, 116, 147, 249, 264, 266, 267 Koval and co-workers,124 however, reported a high rate of failure for distal femoral nonunions treated with retrograde intramedullary nailing. Other sites of nonunion treated by intramedullary nail xation include the clavicle,17 proximal humerus,52, 162 humeral shaft,263 distal humerus,175 and bula.1 Osteotomy The purpose of an osteotomy in the treatment of nonunions is to reorient the plane of the nonunion. Reorientation of the angle of inclination of the nonunion
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FIGURE 2059 Continued. C, The radiograph shows the nal result.
ening or bone transport procedure. In a few selected patients, I have treated this problem with the following protocol: external xator removal, 6 to 8 weeks of casting and bracing (allows complete healing of the pin sites), and reamed, statically locked intramedullary nailing. This technique has been used only in patients who were poor candidates for open techniques (e.g., bone grafting, plate-and-screw xation) because of soft tissue concerns (e.g., morbid obesity, multiple prior soft tissue reconstructions). All of the regenerates have fully matured 3 to 6 months after reamed nailing, and no patient developed an infection (Fig. 2066). Nail xation for femoral nonunions is not uncommon, and the clinical results have generally been favor-
FIGURE 2060. A, The radiograph was obtained at presentation of a 55-year-old woman who was referred in with a patella nonunion after four failed attempts at reconstruction. The patient was treated with open reduction and interfragmentary lag screw xation. B, The nal radiographic result shows solid bony union.
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FIGURE 2061. A, The radiographs were obtained at presentation of an 83-year-old man with a periprosthetic fracture nonunion of the femur. The patient was treated with intramedullary nail stabilization with allograft strut bone graft and with circumferential cable xation. B, The nal radiographic result shows solid bony union and incorporation of the allograft struts. C, The radiographs were obtained at presentation of an 80-year-old woman who was referred in after failing multiple attempts at surgical reconstruction of a periprosthetic femoral nonunion. The patient was treated with plate stabilization with allograft strut bone graft and with circumferential cable xation. D, The nal radiograph shows solid bony union.
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FIGURE 2062. A, Presenting and nal radiographs show a proximal ulnar nonunion in a 60-year-old man referred in after failing three prior attempts at reconstruction. Blade plate xation provided absolute rigid stabilization and, in conjunction with autogenous bone grafting, led to rapid bony union. B, Presenting and nal radiographs show a tibial shaft nonunion that had failed treatment with an external xator. Plate-and-screw xation with autogenous bone grafting led to successful bony union. C, Presenting and nal radiographs show a humeral shaft fracture that had failed nonoperative treatment and had gone on to nonunion. Plate-and-screw xation with autogenous bone grafting produced successful bony union.
from a vertical to a more horizontal position encourages healing by promoting compressive forces across the nonunion site. The osteotomy can be performed through the nonunion site, such as to trim the bone ends at to decrease the inclination of a nonunion of a long bone, or performed adjacent to the nonunion, such as a Pauwels osteotomy for a femoral neck nonunion.11, 181 External Fixation External xation as a method of bone stabilization has been used primarily in the treatment of infected nonunions. The method is commonly employed in combination with serial debridements, antibiotic beads, soft tissue coverage procedures, and bone grafting. The use of external xation as a method of skeletal stabilization has been reported for infected nonunions of the femur,245 tibia,35, 65, 179 and humerus.36 The Ilizarov method is discussed in the section on Methods That Are Both Mechanical and Biologic.
BIOLOGIC METHODS Biologic methods promote bony union by stimulating the local biology at the nonunion site. These methods may be used alone but are more typically used in concert with a mechanical method. Nonstructural Bone Grafts Autogenous Cancellous Graft. Autogenous cancellous bone grafting remains an important weapon in the trauma surgeons armamentarium. Successful treatment of oligotrophic, atrophic, and infected nonunions, as well as synovial pseudarthroses, often depends on copious autologous cancellous bone grafting. Cancellous autograft is osteogenic, osteoconductive, and osteoinductive. The graft stimulates the local biology at the nonunion site in viable nonunions with poor callus formation and nonviable nonunions. Initially, the graft has poor structural integrity, but this situation improves rapidly during the process of osteointegration.
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A
Step 1 Step 2 Step 3 Step 4
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FIGURE 2063. This procedure is used for recannulating a sealed medullary canal associated with a nonunion to be treated with intramedullary nail insertion. A, The site does not have signicant deformity (i.e., proximal and distal canals are aligned): step 1, manual T-handle reaming; step 2, pseudarthrosis chiseling; step 3, passage of a bulb tip guide rod; step 4, flexible reaming. B, The site may have a signicant irreducible deformity (i.e., proximal and distal canals are not aligned): step 1, percutaneous osteotomy; step 2, percutaneous guide wire placement (uoroscopically guided) into the proximal and distal canals; step 3, cannulated drilling of the proximal and distal canals; step 4, pseudarthrosis chiseling; step 5, manual T-handle reaming; step 6, passage of a bulb-tip guide rod; step 7, exible reaming.
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Cancellous autograft is not necessary in the treatment of hypertrophic nonunions. These nonunions are viable and are characterized by motion and often by abundant callus formation. Stabilization results in calcication of unmineralized brocartilage and ultimately in bony union. Bone grafting is unnecessary and should not be performed. Oligotrophic nonunions are viable and typically arise as a result of poor bone-to-bone contact. Cancellous autograft bone promotes bridging of ununited bone gaps. The decision about whether to bone graft an oligotrophic nonunion is determined by the treatment strategy planned. If the strategy involves operative exposure of the nonunion site, such as for plate-and-screw xation, autogenous bone grafting onto a decorticated bony bed is recommended. If the strategy does not involve exposure of the nonunion
site, such as with compression by means of external xation or dynamization of an intramedullary nail, I do not routinely expose the oligotrophic nonunion for open bone grafting. Atrophic and infected nonunions are nonviable. Their blood supply is poor, and they are not capable of callus formation. These nonunions are typically associated with segmental bone defects. The many variables in patients with segmental bone defects makes clinical series reported in the literature difcult to interpret. Surgeons recommendations vary regarding the maximal complete segmental defect that can unite when stimulated with autogenous cancellous bone grafting (see Table 20 6).39, 65, 69, 83, 139, 141, 179 My treatment recommendations for segmental bone defects are shown in Table 207.
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FIGURE 2064. A, The radiograph obtained at presentation shows an infected femoral nonunion resulting from an open femur fracture that occurred 32 years earlier. This 51-year-old man had had more than 20 prior attempts at surgical reconstruction; the most recent was external xation and bone grafting performed at an outside facility. B, The clinical photograph was taken at the time of presentation. C, A clinical photograph shows antibiotic beads in situ. Illustration continued on following page
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FIGURE 2064 Continued. D, Gross specimen following resection. E, A radiograph obtained after radical resection shows a bulk antibiotic spacer that remained in situ for 3 months.
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FIGURE 2064 Continued. F, Radiographs were obtained 7 months after reconstruction using a bulk femoral allograft and a custom femoral nail; the proximal portion of the nail is an antegrade reconstruction nail, and the distal portion of the nail is a retrograde supracondylar nail. G, The clinical photograph was taken 7 months after reconstruction. The patient is ambulating full weight bearing and is pain free for the rst time in 32 years.
Synovial pseudarthrosis is most commonly treated with excision of the pseudarthrosis tissue and opening of the medullary canal. Decortication and autogenous cancellous bone grafting encourage more rapid healing and are recommended. Cancellous autogenous bone graft may be harvested from the iliac crest, the distal femur, the greater trochanter, the proximal tibia, and the distal radius. More osseous tissue can be harvested from the iliac crest than from any other location. Evidence also exists that bone of intramembraneous origin (e.g., ilium) is more osteoconductive than bone of enchondral origin (e.g., tibia, femur, radius).186 A dramatically larger quantity of bone can be harvested from the posterior iliac crest compared with the anterior iliac crest. A variety of techniques have been described for the treatment of nonunions using autogenous cancellous autograft: Papineau technique (open cancellous bone grafting) Posterolateral grafting of the tibia
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FIGURE 2065. Closed intramedullary autogenous cancellous bone grafting can be used to treat diaphyseal bony defects. Autogenous cancellous bone harvested from the iliac crest is delivered to the defect through a tube positioned in the medullary canal.
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Anterior grafting of the tibia (after soft tissue coverage) Intramedullary grafting32 Intramedullary reaming Endoscopic bone grafting121 Percutaneous bone grafting15 Various protocols exist for the timing of bone grafting: Early bone grafting without prior bony debridement or excision Early open bone grafting after debridement and skeletal stabilization Delayed bone grafting after debridement, skeletal stabili zation, and soft tissue reconstruction The major disadvantages of autogenous bone grafting in the treatment of nonunions are the limited quantity of bone available for harvest and donor site morbidity and complications.
Allogenic Cancellous Graft. Allogenic cancellous bone when used in the treatment of nonunions is most commonly mixed with autogenous cancellous bone graft or bone marrow. Because allogenic cancellous bone functions primarily as an osteoconductive graft, mixing it with autograft enhances the grafts osteoinductive and osteogenic capacity. Cancellous allograft may also be added to cancellous autograft bone to increase the volume of graft available to ll a large skeletal defect. Little is known about the efciency of allograft cancellous bone alone as a treatment for nonunion. I do not recommend the use of allogenic cancellous bone (alone or mixed with cancellous autograft) in patients with any recent or past infection associated with their nonunions. Allogenic bone can be prepared in three ways: fresh, fresh-frozen, and freeze-dried. Fresh grafts have the highest antigenicity. Fresh-frozen grafts are less immunogenic than fresh grafts and preserve the grafts bone
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FIGURE 2066. A, The radiograph demonstrates a proximal tibial regenerate in a 54-year-old woman who had undergone bone transport for an infected distal tibial nonunion. Although the technique led to solid bony union of the distal tibial nonunion site, the bony regenerate failed to mature and was mechanically unstable. The patient was treated with removal of her external xator and 8 weeks of bracing. After complete healing of the pin sites, a reamed, statically locked, custom (short) intramedullary nail was placed. B, The radiograph shows solid healing and maturation of the proximal tibial regenerate 8 months after intramedullary nailing.
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FIGURE 2067. A, The clinical photograph shows the bony landmarks for harvesting bone marrow from the posterior iliac crest. The patient has been positioned prone. B, Marrow is harvested in 4-mL aliquots. C, The radiograph and computed tomography (CT) scan were obtained at presentation of a 39-year-old woman who was referred in with a stable, oligotrophic, distal tibial nonunion. D, The radiograph and CT scan 4 months after percutaneous marrow injection show solid bony union. Abbreviation: PSIS, posterior superior iliac spine.
morphogenetic proteins. Freeze-dried grafts are the least immunogenic, have the lowest likelihood of viral transmission, are purely osteoconductive, and have the least mechanical integrity. Bone Marrow. Bone marrow contains osteoprogenitor cells capable of forming bone at the site of fractures and nonunions. Fracture and nonunion models in animals have shown enhanced healing when stimulated with bone marrow grafting.172, 240 The healing response in animals has been especially enhanced when demineralized bone matrix is mixed with bone marrow.240 Animal studies have also shown enhanced bone formation during distraction osteogenesis in a rat femoral model when marrow-derived mesenchymal progenitor cells were injected.194 Percutaneous bone marrow injection is a clinical treatment for fracture nonunion that has been reported with favorable results by several surgeons.43, 44, 226 The technique of percutaneous bone marrow grafting involves harvesting autogenous bone marrow from the anterior or posterior iliac crest using a trocar needle. I prefer to harvest marrow from the posterior iliac crest and use an 11-gauge, 4-inch Lee-Lok needle (Lee Medical Ltd., Minneapolis, MN) and a 20-mL, heparinized syringe (Fig. 2067). Marrow is harvested in small aliquots to increase the concentration of osteoblast progenitor cells. A study
performed in humans161 concluded that the preferred volume of bone marrow aspirated from each site is 2 to 4 mL. I harvest marrow in 4-mL aliquots, changing the position of the trocar needle in the posterior iliac crest between aspirations. Depending on the characteristics (e.g., size, location) of the recipient nonunion site, I typically harvest a total of 40 to 80 mL of marrow. Marrow injection into the nonunion site is performed percutaneously under uoroscopic image using an 18gauge spinal needle. The technique is minimally invasive, has low morbidity, and can be performed on an outpatient basis. The technique works well for nonunions with small defects (<5 mm) that have excellent mechanical stability (see Fig. 2067). Percutaneous marrow injection also enhances healing at the docking site of patients undergoing slow, gradual compression or bone transport. Bone Graft Substitutes. A variety of bone graft substitutes may have a future role in the treatment of nonunions (Table 209). The efciency and indications for these substitutes in the treatment of nonunions remain unclear. Growth Factors. Ongoing research in the area of growth factors holds promise for rapid advancement in the treatment of fracture nonunions. This subject is discussed in Chapter 22.
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TABLE 209
Commercially Available Bone Graft Substitutes

