Tibia Nonunion


Article Author:
Andres Rodriguez-Buitrago


Article Editor:
Alex Jahangir


Editors In Chief:
David Wood
Andrew Wilt
Hajira Basit


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
4/2/2019 1:04:40 AM

Introduction

The process of fracture healing requires a precise balance of biology and stabilization during the healing process. There are four pillars for adequate bone healing: mechanics, osteogenic cells, scaffolds, and growth factors. In some circumstances, this process does not go as expected, and healing does not occur without additional intervention. Definitions vary among different studies, but overall, a diagnosis can be made when there is no evidence of progression of the healing process for 3 months or no healing after 9 months of the injury.[1][2][3][4] This condition will not only have a detrimental effect on the patient’s quality of life, comparable to advanced hip arthrosis and worse than congestive heart failure; but it also has a high impact on the total care costs, double the cost of fractures that heal adequately. Despite the different options available, treatment of tibial nonunions still is challenging for the surgeon.[1],[2],[3],[5][6]

Etiology

The "diamond concept” was introduced by Giannoudis et al., aiming to describe what is needed to achieve adequate fracture healing.[8][7] This concept highlights the importance of three biological factors: osteogenic cells, osteoconductive scaffolds, and growth factors and a fourth factor known as mechanical stabilization. If one or more of these factors are altered, adequate fracture healing will be threatened.

Epidemiology

Approximately 6 million fractures are reported per year in the United States. Of these, between 1.9% to 15% result in nonunion. This rate will vary depending on the fractured bone and the characteristics of the fracture (i.e., open vs. closed). In tibial fractures, the rate of non-union is close to 1.1% if treated nonoperatively and nearly 5% if treated operatively.[8][9] The likelihood of nonunion drastically increases in cases of open fractures.[7]

Pathophysiology

As mentioned, an adequate interplay between host biology and reduction technique are key to achieve fracture healing. The development of a nonunion is multifactorial. Factors that contribute to the development of a nonunion include the following, listed here with known risk factors[8][10][11]:

Fracture and Injury-Related Factors

  • High-energy fractures with significant comminution
  • Type of fracture (closed/open)
  • Location and pattern (highly comminuted or butterfly fragments)
  • Extent of soft tissue injury
  • Bone loss and fracture gaps (greater than 3 mm) 
  • Lack of cortical continuity
  • Infection

Biology and Patient-Related Factors (Local and Systemic)

  • Nutritional status
  • Diabetes
  • Smoking 
  • Inadequate blood supply 
  • Vitamin D deficiency
  • Renal insufficiency
  • Medications (steroids, NSAIDs, opiates, etc.)

Surgical-Related Factors

  • Inadequate stabilization

History and Physical

The evaluation of patients with a suspected or established nonunion should begin with a thorough review of the medical history so risk factors can be identified. Collect information about the type of fracture, fixation method, and previous treatments. When interviewing patients, they might manifest persistence of pain at the fracture site and/or functional limitations. One indication that a nonunion is not present is the patient will not have pain with ambulation or when using the extremity. The physical exam should be done in a standard fashion, with evaluation of the neurovascular status and range of motion. Special attention should be drawn to any signs of infection (skin or soft tissue changes) and mobility at the fracture site, which might indicate the absence of adequate callus formation.[12]

Evaluation

Patients with a suspected nonunion should be initially evaluated with plain radiographs, including AP, lateral, oblique, and weight-bearing films. It is important to look for signs (e.g., gaps or callus formation) or absence of healing, bone quality, signs of infection, associated deformities or length discrepancies, as well as the characteristics of the two fragments (i.e., contact, stability, and bone loss). Once this has been done, the nonunion can be adequately categorized as atrophic, hypertrophic, or oligotrophic. If possible, a comparison with original and postoperative follow-up films should be done to create a timeline and better understanding of the nonunion process.[12] In cases where the fracture site cannot be adequately visualized as a consequence of the hardware or the bone quality, a CT scan is advised. This study will allow better identification of the fracture site and assessment of any rotational deformity. Finally, bone scans can be used to assess bone metabolism.[12] Radiologic studies should be complemented with laboratory workup to evaluate any associated metabolic disease or infection that could explain the nonunion. This workup should include endocrine (i.e., Vitamin D, calcium levels) and inflammatory markers.[12]

Depending on its cause, nonunion classifications are as follows:

  • Septic (infected) or aseptic 
  • Pseudarthrosis
  • Hypertrophic - characterized by inadequate immobilization, but adequate blood supply persists 
  • Atrophic - characterized by inadequate immobilization and inadequate blood supply in the early stages of fracture healing 
  • Oligotrophic - characterized by inadequate reduction with persistence of fracture diastasis; no callus can form

Treatment / Management

Treatment of nonunions should aim to achieve healing of the fracture while preserving functionality. The following are available options for the treatment of non-unions[12]:

Nonoperative Treatment

Conservative treatment/weight-bearing: In some circumstances and special patient characteristics (e.g., elderly patients not eligible for operative treatments), nonunions can be treated with weight-bearing and watchful waiting. Weight bearing can be coupled with operative methods such as dynamization or bone excision.

