Tibial Delayed Union

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The American Academy of Orthopaedic Surgeons

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VOLUME 88-A NUMBER 1 JANUARY 2006

DELAYED UNIONS

OF TH E TIBIA

Delayed Unions

of the TibiaBY LAURA S. PHIEFFER, MD, AND JAMES A. GOULET, MD

An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

Nonunion of the tibial shaft is a com-mon problem that can be disabling.Treatment may require multiple opera-tive procedures, prolonged hospitaliza-tion, and years of disability before aunion is obtained or an amputation isperformed. Most tibial fractures heal af-ter the initial treatment1-4, but non-union is seen by all practitioners whotreat tibial fractures. Early recognitionof a potential nonunion followed by

early intervention will reduce the ulti-mate time to union and lessen the sur-geons and patients frustration. ThisInstructional Course Lecture providesan overview of tibial delayed unionsand the treatment options available tomanage this diverse group of clinicalproblems. We believe that most tibialnonunions can be treated by most or-thopaedic surgeons without referral.

A delayed union is an ununitedfracture that continues to show progresstoward healing or that has not been

present for long enough to satisfy anarbitrary time standard for nonunion.A failure to see evidence of union onradiographs at various time-points

ranging from twenty to twenty-sixweeks has been used by several authorsas the criterion for defining delayedunion5-9. The lack of precision in thedefinition diminishes its value in pub-lished reports. Delayed union mightbest be thought of as the point at whichone should consider altering treatmentto achieve union. Although the deter-mination of a delayed union of a tibialfracture is frequently made at around

twenty weeks, it may be possible to rec-ognize delayed unions of certain frac-tures, especially Gustilo10 type-III openfractures, sooner.

Nonunion of a fracture occurswhen the normal biologic healing pro-cesses of bone cease, so that solid heal-ing will not be achieved without furthertreatment. Nonunion has been definedby the United States Food and Drug Ad-ministration as a fracture that occurreda minimum of nine months previouslyand has not shown radiographic signs

of progression toward healing for threeconsecutive months11. Nonunions areclassified according to their radio-graphic appearance as hypertrophic,

oligotrophic, or atrophic as defined byLaVelle11. This classification helps one tounderstand the mechanical and bio-logic factors contributing to the causeof the nonunion and can be used todirect treatment. Hypertrophic non-unions have abundant callus. Thisindicates an adequate blood supply buta lack of sufficient mechanical stabilityfor completion of fracture-healing.Oligotrophic nonunions have little cal-

lus but still have an adequate blood sup-ply. These nonunions are typically dueto inadequate reduction with little orno contact between the fracture sur-faces. Atrophic nonunions have no orlittle callus and have resorption of thebone. They are thought to be due to adeficient biologic process.

A malunionof a fracture is a frac-ture that has healed but in a nonana-tomic position. Surgical intervention isindicated for a functional malposition,rather than a cosmetic deformity, that

is noted early in the recovery periodfollowing the initial trauma. Closefollow-up of patients with an acute tib-ial fracture and early intervention incases of developing angular deformitywill prevent most unacceptable mala-lignments associated with either earlyfracture-healing or delayed union.

Prevalence

Although reporting methods and defi-nitions have varied from author to au-

Look for this and other related articles in Instructional Course Lectures,

Volume 55, which will be published by the American Academy of Ortho-

paedic Surgeons in March 2006:

Locking Plates for Proximal Tibial Fracture, by Clifford B. Jones, MD


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thor, the prevalence of nonunion anddelayed union can be estimated fromreports published in the literature. Intwenty-two series that included a total

of 5517 fractures, the combined preva-lence of nonunion was 2.5% and thecombined prevalence of delayed unionwas 4.4%1-4,8,12-28. The studies includedseveral large series of predominantlyclosed tibial fractures caused by low-energy trauma. Open fractures withgross contamination and extensive soft-tissue damage have a higher prevalenceof nonunion and delayed union4,15,27,29.In series of open tibial fractures,Clancey et al. reported a 13% preva-lence of delayed union15, Widenfalk etal. reported a 31% prevalence of de-layed union4,and Edwards and Jaworskireported that 41% of grade-III fracturesrequired bone-grafting before unionwas achieved30. Velazco et al. reportedthat the rate of nonunion for type-IIand type-III open tibial fractures was14%27.More aggressive soft-tissue man-agement of open fractures and earlierreoperations for high-risk tibial frac-tures have led to a decrease in the preva-lence of tibial nonunion31.

