Tibial nonunion

Which surgical technique may yield the best results in large, infected, segmental non-unions of the tibial shaft? A scoping review

PURPOSE

Infected nonunion of the tibia with a large segmental bone defect is a complex and challenging condition for the patient and surgeon. This scoping review was conducted to identify existing evidence and knowledge gaps regarding this clinical scenario. Secondly, the objective of this study was to search for a valid recommendation on the optimal treatment.

METHODS

A comprehensive search was conducted in the bibliographic databases: PubMed, Embase.com, and Web of Science Core Collection. Studies reporting on bone transport techniques, the Masquelet technique, and vascularized fibular grafts in bone defects greater than 5 cm were included. Bone healing results and functional results were compared according to duration of nonunion, infection recurrence, bone consolidation, complication rate, external fixation time, and time until full weight-bearing.

RESULTS

Of the 2753 articles retrieved, 37 studies could be included on bone transport techniques (n = 23), the Masquelet technique (n = 7), and vascularized fibular grafts (n = 7). Respective bone union percentages were 94.3%, 89.5%, and 96.5%. The percentages of infection recurrence respectively were 1.6%, 14.4% and 7.0%, followed by respectively 1.58, 0.78, and 0.73 complications per patient.

CONCLUSION

Bone transport was found to be the most widely studied technique in the literature. Depending on the surgeon's expertise, vascularized fibular grafts may be held as a favourable alternative. This review indicates that further high-quality research on large bone defects ( ≥ 5 cm) in patients with infected tibial nonunions is necessary to gain more insight into the potentially beneficial results of vascularized fibular grafts and the Masquelet technique.

Proximal ulna non-union: treatment concept and postoperative outcome

PURPOSE

Non-union of the proximal ulna is a serious complication after surgical treatment of olecranon and complex elbow fractures, frequently leading to poor functional outcome. To date, there is a lack of data regarding optimal treatment strategies and functional outcome parameters after surgical revision.

METHODS

From 02/2010 to 12/2018, 31 patients undergoing surgical treatment of proximal ulna non-union could be included. Follow-up period was seven years (SD 2.5 years). All patients were clinically assessed using a clinical assessment tool set and standard elbow scores (MEPS, OES, DASH score). All complications and unplanned revision surgeries were recorded and all radiographic material was analyzed.

RESULTS

Initial non-union procedures were performed at an average of 6.6 months (SD 3 months) after the index procedures. Those included the use of autologous spongiosa graft in all patients and concomitant compression re-osteosynthesis in 28 patients. Radiological consolidation was achieved in all patients. Overall, patients achieved a good to fair functional outcome with Mayo elbow performance score measuring 78.5 (SD 9.1), DASH score 34.7 (SD 14.4), and Oxford elbow score 31.2 (SD 6.6) points. Initial malreduction/implant-malposition could be identified as a main reason for the occurrence of the non-union. Furthermore, inferior postoperative outcome was detected in patients > 60 years and BMI > 30 kg/m².

CONCLUSION

Using a standardized protocol, bony union and acceptable functional outcomes can be achieved in proximal ulna non-unions. However, surgeons should be aware of potential risk factors and proper initial fracture reduction as key to achieve sufficient bone healing.

Autogenous iliac crest bone grafting for tibial nonunions revisited: does approach matter?

BACKGROUND

Tibial nonunion remains a considerable burden for patients and the surgeons who treat them. In recent years, alternatives to autogenous grafts for the treatment of tibial nonunions have been sought. The purpose of this study was to evaluate the efficacy of autogenous iliac crest bone graft (ICBG) in the treatment of tibial shaft nonunions.

MATERIAL AND METHODS

Sixty-nine patients were identified who underwent ICBG for repair of atrophic or oligotrophic tibial nonunion and had complete data with at least one year of follow-up (mean 27.9 months). Surgical treatments consisted of revision/supplemental fixation ± ICBG. Surgical approaches for graft placement were either posterolateral (PL), anterolateral (AL), or direct medial (DM). Healing status, time to union, postoperative pain, and functional outcomes were assessed.

RESULTS

Bony union was achieved by 97.1% (67/69) of patients at a mean time of 7.8 ± 3.2 months postoperatively. There was no significant difference in mean time to union between the three surgical approach groups: (PL (44.9%) = 7.3 months, AL (20.3%) = 9.2 months, DM (34.8%) = 7.6 months; p = 0.22). Intraoperative cultures obtained at the time of nonunion surgery were positive in 27.5% of patients (19/69). Positive cultures were associated with need for secondary surgery as 8/19 patients (42.1%) with positive cultures required re-operation. Two out of four patients that developed iliac donor site hematomas/infections requiring washout had positive intraoperative cultures as well. There was no difference in final SMFA among the three surgical approach groups.

CONCLUSIONS

Autogenous ICBG remains the gold standard in the management of persistent tibial nonunions regardless of surgical approach. There is a small risk for complication at the iliac crest donor site. Given the high union rate, autogenous iliac crest bone grafting for tibial nonunion remains the gold standard for this difficult condition.

LEVEL OF EVIDENCE

Level III.

Long-term functional outcome and quality of life after successful surgical treatment of tibial nonunions

PURPOSE

Our aim was to evaluate quality of life (QoL) and functional outcome of patients with tibial nonunions after completion of surgical treatment with an average follow-up of five years.