Bone Graft Substitute Collagraft (Zimmer, Inc., Warsaw, IN) Norian SRS (Norian Corporation, Cupertino, CA) Osteoset (Wright Medical Technology, Inc., Arlington, TN) ProOsteon (Interpore Cross International Inc., Irvine, CA) DynaGraft (Gen Sci Regeneration Sciences, Inc., Mississauga, Ontario) Grafton DBM (Osteotech, Inc., Eatontown, NJ) Opteform (Exactech, Inc., Gainsville, FL) Osteol (Sofamor Danek Group, Inc., Memphis, TN)
Mode of Action Osteoconduction Osteoconduction Osteoconduction Osteoconduction Osteoconduction and osteoinduction Osteoconduction and osteoinduction Osteoconduction and osteoinduction Osteoconduction and osteoinduction Contents Hydroxyapatite, tricalcium phosphate, bovine collagen Calcium phosphate, calcium carbonate Calcium sulfate Hydroxyapatite converted from marine coral tricalcium phosphate Demineralized human bone matrix Demineralized human bone matrix Demineralized human bone matrix, human corticocancellous bone chips Demineralized human bone matrix, porcine gelatin
Decortication Shingling, as described by Judet and colleagues110, 111 and Phemister185 (Fig. 2068), entails the raising of osteoperiosteal fragments from the outer cortex or callus from both sides of the nonunion using a sharp osteotome or chisel. Using a chisel, 2- to 3-mm fragments of cortex, each approximately 2 cm long, are elevated. The elevated fragments create a decorticated area approximately 3 to 4 cm long on either side of the nonunion and involve approximately two thirds of the bone circumference. The periosteum and muscle, which remain attached and viable, are then carefully retracted with a Hohmann retractor. This approach greatly increases the surface area between the elevated shingles and the decorticated cortex in which cancellous bone graft can be inserted to stimulate bony healing and ll the dead space. If the bone is very osteoporotic, shingling may substantially weaken the thin cortex and should be used minimally or not at all. Shingling should not be performed over the area of the bone fragments where a plate is to be applied. In these cases, where internal xation (i.e., a plate) is used, the surfaces of the bone fragments that are not covered by the plate can be petaled or drilled. Petaling,159 also called sh-scaling (see Fig. 2068), is performed with a tiny gouge. Once elevated, the osteoperiosteal akes resemble the petals of a ower or scales of a sh. Alternatively, a small drill bit cooled with irrigation can be used to drill multiple holes. Petaling or drilling is performed over an area 3 to 4 cm on either side of the nonunion. These decortication techniques promote revascularization of the cortex, especially when combined with cancellous bone grafting. Electromagnetic, Ultrasound, and Shockwave Stimulation Electrical stimulation of nonunions by invasive and noninvasive methods has gained popularity since the 1970s.21, 178 Although the exact mechanism by which electricity and electromagnetic elds stimulate osteogenesis remains uncertain, some practitioners claim success in a high percentage of cases; I have been delighted by unexpected successes in a few cases (Fig. 2069). The literature, however, does not provide a consensus opinion. Devices available to treat nonunions through electrical stimulation are of three varieties: constant direct current, time-varying inductive coupling, and capacitive coupling. The usefulness of electrical stimulation is limited to the extent that it does not correct deformities and usually requires a long period of nonweight bearing and cast immobilization, which may give rise to muscle and bone atrophy and joint stiffness. The method is seldom effective for atrophic nonunions (particularly those with bone defects), infected nonunions, synovial pseudarthroses, nonunions with gaps or necrotic ends of more than 1 cm, or lax nonunions. Electrical stimulation may be considered as a treatment method for stiff nonunions when there is no signicant deformity or bone defect. Animal studies236 and human trials143 for the treatment of nonunions with ultrasonic stimulation are ongoing. This form of therapy holds promise as an additional adjuvant for nonoperative treatment of nonunions. High-energy extracorporeal shock wave therapy as a treatment of nonunion has been reported by several
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B
FIGURE 2068. Decortication techniques. A, Shingling. B, Fish-scaling (i.e., petaling).
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FIGURE 2069. A, The radiograph was obtained at presentation of a 40-year-old woman who was referred in 26 months after open reduction and internal xation of a distal clavicle fracture. The patient did not want any type of surgical intervention and therefore was treated with external electrical stimulation. B, A radiograph after 8 months of electrical stimulation shows solid bony union.
investigators.220, 223, 246 Valchanou and Michailov246 reported an 85% union rate in 82 delayed unions and nonunions treated with the technique. Similarly, Schaden and associates220 reported a 76% healing rate in patients with nonunions. According to Schaden and co-authors,220 the technique should not be used in patients with a gap at the nonunion site greater than 5 mm; open physes, alveolar tissue, brain or spine, or malignant tumor in the shock wave eld; coagulopathy; pregnancy. METHODS THAT ARE BOTH MECHANICAL AND BIOLOGIC Treatment methods that may be used to improve both the mechanical and biologic status of an ununited limb include structural bone grafts, exchange nailing, synostosis techniques, the Ilizarov method, arthroplasty, arthrodesis, and amputation. Structural Bone Grafts Vascularized Autogenous Cortical Bone Grafts. Vascularized autogenous cortical bone grafts provide structural integrity and living osseous tissue to the site of
bony defects. Evidence exists that vascularized grafts respond to functional loading by hypertrophy, in some cases31, 101 possessing the capacity to increase in strength over time. Vascularized bone grafts may be obtained from the bula,253, 262, 270 iliac crest,214 or ribs.253 Because of its shape, strength, size, and versatility, the vascularized bula has become the preferred graft for most centers using vascularized bone graft techniques. Vascularized bula techniques include free vascularized bular transfer, free vascularized double-barrel bula transfer,109 centralization of the bula,99 and reversed-ow vascularized pedicle bular graft.212 Advantages of vascularized grafts include immediate structural integrity, a one-stage procedure (barring problems or complications), potential for graft hypertrophy, and the ability to span massive segmental defects. Disadvantages include the technically demanding nature of the technique; propensity for fatigue fracture, particularly for lower extremity applications; prolonged non weight bearing for certain lower extremity applications; poorer results in patients with a history of infection88; donor site morbidity (e.g., pain, neurovascular injury, knee or ankle joint instability or limited range of motion); and xation problems when the defect extends to a periarticular region. The procedure is contraindicated for children. Nonvascularized Autogenous Cortical Bone Grafts. Nonvascularized autogenous cortical bone graft can be harvested from the bula, tibia, or iliac crest. Whereas these grafts can be used to reconstruct large defects, they suffer from several disadvantages, including a requirement for prolonged nonweight bearing for lower extremity applications, requirement for prolonged support for upper extremity applications, donor-site morbidity (including fracture for cortical grafts harvested from the tibia), and progressive graft weakening during revascularization (years) and a propensity for fatigue fracture. Bulk Cortical Allografts. Bulk cortical allograft may be used to reconstruct large post-traumatic skeletal defects37 (Fig. 2070; see also Fig. 2064). The technique usually is less technically demanding than vascularized grafting, and there is no associated donor site morbidity; however, the technique is not without signicant complications, including infection, graft failure, and nonunion at the host-graft junction. The availability of bone of virtually every shape and size from the bone bank permits reconstruction of massive skeletal defects in virtually any anatomic location. Graft xation may be achieved using a variety of methods. Because of the ultimate strength, load-sharing characteristics, and ability to protect the graft, I prefer to use intramedullary xation in cases of bulk cortical allograft wherever possible. Bulk allografts can be used for intercalary grafts, alloarthrodesis (Fig. 2071), osteoarticular grafts, and alloprosthesis. Infected nonunions may be treated with bulk allograft as long as the infected cavity has been adequately debrided and sterilized. When using the technique for infected nonunions with massive defects, I perform serial debride ments with antibiotic bead exchanges until the cavity is culture negative. At this point a custom-fabricated, antibiotic-impregnated PMMA spacer is implanted, and
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the soft tissue envelope is closed or reconstructed. At a minimum of 3 months, the spacer is removed, and the defect is reconstructed using bulk cortical allograft (see Figs. 2064 and 2071). Active infection is an absolute contraindication to reconstruction using bulk cortical allograft. The main disadvantages of bulk cortical allograft are its associated complications: infection, fatigue fracture, nonunion of the allograft at the graft-host junctions, and the possibility of disease transmission from donor to recipient. Strut Cortical Allografts. Strut cortical allografts may be used to reconstruct partial (incomplete) segmental defects, reconstruct complete segmental defects in certain