Causes of Nonunion

and Delayed UnionMany factors have been associated withdelayed union or nonunion. Most arerelated to the initial injury. Others arerelated to the patients health and be-havior. Only some are within the sur-geons control. Presenting factors thathave been reported to contribute tononunion or delayed union includefracture displacement, bone loss, asso-ciated fibular fracture, comminution,and infection. The prevalence of de-layed union increases with the severity

of an open fracture18-21,23,32-35

. There is adirect correlation between the energyabsorbed by the hard and soft tissuesand complications related to wound-healing, including delayed union, non-union, infection, and skin slough36,37.The nature of the injury therefore playsa large role in determining the likeli-hood of union.

An anatomic factor that com-monly determines the rate of union oftibial fractures is the degree of preserva-

tion of the tibial blood supply. Theanatomy of the tibial blood supply hasbeen described in detail38-41.The threevascular systems that supply the tibia

are the nutrient vascular system, the pe-riosteal vascular system, and the epi-physeal-metaphyseal vascular system.The nutrient and periosteal vascularsystems are the most important with re-gard to the healing of a tibial shaft frac-ture. The nutrient artery system, whicharises from the entrance of the posteriortibial artery into the posterior tibial cor-tex, distal to the soleal line, is divided atits origin into ascending and descend-ing branches. The nutrient vessels pro-vide the endosteal blood supply to thetibia, supplying as much as 90% of theinner cortex,as shown by Macnab38.Destruction of the endosteal blood sup-ply is most extensive when the fractureoccurs in the middle one-third of thetibia38, but the distribution of non-unions among the proximal, middle,and distal thirds of the shaft appears tobe equal7. The periosteal blood supplyreceives segmental vascular contribu-tions from the surrounding soft tissues,predominantly from the anterior tibialartery. While the posterior and lateralperiosteum has an abundant vascular

supply, the blood supply to the subcuta-neous anteromedial periosteum is lessabundant38. Rhinelander demonstratedthat the periosteal blood supply cantransiently expand to supply the entirebone if necessary40.Periosteal strippingand the resultant loss of vascular sup-ply varies with the fracture type, and in-creased periosteal stripping, as seenwith high-grade open fractures, con-tributes substantially to delayed unionor nonunion42.

Failure to properly manage tibial

fractures has been shown to increase theprevalence of delayed union and non-union. Distraction at the fracture siteand failure to adequately immobilizethe fracture are known to increase thetime to union43. Brown and Urban1, De-hne et al.2, and Sarmiento44 advocatedearly weight-bearing with cast treat-ment as a means of obtaining intermit-tent compression at the fracture site,and they reported low rates of non-union in their series. Adherence to the

principles of open fracture manage-ment, including aggressive multipledbridements, administration of anti-biotics, and rigid immobilization of

fracture fragments, has also been shownto substantially decrease the prevalenceof infection and nonunion42.