METHODS

The following data of 64 patients were retrospectively evaluated: fracture type, type and duration of surgical therapy, range of motion of the knee and ankle and American Orthopaedic Foot and Ankle Society (AOFAS) score. QoL was evaluated with the Short-Form Health Survey (SF-36) questionnaire; pain intensity, patient satisfaction and impairments of daily, professional and sport activities with a ten point visual analogue scale.

RESULTS

QoL, even in cases with successfully completed treatment, was significantly reduced compared with the normal general population. Pain intensity and limited ankle dorsal extension, despite the absence of intra-articular fractures, were significantly correlated with inferior QoL.

CONCLUSIONS

This study emphasises the long-term negative impact of tibial nonunions on patient QoL, even after successful surgical treatment.

A treatment for large defects of the tibia caused by infected nonunion: Ilizarov method with bone segment extension

OBJECTIVES

To investigate the efficacy of the Ilizarov technique with bone segment extension in tibial infected nonunion.

METHODS

From September 2003 to June 2011, we treated 30 patients (21 males, 9 females; age 19-49 years, mean 34.1 years) for tibial infected nonunion with bone defects. Eleven cases were compound fractures internally fixed with steel plates, nine were compound fractures internally fixed with IM Nails, eight were compound fractures externally fixed with external fixation devices, and two were closed fractures internally fixed with steel plates. All 30 patients underwent debridement followed by the Ilizarov technique using bone segment extension.

RESULTS

After follow-up of 12 months-6 years (mean 29 months), stable union of fracture was achieved in all 30 patients. The time from bone fracture to union was 6-24 months, mean 8.8 months; external fixation was in place for 8-14 months, mean 10 months. External fixation index was 41 days/cm. Complications were three cases of pin site infection, one skin allergy, two fractures malunion, one early mineralization and one wire breakage. There were no cases of deep infection, nonunion or stiffness of the knee joint. According to the Paley fracture healing score criteria, 30 cases had excellent outcomes and two were good.

CONCLUSIONS

The Ilizarov technique with bone segment extension is effective in treating tibial infected nonunion with large bone defects.

Bone morphogenetic protein-2 compared to autologous iliac crest bone graft in the treatment of long bone nonunion

This retrospective study investigated the effect of recombinant human bone morphogenetic protein-2 (rhBMP-2) mixed with cancellous allograft on fracture healing compared to iliac crest autograft in the treatment of long bone nonunion. Eighty-nine patients with 93 established long bone nonunions treated between January 2002 and June 2004 at a single academic Level I trauma center were evaluated. Patients with clinical and radiographic evidence of failed fracture union underwent nonunion debridement, revision of fixation, and implantation at the nonunion site of either rhBMP-2 or the standard treatment autologous iliac crest bone graft. Union rate, operative time, estimated intraoperative blood loss, hospital length of stay, and postoperative infections were recorded. Nineteen nonunions received rhBMP-2 on a specialized carrier matrix (an absorbable collagen sponge) mixed with cancellous allograft, and 74 nonunions were treated with autologous iliac crest bone graft. There was no statistical difference in the rate of healing between treatment groups (68.4% vs 85.1%, respectively; P=.09). Incidence of postoperative infection was 16.2% after autologous iliac crest bone graft and 5.3% after rhBMP-2/absorbable collagen sponge (P=.22). Iliac crest autograft was associated with longer operative procedures (257.9±93.0 vs 168.9±86.5 minutes; P=.0007) and greater intraoperative blood loss (554.6±447.8 vs 331.6±357.2 mL; P=.01). These outcomes suggest that rhBMP-2 may provide a suitable alternative to autologous iliac bone graft, with the possible advantages of shorter operative time and reduced intraoperative blood loss, and may be considered as part of the orthopedic surgeon's treatment options.

Bone morphogenetic proteins in clinical applications

The role of bone morphogenetic proteins (BMPs) in bone healing has been shown in numerous animal models. To date, at least 20 BMPs have been identified, some of which have been shown in vitro to stimulate the process of stem cell differentiation into osteoblasts in human and animal models. Having realized the osteoinductive properties of BMPs and having identified their genetic sequences, recombinant gene technology has been used to produce BMPs for clinical application - most commonly, as alternatives or adjuncts in the treatment of cases in which fracture healing is compromised. BMP-2 and BMP-7 are approved for clinical use in open fractures of long bones, non-unions and spinal fusion. However, despite significant evidence of their potential benefit to bone repair and regeneration in animal and preclinical studies, there is, to date, a dearth of convincing clinical trials. The purpose of this paper is to give a brief overview of BMPs and to critically review the clinical data currently available on the use of BMP-2 and BMP-7 in fracture healing.

Femoral diaphyseal aseptic non-unions: is there an ideal method of treatment?

Femoral non-unions represent a formidable challenge for the orthopaedic surgeon. Their successful treatment is frequently time consuming, and requires utilisation of numerous resources. Three main methods of treatment have been described: intramedullary nailing (IMN), plating and external fixation. A systematic review of the existing English literature of femoral diaphyseal non-union treatment methods has been conducted. The gold standard remains exchange nailing despite the fact that plating has reached near equivocal rates of success. In cases where exchange nailing fails, the use of plates and external fixators has been shown to provide useful adjuncts to the nail. Most surgeons have preserved bone grafting as an option at a secondary or tertiary stage, after the initial revision procedure has failed.