ORTHOPAEDIC SURGEON

1. ALATISHE K.A
PRINCIPLES OF MANAGEMENT
OF NON-UNION

2. OUTLINE
 Introduction /definition
 Epidemiology
 Fracture healing
 Aetiology of Non-union
 Classification/types of Non-union
 Clinical features
 Investigations
 Treatment- options, factors that determine Tx options,
principles and complications of tx
 Local perspectives
 Complications of treatment
 Follow-up
 conclusion

3. INTRODUCTION
 A complication of fracture treatment
 May be challenging and expensive
 Outcome is guarded
 The main responsibility lies with the treating
surgeon- should be able to predict # non-union,
prevent and devise appropriate treatment based
on standard practice
 Definition of fracture non-union still controversial
in the literature

4. INTRODUCTION
 FDA panel defines non-union as failure of a
fractured bone to completely heal within 9 months
of injury and shows no visible progressive signs
of healing on serial radiographs over a course of
3 months
 N/B: FDA definition can not be applied to every fracture.
 Non-Union can be established when the biologic
activity of fracture healing has come to a standstill
both clinically and radiological and has no
potential to healing without further intervention

5. INTRODUCTION
 Delayed non-union occurs when a fracture has
not completely healed in the expected time but
still has the potential to heal without further
intervention

6. EPIDEMIOLOGY
 Occurs in 5-10% irrespective of the treatment
method
 100,000 non-union cases annually in the U.S
 Higher in male- “high energy injury theory”
 Paucity of local study
 Likely an increase prevalence in Sub-Saharan
Africa due to poor health care, ignorance, poverty
and high patronage of Traditional Bone
setters(TBS)practitioners

7. FRACTURE HEALING
 The development of callus occurs on both the
periosteal and endosteal surfaces of the fracture.
 Delayed union occurs when periosteal callus
formation ceases prior to complete union leaving
the stability of the fracture dependent on the late
endosteal healing
 Non-union occurs when both the endosteal and
periosteal callus formation fails.

8. FRACTURE HEALING
 Types: Direct and indirect healing
 Determined by degree of strain at the fracture
site( interfragmentary strain theory of Perren)
 Strain <2%- direct healing; 2-<10%-indirect
healing( callus); 10-100%strain- fibrous non-union
 Die- back phenomenon

9. PHASES OF INDIRECT
HEALING
 Haematoma formation
 Inflammation
 Soft Callus
 Hard Callus( Consolidation)
 Remodelling

10. AETIOLOGY
 Aetiology is complex and multifactorial
 However, any factor that negatively affect the phases
of fracture healing can lead to non-union
 Excessive motion at fracture site, loss of blood supply
to the ends or surrounding envelope, initial
displacement, soft tissue interposition
 Aetiology of non-union can be subdivided -Patient’s(
systemic) , fracture Characteristics(local ) and
surgeons’ factors

11. AETIOLOGY
 Patient’s factor- diabetics, immunosupression,
anticancer medications, malnutrition, steroid,
alcohol, NSAIDs, Patronage of TBS, early weight
bearing or use of limb against medical advice
e.t.c

12. AETIOLOGY
 Fracture Characteristics
 Open fracture
 Segmental fracture
 Severe comminuted fractures
 Irradiated bone
 soft tissue interposition
 Osteoporosis
 Bones with precarious blood or end arterial supply( e.g
distal tibia, scaphoid waist #, talar neck #)
 Intact fellow bone
 fractures in special location( intra-articular femur neck)
 Infection

13. AETIOLOGY
 Surgeons’ factor
 Wrong treatment decision- patient selection and
optimization- when to intervene?, how to intervene?
 Poor surgical technique( approach, excessive
periosteal stripping, breech of asepsis& mal-
handling of soft tissue –may predispose to infection,
bone necrosis by overheating with power drill,
wrong implant choice, unstable fixation- increase
strain at fracture site)
 Immobilization of fracture for insufficient time ( such
as untimely cast removal)
 Aggressive rehabilitation- excessive motion at
fracture site before union

14. Non-union classification
 Based on vascularity/viabilty of the fracture ends (
Judet&Judet, Muller, Weber& Cech and colleagues )
 Hypervascular- fracture ends are capable of
biological reaction
• Main problem is inadequate immobilisation or
unstable fixation with consequent excessive motion
at fracture site
 Types of hypervascular non-union are Hyertrophic(
Elephant foot), horse-hoof and Oligotrohic
 Avascular- fracture ends are incapable of biologic
reaction
• Main problem is loss of blood supply to the fracture
ends
 Types of avascular non-union are Torsion wedge,

15. WEBER-CECH
CLASSIFICATION
HYPERVASCULAR AVASCULAR

16. PALEY CLASSIFICATION
 Based on bone defect and deformity(Paley et al)
 Type A- bone defect of <1cm
 A1-mobile Non-Union
 A2- Stiff Non-Union
 A2-1: no deformity
 A2-2: with fixed deformity
 Type B- bone loss of >1cm
 B1- Bone defect, no shortening
 B2- Shortening with no deformity
 B3- both bone defect and deformity

