Diaphyseal long bone nonunions — types, aetiology, economics, and treatment recommendations

Abstract

The intention of the current article is to review the epidemiology with related socioeconomic costs, pathophysiology, and treatment options for diaphyseal long bone delayed unions and nonunions. Diaphyseal nonunions in the tibia and in the femur are estimated to occur 4.6-8% after modern intramedullary nailing of closed fractures with an even much higher risk in open fractures. There is a high socioeconomic burden for long bone nonunions mainly driven by indirect costs, such as productivity losses due to long treatment duration. The classic classification of Weber and Cech of the 1970s is based on the underlying biological aspect of the nonunion differentiating between "vital" (hypertrophic) and "avital" (hypo-/atrophic) nonunions, and can still be considered to represent the basis for basic evaluation of nonunions. The "diamond concept" units biomechanical and biological aspects and provides the pre-requisites for successful bone healing in nonunions. For humeral diaphyseal shaft nonunions, excellent results for augmentation plating were reported. In atrophic humeral shaft nonunions, compression plating with stimulation of bone healing by bone grafting or BMPs seem to be the best option. For femoral and tibial diaphyseal shaft fractures, dynamization of the nail is an atraumatic, effective, and cheap surgical possibility to achieve bony consolidation, particularly in delayed nonunions before 24 weeks after initial surgery. In established hypertrophic nonunions in the tibia and femur, biomechanical stability should be addressed by augmentation plating or exchange nailing. Hypotrophic or atrophic nonunions require additional biological stimulation of bone healing for augmentation plating.

Double plating with autogenous bone grafting as a salvage procedure for recalcitrant humeral shaft nonunion

“…Despite the great advance in orthopedic technology, a surgeon still encounters a patient with humeral shaft nonunion who had already undergone repeated surgery for nonunion. In some circumstances, repeated operative failures to obtain union coupled with soft tissue maladaptation and deformity have left the patient with a profound disability and an abandonment of optimism, especially for patients with poor nancial conditions [2,3,7,10,20]. A number of methods have been designed to treat humeral shaft nonunion in order to provide adequate xation across the fracture sites and improve the local biomechanical environment or blood supply, and each method has its drawbacks.…”

“…Interlocking intramedullary nails have been widely used in acute humeral fractures, pathologic fractures and nonunions of the tibia or femur shaft, as for humerus xation, they have the advantages over plates of fewer tissue traumas, fewer circulatory impairments and lower risk of radial nerve injury [3]. Nailing or exchange nailing for humeral shaft nonunion had been successfully reported by some authors, the concept of this technology is improving nonunion segments biomechanical stability by using of a nail being at least one millimeter thicker than its diameter and fostering healing environment by transporting mesenchymal stem cells into the nonunion sites during reaming procedure [2,21].…”

“…xation (ORIF) of the humeral diaphyseal fracture can lead to a high healing rate with a good functional outcome, posttraumatic nonunion of the humeral shaft is not common [2]. It is reported in the literature that nonunion of the humeral shaft can reach to 2%-10% in non-surgical treatments and up to 13% in operative managements, with atrophic nonunion being the most common type, and commonly seen in the midshaft [3][4][5].…”

Leeds-Genoa Non-Union Index: a clinical tool for asessing the need for early intervention after long bone fracture fixation

“…Long-bone non-union continues to be one of the most common post-fracture fixation complication with an incidence reported to range between 5 and 10% [1][2][3]. Its impact in terms of resource allocation and utilization can be substantial [4][5][6].…”

Tibiapseudarthrosen

“…Sofern die Dynamisierung zur Beschleunigung der knöchernen Durchbauung indiziert ist, sollte diese Maßnahme ca. 6-12 Wochen nach Primärversorgung erfolgen, da nach unserer Erfahrung und in Übereinstimmung mit der Literatur die frühe Dynamisierung die besten Erfolgsaussichten bietet[14,15]. Somit ist die sekundäre Dynamisierung eher zur Behandlung einer verzögerten Frakturheilung als zur Therapie der etablierten Pseudarthrose indiziert.Augmentierende lokale PlattenosteosyntheseVerriegelungsnägel bieten im Vergleich zur Plattenosteosynthese eine hohe axiale und Biegestabilität, aber eine geringe Rotationsstabilität.…”