Multiple patient factors havebeen shown to contribute to delayedunion and nonunion of tibial frac-tures. One of them is malnutrition,which often goes unrecognized. Ade-quate protein is required for healing,and inadequate caloric intake has beenshown to contribute to delayed unionand nonunion45. Simple screening stud-ies such as measurement of serum al-bumin levels and total lymphocytecounts can be performed routinely,even for patients who are not visiblymalnourished. Albumin levels of


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Oblique views are especially helpful foridentifying ununited fractures thatare poorly visualized in the frontal orsagittal plane, and they should be made

routinely for the evaluation of tibialfracture-healing.Tomography and computerized

tomography are frequently useful in theevaluation of tibial union. Traditionaltomography has long aided in this as-sessment by providing sagittal andcoronal views with a limited, and there-fore focused, field of view. Traditionaltomography units, however, are nowrarely available and, in their absence,computerized tomography has beenused to evaluate tibial union. It has hadmixed success, sometimes missing acritical ununited fracture plane54, al-though recent advances, particularlyimprovements in resolution and the ca-pacity to limit metal artifact, have madecomputerized tomography a more use-ful tool for evaluating fracture-healing.As a consequence, computerized to-mography with reconstructed viewscurrently appears to be the most usefulnon-operator-dependent methodfor the evaluation of tibial delayedunion available to most orthopaedicsurgeons55.

Ultrasound has also been usedsuccessfully in some centers to evaluatewhat is presumed to be callus produc-tion in the early healing period follow-ing tibial fractures that are at high riskfor nonunion. Figure 1 is an ultrasoundimage made two months followingreamed intramedullary nailing, withstatic locking, of a tibial shaft fracture ina patient with persistent pain over thefracture site. The image depicts a breakin the cortical continuity (red arrow),which demonstrates that the fracture

has not yet healed. The purpose of theultrasound examination is to determinewhich patients are candidates for earlysurgical intervention, thereby speedingrehabilitation while limiting the needfor secondary surgery. Moed et al. dem-onstrated that use of diagnostic ultra-sound to evaluate early tibial fracture-healing had a positive predictive valueof 97% with a narrow 95% confidenceinterval (0.9 to 1.0)56. The tibia seemsparticularly well suited for ultrasound

study because of its thin overlying softtissue, and the presence of an intra-medullary nail facilitates evaluation ofthe intervening tissue by serving as an

easily identifiable marker. When per-formed by an experienced technician,ultrasound appears to be a very helpfulprognostic aid in the evaluation of earlytibial fracture-healing following in-tramedullary nailing. The greatest limi-tation of this technique may be theexpertise and experience of the techni-cian performing the study.

Whether the tissue seen on ultra-sound examination is bona fide fracturecallus is an important consideration.With limited data to support this con-tention, the validity of an ultrasounddetermination of fracture-healing couldbe questioned despite the apparent clin-ical success of the technique. However,an animal study performed by Moed etal. indicated that there is a direct corre-lation between tissue that is presumedto be callus on ultrasound scans andactual fracture callus as determinedwith histologic examination57.

Treatment

ConsiderationsOptimal treatment of a tibial delayedunion begins with a critical assessment

of both biologic and mechanical fac-tors. The location and configuration ofthe fracture, the classification of theopen fracture, and any previous infec-tion or surgical interventions are essen-tial elements of the history. Physicalexamination determines the status ofthe soft tissue, the presence or absenceof a draining sinus, and the neurovas-cular status of the foot. Initial and cur-rent fracture alignment should beassessed clinically and with radio-graphs. Bone loss should be deter-mined, as an osseous defect limits thechoices for management.

Infection, soft-tissue defects, andmalalignment substantially alter the op-tions for treatment of tibial delayedunions. Both the biologic and mechani-cal problems must be addressed. Aclosed, uninfected delayed union withacceptable alignment requires interven-tion only to achieve union; posterolat-

Fig. 1

Ultrasound image made two months after treatment of a tibial shaft fracture with reamed in-

tramedullary nailing and static locking. The patient had persistent pain over the fracture site,

and the image depicts a break in the cor tical continuity (red arrow), which indicates that the frac-

ture has not yet healed.


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eral bone-grafting, closed reamedintramedullary nailing, and applicationof a compression plate with or withoutbone graft are all acceptable solutions to

the problem. Acceptable approaches toinfection associated with delayed unioninclude thorough dbridement andsoft-tissue coverage in addition to bonestabilization and bone-grafting.

