Management of tibial non-unions according to a novel treatment algorithm

doi:10.1016/j.injury.2015.09.040

Injury

Volume 46, Issue 12, December 2015, Pages 2422-2427

https://doi.org/10.1016/j.injury.2015.09.040 Get rights and content

Abstract

Tibial non-unions represent a spectrum of conditions that are challenging to treat. The optimal management remains unclear despite the frequency with which these diagnoses are encountered. The aim of this study was to determine the outcome of tibial non-unions managed according to a novel tibial non-union treatment algorithm. One hundred and eighteen consecutive patients with 122 uninfected tibial non-unions were treated according to our proposed tibial non-union treatment algorithm. All patients were followed-up clinically and radiologically for a minimum of six months after external fixator removal. Four patients were excluded because they did not complete the intended treatment process. The final study population consisted of 94 men and 24 women with a mean age of 34 years. Sixty-seven non-unions were stiff hypertrophic, 32 mobile atrophic, 16 mobile oligotrophic and one true pseudoarthrosis. Six non-unions were classified as type B1 defect non-unions. Bony union was achieved after the initial surgery in 113/122 (92.6%) tibias. Nine patients had failure of treatment. Seven persistent non-unions were successfully retreated according to the tibial non-union treatment algorithm. This resulted in final bony union in 120/122 (98.3%) tibias. The proposed tibial non-union treatment algorithm appears to produce high union rates across a diverse group of tibial non-unions. Tibial non-unions however, remain difficult to treat and should be referred to specialist units where advanced reconstructive techniques are practiced on a regular basis.

Introduction

The clinical entity of tibial non-union incorporates a variety of conditions that range from mobile to stiff, hypertrophic to atrophic, with deformity or without and even large segmental bone defects with or without limb length discrepancy [1], [2], [3]. The proposed management of these subdivisions are almost as numerous as the variation in non-unions themselves and even within groups the management can be affected by host factors, condition of the surrounding soft tissues and the non-union morphology itself [2], [4].

The treatment of tibia non-unions is mostly based on small series of cases that frequently include a variety of non-union subtypes and even infected cases [2], [5], [6]. Fixation methods vary from internal fixation including conventional compression plating, locked plating, reamed intramedullary nailing to external fixation with either mono-lateral fixators, circular fixators and hybrid fixators [2], [5], [7], [8]. Some authors have proposed cast immobilisation and isolated fibula osteotomy [9]. Adjuvants to surgical management include the use of autogenous bone graft, autologous bone-marrow aspirate, bone morphogenic proteins (BMPs), low intensity ultrasound and hyperbaric oxygen [10], [11], [12], [13], [14], [15]. This lack of uniformity in the available literature has rendered the establishment of an evidence-based, reproducible protocol for the management of tibial non-unions difficult, if not impossible.

In this retrospective review we report the results of the management of uninfected tibial non-unions treated according to our proposed tibial non-union treatment algorithm. In addition, we expand on the concept of mechano-biology and its role in the management of tibial non-unions.

Section snippets

Materials and methods

Between January 2010 and December 2014, 122 consecutive adult patients with uninfected tibial non-unions were treated according to our tibial non-union treatment algorithm (Fig. 1). This treatment strategy represents our current standard of care for tibial non-unions. Four patients were excluded because they did not complete the proposed treatment. These included a 33-year-old male and a 44-year-old female, both who died of systemic complications of chronic disease. Both these patients were HIV

Results

The medical records and serial radiographs of all 118 patients were reviewed. Four patients underwent treatment for bilateral tibial non-unions. The study population consisted of 94 men and 24 women with a mean age of 34 years, ranging from 18 to 73 years. Follow-up ranged from six to 48 months, with an average of 13 months, after external fixator removal (Table 1).

Risk factors for non-union development were identified in 106 patients (89.8%) (Table 2). These included open fractures (n = 87),

Discussion

The optimal treatment of tibial non-unions remains undetermined. Several authors have outlined the principles for the ideal treatment. Kanellopoulus and Gershuni both considered correction of alignment in all planes while limiting any additional compromise to the limb, and maintenance and improvement of function as the ideal treatment strategy [4], [22]. Giannoudis recently introduced the ‘Diamond concept’, which identified four key factors in non-union management, namely the cellular

Conclusion

The proposed tibial non-union treatment algorithm appears to produce high union rates across a diverse group of tibial non-unions. Although these results are encouraging we still recommend that these cases be referred to specialist centres that practice these advanced reconstructive techniques on a regular basis.