cases, augment xation and stability in osteopenic bone, and augment stability in periprosthetic long bone nonunions (see Fig. 2061). Intramedullary Cortical Allografts. Intramedullary cortical allografts are most commonly employed for long bone nonunions that are associated with osteopenia for which the chosen method of treatment is plate-and-screw xation with cancellous autografting. The intramedullary cortical graft is benecial in that it augments stability by acting as an intramedullary nail, greatly improves the screw purchase of the plate-and-screw construct (i.e., each screw traverses four cortices), and provides the added potential for intramedullary healing between host bone
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FIGURE 2070. A, The radiograph was obtained at presentation of a 45-year-old man who was referred in 7 months after open reduction and internal xation of a both-bone forearm fracture. This patient had an open wound draining purulent material over the radius. The patient was treated with serial debridements and antibiotic beads. After serial debridements, the patient was left with a segmental defect of the radius. B, The radiograph shows placement of a bulk cortical allograft over an intramedullary nail and plate-and-screw xation of the ulna.
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FIGURE 2070 Continued. C, A follow-up radiograph at 11 months after reconstruction shows solid union of the proximal host-graft junction but a hypertrophic nonunion of the distal host-graft junction of the radius. The hypertrophic nonunion was treated with compression plating without bone grafting. D, The nal radiograph 14 months after compression plating shows solid bony union.
and the allograft. The technique is particularly useful for humeral nonunions in elderly patients with osteopenic bone who have failed multiple prior treatments (Fig. 2072). Mesh CageBone Graft Constructs. Cobos and co-workers42 rst described a technique for the treatment of segmental long bone defects using a mesh cagebone graft construct. The technique involves spanning the segmental defect using a titanium mesh cage (surgical titanium mesh, DuPuy Motech, Warsaw, IN) of slightly larger diameter than the adjacent bone. The cage is packed with allogenic cancellous bone chips and demineralized bone matrix. This construct is reinforced by an intramed-
ullary nail that traverses the mesh cagebone graft construct. Exchange Nailing In a previous section covering mechanical methods of nonunion treatment, intramedullary nail xation was discussed. That method is distinguished from exchange nailing in that the latter method is both mechanical and biologic. Technique. Exchange nailing requires the removal of a previously placed intramedullary nail. Because a nail already spans the medullary canal at the nonunion site, the problem of a sealed-off canal, as discussed in an earlier
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FIGURE 2071. A, The radiograph was obtained at presentation of a 25-year-old man who had been treated with open reduction and internal xation of an open femur fracture. The patient was referred in 16 months after the injury. Clinical examination revealed gross purulence and exposed bone at the nonunion site, with global knee joint instability and an arc of knee exion-extension of approximately 20. Aspiration of the knee yielded frank pus. B, Radiographs show the site after radical debridement with placement of antibiotic beads and later placement of an antibiotic spacer. C, A radiograph obtained 6 years after alloarthrodesis using a bulk cortical allograft and a knee fusion nail shows solid bony incorporation. The patient is fully ambulatory and has no pain or evidence of infection.
section, is not an issue. Although a deformity may exist at the nonunion site, the medullary canal is already known to accept passage of an intramedullary nail. A rare exception to this rule is the stiff nonunion with a broken nail in which there has been progressive deformity over time. In such a case, removal of a portion of the nail (and insertion of a new nail) may require extensive bony and soft tissue dissection at the nonunion site, and other treatment options may therefore need to be considered. After the previous nail has been removed, the medullary canal is reamed. Reaming is performed with progressively larger reamer tips in 0.5-mm increments. Initially, the reamer utes contain endosteal brous tissue. As
reaming continues, bone is observed in the utes of the reamers. Generally, I try to use an exchange nail that is 2 to 4 mm in diameter larger than the prior nail, and I overream by 1 mm larger than the new nail being implanted. Reaming typically proceeds to a reamer tip size 3 to 5 mm larger than the nail being removed. Occasionally, a custom-manufactured nail with an extra large diameter is necessary for a patient with a very large medullary canal. After reaming, a larger-diameter nail is inserted. I always perform exchange nailing using a closed technique, because it preserves the periosteal blood supply that is so important for the success of the technique. Closed nailing
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also lessens the risk of infection at the nonunion site. Provided that good bone contact exists at the nonunion site, I prefer to statically lock all exchange nails to maximize stability; other surgeons do not believe this is always necessary.45, 87, 238, 257, 267 I do not favor partial
excision of the bula when performing exchange nailing of the tibia, because it diminishes the overall stability of the construct. Modes of Healing. Exchange nailing stimulates healing of nonunions by improving the local mechanical
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FIGURE 2072. A, The radiograph was obtained at presentation of an 83-year-old woman who was referred in 15 months after a humeral shaft fracture. The patient found this humeral nonunion very painful and quite debilitating. Because of the patients profound osteopenia, she was treated with an intramedullary cortical bular allograft and plate-and-screw xation. B, The intraoperative uoroscopic image shows positioning of the intramedullary bula. C, The nal radiograph 7 months after reconstruction shows bony incorporation without evidence of hardware loosening or failure. At follow-up, the patient had no pain and had marked improvement in function.
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FIGURE 2073. A, The radiograph was obtained at presentation of a 51-year-old woman who was referred in with a painful nonunion of the tibia 29 months after intramedullary nail xation of an open tibial fracture. B, Five months after exchange nailing, the tibia is solidly united.
environment in two ways and by improving the local biologic environment in two ways (Fig. 2073). Enlargement of the medullary canal by reaming allows placement of a larger-diameter nail that is stronger and stiffer (provided that the manufacturer does not decrease the wall thickness as the nail diameter increases). The stiffer, stronger nail augments stability at the nonunion site, which promotes bony union. The second mechanical benet of reaming is the widening and lengthening of the isthmic portion of the medullary canal, which enhances mechanical stability by increasing the endosteal cortical contact area of the nail. This effect is particularly dramatic when exchange nailing is performed on a long bone that was initially treated with a small-diameter nail using an unreamed technique. Biologically, the products of reaming act as a local bone graft at the nonunion site and stimulate medullary healing. The second biologic benet of reaming is related to the resulting changes in the endosteal and periosteal circulation. Medullary reaming results in a substantial decrease in endosteal blood ow.22, 85, 107, 164, 231 The loss is accompanied by a dramatic increase in periosteal ow192 and periosteal new bone formation.48 Other Issues. Because exchange nailing improves mechanical stability and biologically stimulates the nonunion site, it is applicable for viable and nonviable nonunions. Three circumstances worthy of discussion are the use of exchange nailing for nonunions with incomplete
bony contact, nonunions associated with deformity, and infected nonunions. Bone Contact. Exchange nailing is an excellent treatment method when good bone-to-bone contact exists at the nonunion site. The technique is less well suited for cases with large partial or complete segmental bone defects. Because healing of these nonunions depends on many factors (e.g., nonunion type, anatomic location, surface area of bone contact, length of bony defect, soft tissue characteristics, patient health and age), it is unlikely that the dilemma regarding which defects will not unite with exchange nailing will ever be solved. We are therefore left with what drives much of medical care: clinical observation. Templeman and co-authors238 advocate exchange nailing (in the tibia) when there is 30% or less circumferential bone loss. Court-Brown and colleagues45 reported failures for exchange nailing only when bone loss (tibia) exceeded a length of 2 cm and involved more than 50% of the circumference of the bone. Although I have used Chapmans32 method of intramedullary bone grafting with excellent results during exchange nailing of long bones with defects, the indications for this technique for nonunion surgery are still evolving. Deformity. Deformity is an interesting situation in long bone nonunions that have previously been treated with an intramedullary nail. I am repeatedly astonished by how a straight nail can result in a very crooked bone (Fig. 2074). Deformities that may ultimately limit the patients