StabilizationIntramedullary Nailing

Intramedullary nailing is the most com-mon form of stabilization currentlyused in the management of unstableacute tibial fractures. Consequently, amajority of the tibiae with a delayedunion that are encountered in currentpractice already have a tibial nail in-serted, and considerations regardingfurther treatment must take this intoaccount. Reamed intramedullarynailing has broad applications in thetreatment of uninfected tibial delayedunions that have previously been man-aged without operative intervention.Treating an infected or previously in-fected tibial delayed union with reamedtibial nailing is associated with a highrisk of infection58,59. Reports on the useof reamed intramedullary nailing in the

setting of previous infection have docu-mented a reinfection rate of 22% to38% even when union is achieved60,61.

When reamed nailing is per-formed in an uninfected tibia with a de-layed union, the autogenous graft thatis created by the reamer seems to stimu-late the fracture site and the procedureprovides greater stabilization than doesnailing without reaming. Union rates of95% to 100% have been reported in as-sociation with reamed nailing for tibialnonunions and delayed unions with no

history of infection15,62,63

. Use of lockedintramedullary nails has had the samesuccess64,65. The mean healing time fol-lowing reamed nailing in this settinghas ranged from five to nine months15,63.Unlike compression plate fixation,reamed intramedullary nailing offersthe advantage of early full function, in-cluding weight-bearing and motion ofthe adjacent joints. Fragments createdby the intraoperative reaming should besent for standard cultures to rule out

the possibility of subclinical infection.Intramedullary nailing may be an

option for an uninfected tibial fracturefor which previous surgical treatment

has failed. A previously placed nail (in-serted without reaming) or plate thathas maintained the alignment of the ca-nal facilitates reamed nailing. Labora-tory and clinical studies have validatedthis approach and have proved that, af-ter application of a plate, vascularitycan be sufficiently reestablished to allowlater intramedullary reaming66-68. It isbest to avoid soft-tissue damage whenthe plate is being removed. Removing asubcutaneous plate and screws throughmultiple small incisions may be prefera-ble to operating through a larger inci-sion, especially if skin quality is poor.Reamed intramedullary nailing has alsobeen proposed as a method of stabiliz-ing open fractures after application ofan external fixator69, with its advocatespointing out the advantages of in-tramedullary nail fixation comparedwith external fixation. However, theprevalence of infection associated withthis procedure was reported to be ashigh as 66% in one series, even with aminimum delay of three months be-tween fixator removal and reamed

nailing70. The risk of infection asso-ciated with reamed intramedullarynailing following prolonged externalfixation seems to be too high to warrantits use.

Most commonly in current prac-tice, delayed unions and nonunions oftibial shafts are associated with a previ-ously inserted intramedullary nail. Justas continued weight-bearing in an ap-propriate brace or cast will often lead tounion of a tibial fracture that is beingtreated nonoperatively, the same treat-

ment may be appropriate for fracturesthat had been initially fixed with an in-tramedullary nail. However, if uniondoes not occur relatively early and it isnot certain that it will occur if the pa-tient is managed with observationalone, the implants may fail and be-come more difficult to extract. More-over, if failure of fracture-healing isaccompanied by disability, pain, ormalalignment, continued watchfulwaiting is no longer warranted.

If the fracture is stable, removalof locking screws from one end of anintramedullary nail (known as dy-namization) might be considered.

Dynamization can be performed as anoutpatient procedure, with local anes-thesia, which lends it popularity. Theprocedure is viewed favorably by manyorthopaedic surgeons, but the value ofdynamization in the treatment of de-layed union of the tibia has been poorlydocumented. Success rates have beenthought, principally on the basis of an-ecdotal reports, to approach 50% forwell-chosen patients. In contrast,Court-Brown et al. reported that dy-namization appears to have little effecton the speed of fracture union71. Wu etal. demonstrated a 54% rate of unionof tibial and femoral fractures afterdynamization72. Although there is littleobjective evidence to support routinedynamization of tibial nails, the risksand costs of the procedure seem rela-tively minor compared with those ofmore invasive operative alternatives. Asa result, dynamization remains a rea-sonable treatment option for patientswith a tibial fracture that is well alignedand not associated with substantialbone loss.

