Management of tibial non-unions according to a novel treatment algorithm
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.
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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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Present address: Department of Orthopaedic Surgery, Greys Hospital, Pietermaritzburg, KwaZulu-Natal 3201, South Africa.