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function require correction. Deformity correction can be rapid or gradual and can be performed concurrently with or after (i.e., sequential approach) successful treatment of the nonunion. In the case of a previously nailed long bone, clinically signicant deformities may include length, angulation, and rotation. Translational deformities are limited by the nail (if the nail is not broken) and are generally not clinically signicant. When the nonunion is associated with a clinically signicant deformity, the rst decision to be made is whether to address both problems at the same time or to address healing the bone rst, with deformity correction to follow. In the latter case, exchange nailing may be
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FIGURE 2074. The radiograph was obtained at presentation of a 22-year-old man who was referred in after multiple failed treatments of a tibial nonunion. Notice that a very crooked bone can result despite the use of a straight nail.
undertaken as described previously. If the decision is to address both problems concurrently, the next decision to be made is whether to correct the deformity gradually or rapidly. If the status of the soft tissues, bone, or both favor gradual correction, exchange nailing is rejected in favor of Ilizarov external xation. If rapid deformity correction is thought to be safe, exchange nailing with acute deformity correction simplies the overall treatment strategy and is an excellent technique. Acute deformity correction is relatively simple for lax nonunions. Stiff nonunions may require a percutaneously performed osteotomy and the use of a femoral distractor or a temporary external xator to perform an acute deformity correction. I do not generally favor direct open exposure of the nonunion site when using intramedullary nail techniques (see section on Intramedullary Nail Fixation). Infection. Although numerous surgeons have reported cases of intramedullary nail xation for infected nonunions,3, 87, 123, 124, 147, 228, 264 the results of exchange nailing as a treatment for these cases has not been well documented in the literature. I do not favor the use of intramedullary nailing as a means of providing mechanical stability in infected nonunions when the injury has been previously treated with a method other than nailing. Placement of an intramedullary nail can result in the conversion of an isolated infection to one that seeds the entire medullary canal. In the case of exchange nailing, the situation is entirely different. Because an intramedullary nail is already in situ, it is likely that the intramedullary canal is already infected to some degree along its entire length. Because medullary contamination is already present, I am not strictly opposed to the use of exchange nailing for infected nonunions (Fig. 2075). Exchange nailing for infected nonunions is best suited for the lower extremity in patients who may be poor candidates for plate-and-screw xation (e.g., osteopenic bone, multiple prior soft tissue reconstructions, segmental nonunions) or external xation (e.g., poor compliance, cognitive impairment), because the load-sharing characteristics of a nail may be of great benet. Adequate bone contact and the absence of clinically signicant deformity are prerequisites for the use of this technique. When exchange nailing is used for infected nonunions, the medullary canal should be aggressively reamed as a means of debridement of infected and necrotic bone and endosteal soft tissue. Reaming should continue using progressively larger reamer tips in 0.5-mm increments until the reamer utes contain what appears to be viable, healthy bone. All reamings should be sent for culture and sensitivity in cases of known or suspected infection. The medullary canal is then irrigated with copious antibiotic solution, and a larger diameter nail is placed, as previously described. Literature Review. The results reported in the literature for exchange nailing as a treatment for uninfected tibial nonunions have been uniformly excellent. CourtBrown and co-authors45 reported an 88% rate of union (29 of 33 cases) after exchange nailing of the tibia; the remaining four cases united after a second exchange nailing. Templeman and co-workers238 reported a 93% rate of union (25 of 27 cases) after an exchange tibial nailing procedure. Wu and colleagues268 reported a 96%
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FIGURE 2075. A, The radiograph shows the site of an actively draining infected femoral nonunion resulting from a gunshot blast in a 23-year-old man. This patient was treated with serial debridements followed by exchange nailing (with intramedullary autogenous iliac crest bone grafting) of the femoral nonunion. B, The radiograph obtained 13 months after treatment shows solid bony healing. This patient has no clinical evidence of infection.
rate of union (24 of 25 cases) with exchange nailing of the tibia. The results reported in the literature for exchange nailing of femoral nonunions have been less consistent and generally not as good. Oh and co-workers163 reported a 100% union rate for 13 femoral nonunions treated with exchange nailing. Christensen38 also reported a 100% union rate for 11 femoral nonunions treated with exchange nailing. Hak and associates87 reported a 78% rate of union (18 of 23 cases) after exchange nailing for nonunions of the femoral shaft. The rate of union was 100% (8 of 8 cases) in nonsmokers, compared with only 67% (10 of 15 cases) in smokers. Weresh and associates257 reported a union rate of only 53% (10 of 19 cases) for exchange nailing of nonunions of the femoral shaft. The results of exchange nailing for humeral shaft nonunions have also been suboptimal. McKee and coworkers146 reported a 40% union rate (4 of 10 cases) for
exchange nailing of humeral nonunions. Flinkkila and co-authors72 described 13 humeral shaft nonunions treated with antegrade exchange nailing. The rate of union after the rst exchange nailing was only 23% (3 of 13 cases). Only three additional nonunions united after a repeat exchange nailing. Summary of Exchange Nailing. Based on a thorough review of the literature and my own clinical experience with exchange nailing, the following summary comments and recommendations are offered: 1. Exchange nailing achieves healing in 90% to 95% of tibial nonunions. 2. Exchange nailing remains the treatment of choice for nonunions of the femoral shaft, but the rate of success is probably lower than that for tibial nonunions. 3. The supracondylar femur is poorly suited for stabilization of a nonunion with an intramedullary nail
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(supracondylar fractures probably require a lesser degree of stability than nonunions). The medullary canal is ared in this region, and there is poor cortical bone contact with the nail. The reamings are probably poorly contained at the site of nonunion when exchange nailing is performed in this region. It is also possible that reaming during exchange nailing for nonunions of the supracondylar region does not produce increased periosteal blood ow and new bone formation. Dismal results have been reported by Koval and co-workers124 using intramedullary nail xation for distal femoral nonunions. Exchange nailing is a poor treatment method for supracondylar nonunion of the femur; other treatment methods should be used (Fig. 2076). 4. Poor results have been reported for exchange nailing of humeral shaft nonunions.72, 146 Nail removal, plateand-screw xation, and autogenous cancellous bone grafting is effective in most cases. Ilizarov methods may be required for more complex cases. In my opinion, there is no clear role for exchange nailing for humeral shaft nonunions. Synostosis Techniques The leg and forearm are unique in that structural integrity is provided by paired bones. This anatomic arrangement permits the use of unique methods for the treatment of nonunions that are associated with bone defects.
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FIGURE 2076. The radiograph shows a supracondylar femoral nonunion in a 57-year-old man who was referred in after failure of two prior exchange nailing procedures. Exchange nailing is a poor treatment method for nonunions in this region.
