[Tibia nonunion after intramedullar nailing for fracture: decortication and osteosynthesis by medial plating]

Aseptic nonunion of the tibia treated by plating and bone grafting: retrospective study about 40 cases

Objective

The objective of this study was to evaluate the clinical and radiological results of the treatment of aseptic nonunion of the tibia by plating and bone grafting.

Material and Methods

This retrospective study included 40 patients with aseptic nonunion of the tibia, treated in the Trauma-Orthopedic department B4 of CHU Hassan II in Fez-Morocco. The average age was 41 years (range 25–60 years). The initial fractures were in the middle third of the tibia for the majority of our patients. We used the ASAMI criteria to assess the results.

Results

We found 45 patients with aseptic nonunion of the tibia who were treated by the same surgical team and followed in postoperative consultation for a fixed period of 10 months. Three patients lost to follow-up and two patients refused the treatment. In 37 patients (92.5%), union was obtained after a mean delay of 4.3 months (range 3–7 months). The average time from initial treatment to treatment for nonunion was eight months (range 6–10 months). According to the ASAMI classification, bone results were excellent in 26, good in 8, fair in 3 and poor in 3; functional results were excellent in 10, good in 16, fair in 11 and poor in 3.

Conclusions

Our study suggests that the combination of screwed plate and autograft in the treatment of aseptic nonunion of the tibia has provided satisfactory results. A well-codified management of the initial fracture remains the gold key to prevent the occurrence of pseudarthrosis.

Effect of decortications on union rate of tibial plating

Tibial fracture is the most common long bone fracture. Because of the superficial location of the tibia, surgery is usually required for the treatment of fractures to achieve union. The goal of this study was to evaluate the effect of decortication on the faster union of fractures treated with compression plates. In this clinical trial, conducted from 2009 to 2013, 42 patients were randomly assigned to the decortication (20 patients) and control (22 patients) groups. Follow-up was performed every 2 weeks until union was achieved, and then patients were examined after 6 and 9 months for analysis of final union. Mean time to weight bearing with 2 crutches, weight bearing with 1 crutch, weight bearing with a cane, and complete weight bearing without pain in the control group (receiving only the compression plate) was 5.59, 7.50, 9.32, and 11.05 weeks, respectively. Mean time to weight bearing with 2 crutches, weight bearing with 1 crutch, weight bearing with a cane, and complete weight bearing without pain in the decortication group was 4.90, 6.35, 7.75, and 9.25 weeks, respectively. All 4 values were significantly higher in the decortication group compared with the control group (P<.05). Erythema and signs of inflammation were significantly associated with decortication and were more common in the decortication group. No infection, broken plate, or nonunion occurred in either group. Because decortication had a significant effect on achieving union in nonunion fractures, it could be used to induce faster clinical union in acute tibial fractures.

Low-intensity pulsed ultrasound for non-union treatment: a 14-case series evaluation

INTRODUCTION

Non-union is presently managed exclusively by surgery, but alternative treatments are under evaluation.

OBJECTIVE

To assess the benefit of external ultrasound stimulation in surgically treated lowerlimb long-bone non-union.

PATIENTS AND METHODS

A retrospective series of 14 patients were treated using the Exogen(®) ultrasound stimulator (Smith & Nephew Inc., Memphis, TN, USA) as part of management of surgically treated long-bone non-union. They received 20min stimulation daily over a period of 3 months. Regular clinical and radiological follow-up checked treatment efficacy.

RESULTS

The mean interval to initiation of Exogen(®) treatment after initial surgery was 361 days (range, 6, 38 months). Bone consolidation was obtained in 11 of the 14 cases (79%), and within 3 months of initiation of Exogen(®) treatment in 27% (3/11), within 6 months in 27% (3/11) and within 9 months in 46% (5/11). There were no treatment-linked complications. There was no significant correlation between interval to initiation of ultrasound treatment and bone consolidation. Associated sepsis or atrophy did not significantly impact treatment efficacy.

DISCUSSION

The reference treatment strategy in non-union is surgical revision, with consolidation rates ranging from 85 to 100% according to the series. This attitude entails risk of complications, notably infection and postoperative pain. The present results were comparable to those of the literature, with 79% bone consolidation and no complications. Ultrasound stimulation proved an effective and non-invasive treatment for non-union.

LEVEL OF EVIDENCE

Retrospective study, level IV.

Efficacy of minimally invasive techniques for enhancement of fracture healing: evidence today

The successful treatment of nonunions represents a major challenge for orthopaedic surgeons. Lately, ongoing advances made in the field of molecular medicine and molecular biology have increased our understanding of the pathways and involvement of mediators surrounding the bone healing process. As a result, the surgeon's armamentarium has been increased in terms of options for intervention. This article aims to provide an overview of minimally invasive techniques applicable in the treatment of nonunions of fractures.

Classification of non-union

A substantial number of experimental and clinical studies have established that the cornerstones for successful bone-healing are biomechanical stability and biological vitality of the bone, as they both provide an environment in which new bone can be formed. Non-union of long bones is a significant consequence in treating fractures. Many approaches to prevent fracture non-union have been proposed. Depending on the type and location of the non-union, treatment options include various types of bone fixation, with or without supplemental bone graft or other biophysical enhancements.