Electrical stimulator/electromagnetic fields: Growth factors are stimulated in response to the electric and electromagnetic fields.[12][13]

Ultrasound (low-intensity pulsed ultrasound [LIPUS]): Low sine waves will promote bone healing by increasing the osteoblastic response.[14] 

Operative Treatments

When an operative treatment has been considered, intraoperative culture should always be performed to diagnose a subclinical infection. Radiologic findings and patient characteristics should guide the clinician in the decision of what operative treatment should be done. The following are treatment options: 

Nail dynamization and nail exchange: Nail Dynamization and exchange have two similar indications; comminuted fractures and absence of cortical contact after IM Nail.[9]

  • Nail dynamization - A relatively low-cost treatment done when axial stability has been achieved and maintained. The dynamization is achieved by removing interlocking bolts distant to the fracture site facilitating compression and loading across the fracture site.[12][9][15]
  • Nail exchange - Removal of the prior intramedullary nail, reaming and use of a nail with a larger diameter. With this, the reaming process will biologically activate the fracture site, and better axial and mechanical stability can be achieved.[17][15][9]

Partial fibulectomy: This procedure can be done on its own or combined with other procedures. Two important requisites have to be fulfilled, a stable nonunion and the fibulectomy has to be done in another site different.[12]

External fixation: Considered in complex nonunions (e.g., when internal fixation is not possible or not recommended due to infection, substantial deformity and/or bone loss).[12]

Bone grafting: Traditionally, iliac crest bone graft has been used when poor vascular supply is present. This treatment option aims to provide an adequate environment for bone formation (biological factors of the diamond concept).

Cell therapy: The use of mesenchymal cells within the fracture gap creates a healing environment.  [16][17]

Amputation: Considered when adequate functional outcomes cannot be achieved.

Differential Diagnosis

Delayed unions are fractures with a slow progression to healing and require some type of intervention.

Prognosis

Prognosis of tibial fractures can be evaluated using the RUST (Radiographic Union Score for Tibial fractures) score, in which all the bone cortices are evaluated, looking for the presence/absence of fracture line and bone callus. The Nonunion Risk Determination (NURD) score considered are the RUST scores, open/closed fracture, compartment syndrome, fracture classification (IIIB tibia), concomitant chronic disease, smoking status, infection, female sex, and American Society of Anesthesiologists (ASA) score. This model allows the clinician to identify those patients at risk of nonunion within 3 months of injury.[17]

Consultations

This condition has myriad presentations, and each patient and their expectations are different, so the surgeon must act accordingly. Consult plastic surgery in those cases in which the soft tissue is compromised or a flap is expected and infectious diseases in cases of an infected nonunion. Consult with physical and occupational therapy should be considered, aiming to achieve independence and early range of motion.

Pearls and Other Issues

Keep in mind the "diamond concept." Minimizing the risk of nonunion is based on patient factors and surgeon-related factors (mechanical). The following can help a practitioner avoid additional risk factors to the patient:

  1. Achieving adequate stability during the fixation 
  2. Minimizing intraoperative trauma (preserve biology) 
  3. Not over-distracting the injury
  4. Considering biologic enhancement in cases in which it is considered necessary

Enhancing Healthcare Team Outcomes

Non-union of the tibia may occur for many reasons. Thus, these patients are best managed by an interprofessional team that includes an orthopedic surgeon, physical therapist, infectious disease expert, vascular surgeon, plastic surgeon and wound care nurses. [Level V]

This condition has a myriad of presentations, and each patient and their expectations are different, so the surgeon must act accordingly. Consult plastic surgery in those cases in which the soft tissue is compromised or a flap is expected and infectious diseases in cases of an infected nonunion. Consult with physical and occupational therapy should be considered, aiming to achieve independence and early range of motion.


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Tibia Nonunion - Questions

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A 60-year-old patient with diabetes mellitus but no other significant past medical history was treated six months ago with an intramedullary nail to treat a tibial shaft fracture. He continues smoking one pack per day despite education. Nail dynamization was previously attempted, but the patient persists with pain with weight-bearing and touch at the fracture site. What is the most likely diagnosis?