The literature regarding these techniques is fraught with inconsistencies and contradictions of terminology. This situation has led to confusion regarding the precise meaning of the following terms: bula-pro-tibia, bula transfer, bula transference, bula transposition, bular bypass, bulazation, medialization of the bula, medialward bone transport of the bula, posterolateral bone grafting, synostosis, tibialization of the bula, transtibiobular grafting, and vascularized bula transposition. For clarity and simplicity, all of these various techniques can be distinguished as a synostosis technique or as local grafting from the adjacent bone (Fig. 2077). Synostosis techniques for nonunions entail the creation of bone continuity between paired bones above and below the nonunion site. Success of the procedure does not necessarily depend on healing of the fragments of the ununited bone to one another. To qualify as a synostosis technique, the bone neighboring the ununited bone must unite to the proximal and distal fragments of the ununited bone such that the neighboring bone transmits forces across the nonunion site. From a functional standpoint, this becomes a one-bone extremity. Several techniques have been used to create a tibiobular synostosis for the treatment of tibial nonunions. Unfortunately, some of the methods described as synostosis techniques are not. Milch151, 152 described a tibiobular synostosis technique for nonunion using a splintered bone created by longitudinally splitting the bula, which could be augmented with autogenous iliac bone graft. McMaster and Hohl148 used allograft cortical bone as tibiobular crosspegs to create a tibiobular synostosis for tibial nonunion. Rijnberg and van Linge197 described a technique to treat tibial shaft nonunions by creating a synostosis with autogenous iliac crest bone graft through a lateral approach anterior to the bula. Lieberg and Heston136 described an unusual case report of a distal tibial-bular fracture, with a bone defect treated by telescoping the proximal bular fragment into the distal tibial fragment. In the strict denition given earlier, this should not be considered a synostosis technique. The posterolateral approach to the tibia for bone grafting or bular transference was described by Harmon89 in 1945. Posterolateral bone grafting75, 185 for nonunion can result in bridging of the ununited site directly (which does not create a synostosis or require an intact bula) or a tibiobular synostosis above and below the nonunion site (for which the bula must be intact). Ilizarov103 described the technique of medialward (horizontal) bone transport of the bula to create a tibiobular synostosis for the treatment of tibial nonunions with massive segmental bone loss (see Fig. 2077). Weinberg and colleagues256 described a two-stage technique for creating proximal and distal tibiobular synostoses for cases with massive bone loss. In the rst stage, a distal tibiobular synostosis was created; at least 1 month later, a proximal tibiobular synostosis was created. The surgeons referred to this synostosis technique as a bular bypass procedure. Doherty and Patterson57 also described a bular bypass operation in 14 cases of tibial nonunion. Several different techniques were used, and not all of them involved the creation of a synostosis. Because of
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Examples of traditional synostosis techniques
Examples of Ilizarov synostosis techniques
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Examples of local grafting techniques
FIGURE 2077. Synostosis techniques for bony defects of the tibia (A, B) are compared with local bone grafting from the bula for bony defects of the tibia (C).
the inconsistent use of bular bypass in the literature, this term should probably be avoided. Like bular bypass, bula-pro-tibia is a term that is used inconsistently in the literature. Campanacci and Zanoli28 described a technique to create proximal and distal tibiobular synostoses to treat tibial nonunions without large defects. The surgeons used internal xation to stabilize the proximal and distal tibiobular articulations. They referred to this technique as bula-pro-tibia or double tibiobular synostosis. Banic and Hertel12 described a double-vascularized bula technique for large tibial defects. The lateral graft was the bula with its intact blood supply, which creates a synostosis proximal and distal to the defect. The authors referred to this lateral graft as a bula-pro-tibia. Ward and co-authors247 also described Huntingtons bular transference, which is not a synostosis technique, as a bula-pro-tibia. May and co-workers141 described transference of a vascularized bular graft to ll the defect as a bula-pro-tibia. Other terms that are occasionally confused in the literature with tibiobular synostosis include bular transference, bular transfer, bular transposition, and tibialization. None of these terms refers to procedures that create a synostosis above and below the defect such that the neighboring bone transmits forces across the nonunion. Huntington99 was the rst to describe a two-stage procedure to transfer a bular graft (i.e., bula transference) directly into a tibial defect. Several others have
described various techniques of transferring a vascularized bular graft into a posterolateral position2, 31, 229 or directly into the proximal and distal tibial fragments in the line of load bearing.10, 119, 120 Some also refer to these techniques as tibialization of the bula2, 10 or bula transposition.229 The synostosis method may also be used to treat segmental defects or persistent nonunions of the forearm (Fig. 2078). It results in the creation of a one-bone forearm. In the forearm, this technique is most commonly used for forearm nonunions when there is massive bone loss in the radius and ulna. Successful union of a proximal ulna segment with a distal radial segment leads to restoration of function to the upper extremity with the exception of forearm pronation and supination. Ilizarov Method Ilizarov techniques for treatment of nonunions have many advantages, including minimal invasiveness, promotion of bony tissue generation, minimal soft tissue dissection, versatility, use in cases of acute or chronic infection, stabilization of small intra-articular or periarticular bone fragments, simultaneous bony healing and deformity correction, immediate weight bearing, and early joint mobilization. The Ilizarov construct provides mechanical strength and stability, resisting shear and rotational forces. The technique is unique in that the tensioned wires allow for the trampoline effect during weight-bearing activities. The method also allows for augmentation of treatment
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through frame modication when the nonunion is failing to show progression to healing. Frame modication usually is not associated with pain, does not require anesthesia, and can be performed in the ofce. The need for frame modication should not be considered treatment failure; rather, it is the need for continued treat-
ment. Modifying the treatment with other methods such as plate-and-screw xation or intramedullary nail xation requires repeat surgical intervention and should therefore be considered treatment failure. The Ilizarov method is applicable for all types of nonunions. The method is particularly useful for non-
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FIGURE 2078. Two cases of forearm nonunion treated with synostosis. A, The presenting radiograph and clinical photograph were obtained for a 32-year-old man who was referred in with segmental bone loss from a gunshot blast to the forearm. B, The radiograph and clinical photograph show the forearm during bone transport of the proximal ulna into the distal radius to create a one-bone forearm (i.e., synostosis). C, The radiograph and clinical photographs show the nal result. D, The radiograph was obtained for a 48-year-old man who presented after multiple failed attempts at a synostosis procedure of the forearm. Illustration continued on following page
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FIGURE 2078 Continued. E, The radiograph shows the forearm during Ilizarov treatment with slow, gradual compression. F, The nal radiograph shows solid bony union.
TABLE 2010
Ilizarov Treatment Modes
Monofocal Compression Sequential distraction-compression Distraction Sequential compression-distraction Bifocal Compression-distraction lengthening Distraction-compression transport (bone transport) Trifocal Various combinations
unions associated with infection, segmental bone defects, deformities, and multiple prior failed treatments. A variety of modes of treatment can be employed using the Ilizarov external xator, including compression, distraction, lengthening, and bone transport. Treatment may be monofocal, such as with simple compression or distraction across the nonunion site. Bifocal treatment denotes that two healing sites exist, such as a bone transport where healing must occur at the distraction site (i.e., regenerate bone formation) and the docking (nonunion) site. Trifocal treatment denotes that three healing sites exist, such as in a double-level bone transport (Table 2010). Compression (monofocal) osteosynthesis can be used
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FIGURE 2079. In this example, Ilizarov treatment of a hypertrophic distal humeral nonunion uses gradual monofocal compression. A, The presenting radiograph shows the initial condition. B, The radiograph was obtained during treatment using slow compression. Notice the bending of the wires proximal and distal to the nonunion site, indicating good bony contact. C, The nal radiograph shows solid bony union.
for a variety of nonunion types. The technique allows not only for simple compression, but also for differential compression to enable deformity correction. The technique is applicable for hypertrophic nonunions (although distraction classically is used in these cases) (Fig. 2079), oligotrophic nonunions (Figs. 2080 to 2082), and according to Professor Ilizarov, synovial pseudarthroses.106, 225 Slow, gradual compression is generally applied at a rate of 0.25 to 0.5 mm per day for a period of 2 to 4 weeks. Because the rings spanning the nonunion site are moving closer together to a greater extent than the bone is moving (because the bone ends are in contact), the wires on either side of the nonunion site are seen to bow (see Figs. 2079 and 2080). Compression stimulates healing for most hypertrophic and oligotrophic