Conflict of interest

The authors declare that they have no conflict of interests and no financial support was received for this study.

Ethical statement

The study was authorised by the Biomedical Research Ethics Committee of the University of KwaZulu-Natal (BE 086/14) and performed in accordance with the Ethical standards of the 1964 Declaration of Helsinki as revised in 2000.

Authors’ contributions

Both authors made contributions towards the conception and design of the research, acquisition of data and drafting of the manuscript. The final manuscript was read and approved by both authors.

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Citation Excerpt :
Fibula osteotomies were done in all cases (n = 169, 100%) and formed the main adjuvant treatment. Seven tibias (4.1%) required additional bone grafting at the initial surgery [32,42–44]. Monolateral external fixation was employed in three studies and accounted for the management of 86 non-unions (9.4%), including ten (11.6%) hypertrophic and 76 (88.4%) atrophic non-unions (45–47).
Tibia fractures are the most common long bone injuries encountered in the trauma population. The majority are treated successfully but non-union remains a common complication. A systematic review of current evidence regarding the management for aseptic diaphyseal tibial non-unions was undertaken.
A systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA), was conducted.
A total of 632 publications were screened for inclusion. Full text review of 91 studies resulted in 26 publications being retained for final review. The majority of patients included in the studies either underwent exchange nailing (n = 315) or primary intramedullary nailing (n = 174) with respective union rates of 88% and 95% being achieved. The highest union rate (97%) was achieved with the use of fine wire external fixation. The major adjuvant treatment modalities were fibula osteotomies (n = 372; 41%), fixation dynamization (n = 208; 23%) and bone grafting (n = 183; 20%).
The lack of standardization in reporting of outcomes and the diversity of management strategies employed precludes definitive conclusions or recommendations. Further research is required to ascertain the ideal treatment strategy in the management of aseptic tibial diaphyseal non-unions.
IV.
Treatment of infected tibial non-unions using a BMAC and S53P4 BAG combination for reconstruction of segmental bone defects: A clinical case series
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Treatment of infected non-unions of the tibia is a challenging problem. The cornerstones of optimal infected non-union treatment consist of extensive debridement, fracture fixation, antimicrobial therapy and creation of an optimal local biological bone healing environment. The combination of S53P4 bioactive glass (BAG), as osteostimulative antibacterial bone graft substitute, and bone marrow aspirate concentrate (BMAC) for the implantation of mesenchymal stem cells and growth factors might be a promising combination. In this paper, preliminary results of a new treatment algorithm for infected non-unions of the tibia is presented.
In this retrospective case series patients with infected non-unions of the tibia are treated according to a new treatment algorithm. Patients are treated with extensive debridement surgery, replacement of the osteosynthesis and implantation of S53P4 BAG and BMAC in a one-stage or two-stage procedure based on non-union severity. Subsequently patients are treated with culture based antibiotic therapy and followed until union and infection eradication.
Five patients with an infected non-union were treated, mean age was 55, average NUSS-score was 44 and the average segmental bone defect was 4.6cm. One patient was treated in a one-stage procedure and four patients in a two-stage induced membrane-, or “Masquelet”-procedure. On average, 23 ml S53P4 BAG and 6.2 ml BMAC was implanted. The mean follow-up period was 13.6 months and at the end of follow-up all patients had clinical consolidation with an average RUST-score of 7.8 and complete eradication of infection.
These early data on the combined implantation of S53P4 BAG and BMAC in treatment of infected non-unions shows promising results. These fracture healing results and eradication rates resulted in promising functional recovery of the patients. To substantiate these results, larger and higher quality studies should be performed.