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Which of the following is not an operative treatment option for nonunion of the tibia?



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A 32-year-old female who suffered a tibial shaft fracture one month and a half ago presents for a second opinion about her treatment. The patient was treated with an intramedullary nail at an outside hospital. She's concerned about her progress since she heard her doctor saying that "there was a fracture gap." Wounds are healed, her physical exam is negative. Her new x-rays show that a small fracture gap is still visible, but there are signs of callus formation. What is the best next step?



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Which of the following is not a key component of the diamond concept?



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A 45-year-old patient comes to the clinic for his nine months after being treated with an intramedullary tibial nail. The patient was lost to follow-up after six weeks. He refers persistence of limp and pain while weight-bearing that started soon after he started driving three months ago. The physical exam is noncontributory. Which is the first step in the management of this patient?



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Tibia Nonunion - References

References

Calori GM,Albisetti W,Agus A,Iori S,Tagliabue L, Risk factors contributing to fracture non-unions. Injury. 2007 May     [PubMed]
Fong K,Truong V,Foote CJ,Petrisor B,Williams D,Ristevski B,Sprague S,Bhandari M, Predictors of nonunion and reoperation in patients with fractures of the tibia: an observational study. BMC musculoskeletal disorders. 2013 Mar 22     [PubMed]
Hak DJ, Management of aseptic tibial nonunion. The Journal of the American Academy of Orthopaedic Surgeons. 2011 Sep     [PubMed]
Litrenta J,Tornetta P 3rd,Vallier H,Firoozabadi R,Leighton R,Egol K,Kruppa C,Jones CB,Collinge C,Bhandari M,Schemitsch E,Sanders D,Mullis B, Dynamizations and Exchanges: Success Rates and Indications. Journal of orthopaedic trauma. 2015 Dec     [PubMed]
Im GI, Clinical use of stem cells in orthopaedics European cells     [PubMed]
Gómez-Barrena E,Rosset P,Lozano D,Stanovici J,Ermthaller C,Gerbhard F, Bone fracture healing: cell therapy in delayed unions and nonunions. Bone. 2015 Jan     [PubMed]
O'Halloran K,Coale M,Costales T,Zerhusen T Jr,Castillo RC,Nascone JW,O'Toole RV, Will My Tibial Fracture Heal? Predicting Nonunion at the Time of Definitive Fixation Based on Commonly Available Variables. Clinical orthopaedics and related research. 2016 Jun     [PubMed]
Özkan S,Nolte PA,van den Bekerom MPJ,Bloemers FW, Diagnosis and management of long-bone nonunions: a nationwide survey. European journal of trauma and emergency surgery : official publication of the European Trauma Society. 2018 Jan 15     [PubMed]
Brinker MR,O'Connor DP, Management of Aseptic Tibial and Femoral Diaphyseal Nonunions Without Bony Defects. The Orthopedic clinics of North America. 2016 Jan     [PubMed]
Bell A,Templeman D,Weinlein JC, Nonunion of the Femur and Tibia: An Update. The Orthopedic clinics of North America. 2016 Apr     [PubMed]
Calori GM,Giannoudis PV, Enhancement of fracture healing with the diamond concept: the role of the biological chamber. Injury. 2011 Nov     [PubMed]
Brinker MR,O'Connor DP,Monla YT,Earthman TP, Metabolic and endocrine abnormalities in patients with nonunions. Journal of orthopaedic trauma. 2007 Sep     [PubMed]
Kreder HJ, Tibial nonunion is worse than having a myocardial infarction: Commentary on an article by Mark R. Brinker, MD, et al.: "The devastating effects of tibial nonunion on health-related quality of life". The Journal of bone and joint surgery. American volume. 2013 Dec 18     [PubMed]
Brinker MR,Hanus BD,Sen M,O'Connor DP, The devastating effects of tibial nonunion on health-related quality of life. The Journal of bone and joint surgery. American volume. 2013 Dec 18     [PubMed]
Ryaby JT, Clinical effects of electromagnetic and electric fields on fracture healing. Clinical orthopaedics and related research. 1998 Oct     [PubMed]
Claes L,Willie B, The enhancement of bone regeneration by ultrasound. Progress in biophysics and molecular biology. 2007 Jan-Apr     [PubMed]
Tosounidis TH,Calori GM,Giannoudis PV, The use of Reamer-irrigator-aspirator in the management of long bone osteomyelitis: an update. European journal of trauma and emergency surgery : official publication of the European Trauma Society. 2016 Aug     [PubMed]

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