17.  Based on presence or absence of infection
 Aseptic Non-union
 Septic Non-union- further subdivided by Jain and
SinhaGroup Subgroup Description
A (Non-draining) No pus drainage in the last three months
A1 Fracture gap <4cm after debridement
A2 Fracture gap >4cm after debridement
B (Draining) Actively draining pus or drained pus in < 3months
B1 Fracture gap < 4cm after debridement
B2 Fracture gap > 4cm after debridement

18. CLINICAL FEATURES-Hx
 Usually complains of persistent limb
deformity/abnormal movement with or without pain
 +/-shortening of limb
 difficulty with the use of the limb(poor function)
 There may be associated discharging sinus
 Enquire about Hx of mechanism of injury, open
#,bone loss, TBS care, method of treatment;
 If non-surgical tx- duration of cast immobilisation
 If surgical?-hx of immediate post-op events, duration
of treatment, rehabilitation after initial surgery and
treatment so far
 Medial co-morbidities-like DM, HIV, HBSS etc
 Any medications e.g anti cancer, NSAIDS, steriods
e.t.c

19. CLINICAL FEATURES-
examination
 Scars around fracture location( such as Surgical or
puckered scars)
 Scarifications marks
 Discharging Sinuses with surrounding area of
hyperpigmentation
 Wasting of the limb( from disuse)
 +/-Deformity
 shortening of the limb is a common finding
 Non-tender abnormal mobility at fracture(
pseudoarthrosis)
 Stiff adjacent joint
 Neurovascular status should be assessed.

20. INVESTIGATIONS
 Plain radiograph- Atleast 2views( Standard AP,
lateral +/- Oblique)
 Persistence of fracture gap( lucency lines)
 Sclerosed margins of the fracture ends with
surrounding Osteopenia( as in atrophic non-union)
 Conical or tapered bone ends ( as in atrophic non-
union)
 Medullary plug
 No sign of callus or elephant foot type of callus on
both sides of the fracture line but not bridging
 Any bone defect or gap?
 Implant in-situ:- stable or unstable?

21. INVESTIGATION

22. INVESTIGATIONS
 ULTRASOUND
 CT-Scan – to determine non-union in doubtful
instances. it has sensitivity of 100% but low
specificity
 MRI- viability of the ends and to rule out
Avascular necrosis in some bones such as
scaphoid ,talus , femur head
 Scintingraphy with Strontium -85 or Technicium-
99 to determine the biologic activity at the
fracture ends
 Infection Screens : FBC, ESR,CRP and IL-6(
combination of these markers increase the

23. PRINCIPLES OF TREATMENT
 The primary objective in the treatment of non-union is
to achieve solid union of the fracture site, one that
will endure and allow the patient to regain a good
level of function
 Establish a diagnosis of non-union
 Identify the type of non-union and exclude infection
 Proper counselling
 Optimisation of medical co-morbidities
 Determine stability of the implant in event of septic
non-union with implant in-situ
 Control infection in Septic non-union before definitive
treatment( Consensus agreement)

24. PRINCIPLES OF TREATMENT2
 Options- non-surgical and surgical
 Non-surgical options – low-intensity USS, bone marrow injection
and Electrical stimulation to induce osteogenesis
 Surgical options
 Closed reduction under C-arm and compression with ilizarov
device( Transformation Osteogenesis)
 Open reduction , internal fixation (plate or nail) and bone graft
 Staged procedure in septic non-union (debridement, antibiotic
spacer and definitive tx- external fixation with lengthening
procedure)
 Ablative procedure in uncontrolled septic non-union following
failed multiple surgical interventions
 Factors determing choice of treatment: weber-Cech /Paley class,
infection status, LLD, soft tissue integrity and surgeon’s
preference

25. GENERAL PRINCIPLES OF
SURGICAL TREATMENT
 Indication established
 Optimise for surgery, stop alcohol and smoking
 Appropriate anesthesia
 Antibiotic prophylaxis
 Consider soft tissue cover when planning skin
incision( may require Plastic surgeons’ input or
presence)
 Excision of interposing fibrous tissue, and
sclerotic edges until raw bleeding surface is
observed
 Avoid excessive or circumferential periosteal
stripping around fracture site

26. GENERAL PRINCIPLES OF
SURGICAL TREATMENT2
 Gentle handling of bone with bone holding forceps- to
avoid damage to periosteum and crushing
osteoporotic bone
 Removal of medullary plug , to open up the medullary
vascular channels
 Take bone edges and marrow content for m/c/s
 Proper alignment and determine if any lengthening
procedure will be required?- same sitting or delayed)
 Compression and rigid fixation – external or internal