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La pseudarthrose est la complication la plus rencontrée au décours des fractures diaphysaires de la jambe. Sa prise en charge diffère en fonction du type de pseudarthrose. Les objectifs de cette étude étaient de décrire l’aspect épidémiologique et d’évaluer les résultats de notre prise en charge selon un algorithme précis. L’hypothèse était qu’en milieu précaire, l’utilisation d’un algorithme précis améliore la prise en charge. L’étude prospective a été menée de janvier 2012 à décembre 2015. Elle portait sur tous les types de pseudarthrose de l’adulte pris en charge dans le service. Les patients inclus devaient avoir 16 ans et plus, être suivis et évalués après un recul minimum de 12 mois. Les pseudarthroses étaient classées selon Weber-Čech qui répartissait les pseudarthroses en vitale (hypertrophique, légèrement hypertrophique et oligo-atrophique) et en avitale (nécrotique partielle, nécrotique, atrophique et défect osseux). Un algorithme tenant compte de l’état septique, du type de pseudarthrose et du défect osseux guidait la prise en charge. Les pseudarthroses vitales (ostéogéniques) et avitales (non ostéogéniques) aseptiques étaient traitées en un temps opératoire. Celles septiques et avec défects osseux étaient traitées de manière séquentielle. Les reprises chirurgicales étaient toujours autorisées devant la poursuite de l’infection et/ou de l’absence de consolidation. Les résultats étaient évalués selon les critères de l’« Association for the Study and the Application of the Method of Ilizarov (ASAMI) ». Cent quatre pseudarthroses étaient incluses chez 104 patients (85 hommes, 19 femmes) d’âge moyen 35,5 ans (16–74). Les pseudarthroses étaient vitales dans 69 cas et avitales dans 35 cas. La décortication ostéomusculaire était pratiquée dans 75 cas. Le nombre d’interventions subies au cours de l’étude était en moyenne de 2 (1–6). Aucune infection du site opératoire n’était observée au cours de la prise en charge des pseudarthroses aseptiques. Au recul moyen de 16,8 mois (12–45), 101 des 104 pseudarthroses avaient consolidé. Deux patients gardaient une pseudarthrose septique et un patient consolidé au plan osseux gardait une fistule productive. Ces trois patients étaient tous immunodéprimés (HIV+). Le score d’ASAMI au plan osseux était excellent chez 67 patients, bon chez 24, passable chez 4, mauvais chez 9 et au plan fonctionnel, excellent chez 58 patients, bon chez 27, passable chez 15, mauvais chez 3. Aucune amputation n’a été nécessaire. Le respect d’une procédure codifiée dans la prise en charge des pseudarthroses permet un résultat satisfaisant même en situation précaire.
Étude de cohorte prospective niveau de preuve IV.
Treatment of recalcitrant atrophic non-union of the humeral shaft with BMP-7, autologous bone graft and hydroxyapatite pellets
2016, Injury
Recalcitrant humeral non-union is a disabling condition that is extremely difficult to treat. The use of BMP-7 has been proposed to improve bone healing. This is a report of the results obtained in 12 patients with recalcitrant humeral non-union treated using stable fixation with a long locking compression plate and BMP-7, autologous bone graft and hydroxyapatite pellets applied at the non‐union site. Patients had up to three surgical attempts at non-union healing prior to our treatment. The average time from the initial fracture to our surgery was 5.2 years. Average follow‐up was 5.3 years. At follow-up, non-union had healed in all patients by an average of 7.3 months. All the patients were very satisfied with their final results, despite a restricted range of motion of the elbow and a moderate muscular atrophy, which was frequently observed. Our study shows that BMP-7 associated with autologous bone grafting and hydroxyapatite pellets after stable fixation is an effective adjuvant to stimulate bone healing in the treatment of recalcitrant humeral non-union.
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¹: Present address: Department of Orthopaedic Surgery, Greys Hospital, Pietermaritzburg, KwaZulu-Natal 3201, South Africa.

View full text

Management of tibial non-unions according to a novel treatment algorithm

Abstract

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusion

Conflict of interest

Ethical statement

Authors’ contributions

Injury

Injury

Orthop Traumatol Surg Res

Injury

Injury

Injury

Injury

Curr Orthop

Clin Biomech

Injury

Ilizarov treatment of tibial nonunions with bone loss

Clin Orthop Relat Res

A revised protocol for more clearly classifying a nonunion

J Orthop Surg

Management of nonunion of fractures by distraction with correction of angulation and shortening

J Bone Joint Surg [Br]

Distraction of hypertrophic non-union of tibia with deformity using Ilizarov/Taylor Spatial Frame: report of two cases

Arch Orthop Trauma Surg

Treatment of tibial nonunion and bone loss with the Ilizarov technique

Instruct Course Lect

Clinical advances in the treatment of fracture nonunion: the response to mechanical stimulation

Curr Opin Orthop

Partial resection of fibula in treatment of ununited tibial shaft fractures

Indian J Orthop

Adjunctive hyperbaric oxygen therapy in the treatment of atrophic tibial nonunion with Ilizarov external fixator: a radiographic and scintigraphic study in rabbits

Acta Orthop Traumatol Turc

Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses

J Bone Joint Surg [Am]