nonunions. Compression is usually unsuccessful for infected nonunions with purulent drainage and segments of intervening necrotic bone. There is disagreement regarding the usefulness of simple compression as a treatment for atrophic nonunions.131, 166 Slow compression over a nail using external xation (SCONE) is a useful method for certain patients who have failed treatment using intramedullary nail techniques. I have used this technique with Ilizarov external xation with great success in two distinct patient populations who have femoral nonunions and retained intramedullary nails: those who have failed multiple exchange femoral nailings (Fig. 2083) and morbidly obese patients with distal femoral nonunions that failed to unite after primary retrograde nail fracture xation (Fig. 2084). The SCONE
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FIGURE 2080. An oligotrophic nonunion of the distal humerus was treated with slow, gradual compression using Ilizarov external xation. A, The presenting radiographs show the nonunion. B, The radiograph was obtained during treatment using slow, gradual compression. Notice the bending of the wires, indicating good bony contact. C, The nal radiographs show solid bony union.
method is performed with percutaneous application of the external xator so that no further disruption of the soft tissues is required at the nonunion site. The method augments stability and allows for monofocal compression at the nonunion site (the nail cannot be left statically locked during compression). The presence of the nail in the medullary canal encourages pure compressive forces and discourages translational and shear moments. Compression over a nail as a treatment for humeral nonunion has been described by Patel and co-workers.177 Sequential monofocal distraction-compression has been recommended as a treatment for lax hypertrophic nonunions and atrophic nonunions.166 According to Paley,166 distraction disrupts the tissue at the nonunion site, frequently leading to some poor bone regeneration. This poor bone regeneration is stimulated to consolidate when the two bone ends are brought back together again. Distraction is the treatment method of choice for stiff hypertrophic nonunions, particularly those associated with deformity (Fig. 2085). Distraction of the abundant brocartilaginous tissue at the nonunion site stimulates new bone formation30, 103, 166, 213 (although the exact biologic mechanism remains obscure) and results in nonunion healing in a high percentage of cases. Catagni
and co-authors30 described 21 stiff hypertrophic nonunions (many associated with deformity) treated with distraction using the Ilizarov method. Union was achieved in all cases, with an average Ilizarov treatment time of 6.5 months in the external xator. Saleh and Royston213 reported successful treatment of 10 hypertrophic nonunions associated with deformity using distraction. Sequential monofocal compression-distraction is applicable for stiff hypertrophic and oligotrophic nonunions. The method involves an initial interval of compression followed by gradual distraction for lengthening or deformity correction. This method is not recommended for atrophic, infected, and lax nonunions.86, 166 Bifocal compression-distraction lengthening involves acute or gradual compression across the nonunion site with lengthening through an adjacent corticotomy (Fig. 2086). This method is applicable for nonunions associated with foreshortening. It is also applicable for nonunions with segmental defects. Bone defects may also be treated with bifocal distraction-compression transport (i.e., bone transport) (Fig. 2087). This method involves the creation of a corticotomy (usually metaphyseal) at a site distant from the nonunion. The bone segment produced by the corticotomy is then transported toward
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the nonunion site (lling the bony defect) at a gradual rate. As the transported segment arrives at the docking site, compression is successful in many cases in obtaining union. Occasionally, bone grafting with marrow or open bone graft is required as previously described. In a study of dogs undergoing distraction osteogenesis, Aronson7 reported that blood ow at the distraction site increased nearly 10-fold relative to the control limb, peaking about 2 weeks after surgery. The distal tibia, remote from the site of distraction, also showed a similar pattern of increased blood ow. Because corticotomy and bone transport result in profound biologic stimulation, similar to bone grafting, many surgeons nd bone
transport using the Ilizarov method an attractive alternative for the treatment of atrophic nonunions. The bone formed at the corticotomy site in lengthening and bone transport is formed under gradual distraction (distraction osteogenesis).8, 9, 55, 102, 160 The tension-stress effect of distraction causes neovascularity and cellular proliferation. Bone regeneration occurs primarily through intramembranous bone formation. Distraction osteogenesis depends on a variety of mechanical and biologic requirements being met. The corticotomy or osteotomy must be performed using a low-energy technique. Corticotomy or osteotomy in the metaphyseal or metadiaphyseal region is preferred over
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FIGURE 2081. An oligotrophic nonunion of the distal tibia was treated with gradual deformity correction, followed by slow, gradual compression using Ilizarov external xation. A, The presenting radiograph shows the nonunion. B, The radiograph was obtained during treatment. Illustration continued on following page
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FIGURE 2081 Continued. C, The nal radiographs show solid bony union with complete deformity correction.
diaphyseal sites because of the superior regenerate formation. Stable external xation promotes a good bony regenerate. Depending on patient characteristics, a latency period of 7 to 14 days before distraction is recommended. The distraction phase classically is performed at a rate of 1.0 mm per day in a rhythm of 0.25 mm of distraction performed four times per day. The rate and rhythm is controlled by the treating physician, who carefully monitors the progression of the regenerate as seen on radiographs. Some patients make bony regenerate more slowly and require a rate less than 1.0 mm per day. I typically begin the distraction in most patients at 0.75 mm per day. After distraction, maturation and hypertrophy of the bony regenerate occur during the consolidation phase. The consolidation phase usually is two to three times as long as the number of days of the distraction phase, but this varies widely among patients. The choice of treatment strategy for infected nonunions and nonunions associated with segmental defects depends on many factors, such as bone, soft tissue, and medical health characteristics, and no clear consensus exists among treating physicians. Treatment options include conventional methods (i.e., resection, soft tissue coverage, massive cancellous bone grafting, and skeletal stabilization), and Ilizarov methods. Using Ilizarov methods, two different strategies can be employed: bifocal compressiondistraction (i.e., lengthening) or bifocal distraction-
compression transport (i.e., bone transport). Several published reports have compared these various methods. Green83 compared bone grafting and bone transport in the treatment of segmental skeletal defects. For defects of 5 cm or less, the author recommended the use of either technique. For larger defects, the author recommended bone transport or free composite tissue transfer. In a similar study, Marsh and co-workers139 compared the results of resection and bone transport against less extensive debridement, external xation, bone grafting, and soft tissue coverage. Results for the groups were similar in terms of healing rate, healing and treatment time, eradication of infection, nal deformity, complications, and total number of operative procedures. The nal limb-length discrepancy was signicantly less in the group treated with bone transport. Cierny and Zorn39 compared the results of treatment of segmental tibial defects using conventional methods (i.e., massive cancellous bone grafts and tissue transfers) with Ilizarov methods. The Ilizarov group averaged 9 fewer hours in the operating room, 23 fewer days of hospitalization, 5 months less disability, and a savings of nearly $30,000 per case. Ring and coworkers198 compared autogenous cancellous bone grafting with Ilizarov treatment in 27 patients with infected tibial nonunions. The investigators concluded that the Ilizarov methods may best be used in cases of large limb-length discrepancy and for very proximal or distal metaphyseal nonunions. The results of acute shortening with subsequent relengthening compared with bone transport for tibial defects were reported by Paley and colleagues.169 Comparing 21 acute shortening with subsequent relengthening cases with 21 bone transport cases, the surgeons concluded that both techniques provided excellent overall results, although acute shortening with subsequent relengthening was associated with a signicantly lower complication rate and less time in the external xator.169 Arthroplasty In certain situations, joint replacement arthroplasty may be the chosen treatment method for a fracture nonunion. This method has the advantages of early return to function with immediate weight bearing and joint mobilization. The main disadvantage of the method is the excision of native anatomic structures (e.g., bone, cartilage, ligaments). Arthroplasty as a treatment of nonunion is indicated in older patients with severe medical problems when a relatively short course of treatment and early ambulation may be required for survival; long-standing, resistant periarticular nonunions; periarticular nonunions associated with small osteopenic fragments if adequate purchase is not obtainable; nonunions associated with painful, post-traumatic or degenerative arthritis; and periprosthetic nonunions that cannot be readily stabilized by conventional methods or that have failed conventional treatment methods (Fig. 2088). Arthroplasty as a method of treatment for nonunion has been used in the hip,46 knee,6, 74, 219, 258 shoulder,77, 91, 162 and elbow.155, 173 Arthrodesis Arthrodesis as a treatment method for nonunion is indicated for patients with previously failed (ununited) arthrodesis procedures (Fig. 2089), infected periarticular