27. GENERAL PRINCIPLES OF
SURGICAL TREATMENT3
 Induce osteogenesis with bone graft or bone graft
substitute ( though not mandatory in
hypervascular non-union)
 A suction drain is nearly always advisable.
 Active mobilisation to avoid joint stiffness and
promote periosteal vascular inflow through
muscles
 Continue intravenous or oral bacteriocidal
antibiotics until the cultures are negative

28. TREATMENT OF HYPERTROPHIC
NON-UNION
 General principles apply
 Requires #compression
 May require osteotomy of intact fellow bone e.g fibulotomy
 Compression plating preferred over IM nailing
 When using a nail, Use an AO distractor in compression, or
another device to compress the fracture site and lock the nail
statically in compression
 Ilizarov device for compression esp in metaphyseal region ;
and for lengthening if required
 Bone grafting not mandatory( however, no harm in
bone grafting all non-unions)
 With implant in-situ (e,g locked IM Nail): the options
are
 Nail Dynamization
 Exchange Nailing ( with a bigger nail )
 Nail removal and compression plating plus bone grafting

29. TREATMENT OF ATROPHIC NON-
UNION
 General principles apply
 Excise all interposing fibrous tissue, bone ends and
re-canalise the marrow
 Choice of implant depends on #location, degree of
osteoporosis and residual shortening after
debridement
 Locking compression plate preferred
 Hydroxyapatite coated screws are added advantage
for construct stability
 Bone grafting mandatory( on-lay, in-lay, phemister
et.c)
 Ilizarov may be the only viable option in some cases
where principles of compression plating not
achievable e.g 8cortices above and below.
 In elderly with atrophic non-union around the joint,
joint replacement with tumor prosthesis may be the

30. PRINCIPLES OF SURGICAL
TREATMENT IN SEPTIC NON-
UNION
 Eradication of infection and achieving union are
the primary objectives.
 Is it draining or non-draining?- Jain and Sinha
class
 Determine stability of the implant ( if present)
 Any bone gap and need for bone lengthening?-
must be discussed with patient

31. PRINCIPLES OF SURGICAL
TREATMENT IN NON-DRAINING
SEPTIC NON-UNION
 Two schools of thought ( if the implant is stable)
 1. Antibiotic therapy and delayed implant removal
once union has been established ( argument is that
infection only delays but does not prevent union)
 2. Early removal of implant, debridement and
application of external device for bone
stabilization+/- lengthening or bone transport(
argument is that antibiotics won’t penetrate through the biofilm on the
implant and infection control can only be achieved by removal of
implant)
 If there is implant failure with septic non-union,
the consensus is early removal of implant,
debridement and application of external device
for bone stabilization+/- lengthening

32. PRINCIPLES OF SURGICAL
TREATMENT IN DRAINING
SEPTIC NON-UNION
 The objective is to convert draining to non-
draining non-union for several months and
promote union
 Conventional Steps( staged)
 radical debridement +/- flap cover ( same sitting)
 antibiotic therapy ( Parenteral and local- herafil
beads)
 When no signs of infection ( usually 6-8weeks),
then definitive treatment with bone grafting
 Active (same sitting)
 Debride, align/ stabilise and compress with external
fixator( e.g ilizarov /LRS, bone graft, corticotomy
and commencement of distraction and skin cover

33. Post-operative Care
 most difficult decision is determining when to
commence the patient's rehabilitation program- to
avoid strain on the non-union site
 Can support the limb with a functional brace
 Wound and pin site care
 Analgesics
 Antibiotics
 VIT D, Calcium supplements
 Measurement of residual limb shortening and
give bone distraction instructions
 Psychological care

34. Follow-up
 Clinically and radiologically until union, limb
length restored and optimal function is achieved
 Appropriate lab testing

35. COMPLICATIONS OF
TREATMENT
 Vascular injuries- anatomy often distorted
 Nerve injuries( e.g wrist drop in humeral #non-union
tx)
 Osteoporosis
 Infection ( e.g in presumably aseptic non-union)
 Treatment failure( fracture still non-united after
intervention)
 Joint stiffness
 Pin site infection
 Iatrogenic fractures
 Regenerate fracture
 LLD

36. LOCAL PERSPECTIVES
 TBS is a major aetiology
 Very severe and Challenging cases exist
 Patients fund health care from Out-of –pocket
 Well experienced Trauma surgeons are available
 Surgical treatment is the standard of care in our
environment

37. CONCLUSION
 Understanding natural course of fracture , how
and when to intervene in the event of non-union
is a sine qua non to successful outcome
 Counselling of patients is a MUST before
intervention
 Prevention should be emphasized- biologic
fixation, proper technique and implants, rigid
fixation are some of the measures
 Treatment should be multidisciplinary and
principles of treatment should be strictly adhered
to

38. THANK YOU