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nonunions, unreconstructable periarticular nonunions in anatomic locations that are not believed to have good long-term result with joint replacement arthroplasty (e.g., ankle), unreconstructable periarticular nonunions in very young patients who are not believed to be good long-term candidates for joint replacement arthroplasty, infected nonunions in which debridement necessitates removal of important articular structures (see Fig. 2071), and nonunions associated with unreconstructable joint instability, contracture, or pain that are not amenable to joint replacement arthroplasty (see Fig. 2071). An alloarthrodesis procedure may be performed when a segmental bone defect extends to include the epiphyseal region in a patient for whom an alloprosthesis is contraindicated (Fig. 2071).
Amputation The decision to amputate or reconstruct the severely injured extremity is a difcult one. Lange and associates132 published absolute and relative indications for amputation in the patient with an acute open fracture of the tibia associated with a vascular injury. Because a delay in amputation of the severely injured limb may lead to serious systemic complications or even death, rapid and resolute decision making in the acute setting is of paramount importance. The decision to amputate or reconstruct a nonunion is a different matter entirely, and little guidance is found in the literature. These patients do not present in extremis and have typically been living with the problem for a long Text continued on page 598
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FIGURE 2082. An oligotrophic nonunion of the proximal tibia was treated with slow, gradual compression using Ilizarov external xation. A, The presenting radiographs show the nonunion. B, The radiograph was obtained during treatment using slow, gradual compression. C, The nal radiographs show solid bony union.
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FIGURE 2083. A resistant femoral nonunion was successfully treated with slow compression over a nail using external xation (i.e., SCONE technique). A, The presenting radiograph shows a femoral nonunion. The patient is a 67-year-old man who was referred in after failure of two exchange nailings and two open bone graft procedures. B, The radiograph was obtained during treatment with the SCONE technique. C, The clinical photograph was taken during treatment. D, The nal radiographs show solid bony union.
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FIGURE 2084. This distal femoral nonunion was successfully treated in a morbidly obese, elderly, diabetic woman referred in 10 months after retrograde intramedullary nailing for a fracture. A, Presenting radiographs show a distal femoral nonunion. B, The radiograph was obtained during treatment with slow compression over a nail using external xation (i.e., SCONE technique). C, Final radiographs show solid bony union. D, The clinical photograph demonstrates successful treatment.
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SECTION I General Principles FIGURE 2085. A stiff, hypertrophic nonunion of the femoral shaft was treated with distraction. A, Presenting radiographs demonstrate the nonunion. B, The radiograph was obtained during treatment by distraction using the Ilizarov external xator. Notice that differential distraction also results in deformity correction. C, The nal radiograph shows solid bony union and deformity correction.
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Presentation Bone loss Early contact/ lengthening Bone loss Bone transport
FIGURE 2087. Distraction-compression transport (i.e., bone transport) can be used to treat bone defects.
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FIGURE 2086. Compression-distraction lengthening is applicable for nonunions associated with foreshortening or bone defects.
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FIGURE 2088. A, The radiograph was obtained at presentation of an 82-year-old woman who was referred in with a distal femoral periprosthetic nonunion. The patient had been wheelchair bound for 2 years and had three prior failed attempts at nonunion treatment. B, The radiograph shows the site after resection of the nonunion and revision joint replacement arthroplasty. The patient had excellent pain relief and resumed ambulation without the need for walking aids.
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FIGURE 2089. A, The radiographs were obtained at presentation of a 25-year-old man who had undergone a total of 18 prior ankle operations and ve failed prior attempts at ankle arthrodesis. B, The patient was treated with percutaneous hardware removal and gradual compression using an Ilizarov external xator. The ankle joint was not operatively approached, and no bone grafting was performed. C, The nal radiograph after simple, gradual compression shows solid fusion of the ankle.
time. In their study assessing quality of life in 109 patients with post-traumatic sequelae of the long bones, Lerner and co-workers134 described the choice determinants for patients undergoing amputation: First choice determinant: cease medical and surgical treatment of the nonunion Second choice determinant: recommendation by a doctor Third choice determinant: belief that no cure is possible There are no absolute indications for amputation of a chronic ununited limb. Because each nonunion case is distinctive and may include multiple complex issues, applying specic treatment algorithms is usually not helpful.
Amputation of an ununited limb should be considered in several situations: 1. Sepsis arises in a frail, elderly, or medically compromised patient with an infected nonunion, and there is concern about the patients survival. 2. Neurologic function (motor or sensory or both) of the limb is unreconstructable to the extent that it precludes restoration of purposeful limb function. 3. Chronic osteomyelitis associated with the nonunion is in an anatomic area that precludes reconstruction (e.g., diffuse chronic osteomyelitis of the calcaneus). 4. The patient wishes to discontinue medical and surgical treatment of the nonunion and desires to have an amputation.
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It is recommended that all patients considering amputation for a nonunion seek a minimum of two opinions from orthopaedic surgeons specializing in reconstructive nonunion techniques. Amputation should not be undertaken simply because the treating physician has run out of ideas, treatment recommendations, or stamina. There is no shame in referring to a colleague the motivated patient who has a recalcitrant nonunion but wishes to retain his or her limb. After the limb has been cut off, it cannot be cut back on.
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SUMMARY
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz The care of the patient who has a nonunion is always challenging and sometimes troubling. These cases are problematic, and the patient often has myriad other health issues. Because of the various nonunion types and the constellation of possible problems related to the bone, soft tissues, prior treatments, patient health, and other factors, no simple treatment algorithms are possible. The care of these patients requires patience with the ultimate goal of bony union and restoration of function, limiting impairment and disability. An approach to the evaluation and treatment of these patients has been provided, but a few simple axioms bear emphasis and are presented as The 10 Commandments of Nonunion Treatment: 1. Examine thy patient, and carefully consider all available information. 2. Thou shall learn about the personality of the nonunion from the prior failed treatments. 3. Thou shall not repeat failed prior procedures that have not yielded any evidence of healing effort. 4. Thou shall base thy treatment plan on the nonunion type and the treatment modiers, not upon false prophecies. 5. Thou shall forsake the use of the same hammer for every single nail, because the treatment of nonunions requires surgical expertise in a wide variety of internal and external xation techniques. 6. Honor thy soft tissues, and keep them whole. 7. Thou shall consider minimally invasive techniques (e.g., Ilizarov method, bone marrow injection) when extensive surgical exposures have failed. 8. Thou shall not take the previous treating physicians name or treatment method or results in vain, particularly in the presence of the patient. Honor thy referring physicians, and keep them informed of the patients progress. 9. Thou shall burn no bridges and shall leave thyself the option of a next treatment plan. 10. Thou shall covet stability, vascularity, and bone-tobone contact.
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Acknowledgments The author thanks Daniel P. OConnor, Joseph J. Gugenheim, M.D., Jeffrey C. London, M.D., Ebrahim Delpassand, M.D., and Michele Clowers for editorial assistance with the manuscript, and Rodney K. Baker for assistance with the gures.
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SECTION I General Principles

Type of Fracture Healing Based on Type of Stabilization

Indirect Bone Healing

Predisposing Factors: Instability, Inadequate Vascularity, and Poor Bone Contact

Healing through Callus

Direct Bone Healing

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CHAPTER 20 Nonunions: Evaluation and Treatment

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SECTION I General Principles

Other Contributing Factors

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CHAPTER 20 Nonunions: Evaluation and Treatment

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SECTION I General Principles

Copyright 2003 Elsevier Science (USA). All rights reserved.

CHAPTER 20 Nonunions: Evaluation and Treatment

Pain (0 to 10 VAS): Was Injury Work Related?:

NONUNION TYPE Hypertrophic Oligotrophic Atrophic Infected Synovial Pseudarthrosis

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SECTION I General Principles

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CHAPTER 20 Nonunions: Evaluation and Treatment

Copyright 2003 Elsevier Science (USA). All rights reserved.

SECTION I General Principles

prior harvesting by plain radiographs or a computed tomography (CT) scan.

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CHAPTER 20 Nonunions: Evaluation and Treatment

Copyright 2003 Elsevier Science (USA). All rights reserved.

SECTION I General Principles

Copyright 2003 Elsevier Science (USA). All rights reserved.

CHAPTER 20 Nonunions: Evaluation and Treatment

Fracture line orientation

Stability to axial compression

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SECTION I General Principles

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CHAPTER 20 Nonunions: Evaluation and Treatment

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SECTION I General Principles

Normal Values 130 (range, 124136) 84 (range, 8089)

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CHAPTER 20 Nonunions: Evaluation and Treatment

Axis of proximal segment

CORA Print Graphic

Bisector Axis of distal segment

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SECTION I General Principles

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CHAPTER 20 Nonunions: Evaluation and Treatment

Copyright 2003 Elsevier Science (USA). All rights reserved.

SECTION I General Principles

Copyright 2003 Elsevier Science (USA). All rights reserved.

CHAPTER 20 Nonunions: Evaluation and Treatment

Copyright 2003 Elsevier Science (USA). All rights reserved.

SECTION I General Principles

Copyright 2003 Elsevier Science (USA). All rights reserved.

CHAPTER 20 Nonunions: Evaluation and Treatment

Copyright 2003 Elsevier Science (USA). All rights reserved.

SECTION I General Principles