Exchange nailing is performedby removing an existing intramedul-lary nail from the tibia, reaming themedullary canal, and inserting alarger-diameter nail. If reamed nailinghas already been performed in themedullary canal, the canal should bereamed to accommodate a nail that isat least 1 mm larger than the existingnail. If the medullary canal is large or ifthe existing intramedullary nail is par-ticularly small, then an even larger nailmay be needed, and reaming should

proceed until bone is clearly seen onthe reamers.

Exchange nailing has been rea-sonably well evaluated, with consistentfindings in the published series. Tem-pleman et al. treated twenty-eightdelayed unions or nonunions with ex-change nailing, and they achieved a93% success rate following the first pro-cedure and a 100% rate of union fol-lowing a second exchange nailing inthose patients in whom the initial ex-


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change nailing had failed73. They re-ported three malunions. Court-Brownet al. evaluated the results of exchangenailing for thirty-three tibial nonunions

and found that twenty-nine (88%)united after one exchange nailing pro-cedure and the remaining four unitedafter a single repeat exchange nailingprocedure. Both Templeman et al. andCourt-Brown et al.74 reported an unex-pectedly high rate of infection. Temple-man et al. reported three infections(11%), and Court-Brown et al. found a12% prevalence of wound sepsis, withone deep infection. Other series havedemonstrated similar findings75-76. Onthe basis of the findings in these studies,we currently recommend that the tibialnail be removed and the intramedul-lary reaming be performed before theinitiation of perioperative antibiotics.We routinely send material produced bythe intramedullary reaming to the mi-crobiology laboratory for culture andsensitivity testing, and we continue toadminister antibiotics for a prolongedperiod (usually six weeks) after surgeryif bacteria are found in the medullaryspace. Figures 2-A, 2-B, and 2-C are aseries of radiographs of a fifty-two-

year-old man in whom a closed commi-

nuted fracture of the tibial shaft with anassociated compartment syndrome wasinitially treated with four compartmentfasciotomies and reamed intramedul-lary nailing. Five months postopera-tively, the patient had persistent painover the fracture site and radiographicfindings consistent with a delayedunion. He showed no clinical signs ofinfection, and the preoperative labora-tory values were unremarkable. Hewas treated with exchange reamedintramedullary nailing. Methicillin-

resistant Staphylococcus aureus grew onculture of material produce by the med-ullary reaming. The patient was treatedwith intravenous antibiotics for sixweeks, and clinical and radiographichealing was seen two months after theprocedure.

Exchange nailing poses fewertechnical challenges than primarynailing, but several procedural issuesbear mention. First, unless a fibularmalunion prevents the achievement of

acceptable tibial alignment, thereseems to be little need to perform a fib-ular osteotomy in conjunction with thereamed exchange nailing. Second,

interlocking screws rarely seem to benecessary, and their use may be coun-terproductive in the treatment of mid-diaphyseal fractures that have beenpresent for more than three monthsand have been stabilized by a fibrousunion. However, because Templemanet al.73 reported three relatively minordistal tibial malunions followingreamed exchange tibial nailing donewithout distal interlocking screws, wehave a low threshold for insertion ofinterlocking screws for fractures nearthe metaphyseal-diaphyseal junction.

External Fixation

External fixation is the preferredmethod of stabilization for patientswith a delayed union of a tibial fracture

and a previous infection. External fixa-tion may also be considered for defini-tive fixation of grade-II and III openfractures that had not been managedearly with intramedullary fixation andfor patients with compromised softtissue77. Experimental and clinical stud-ies have shown a single-frame anteriorfixator with use of 4.5-mm or 5.0-mmhalf-pins to be an adequate device78-80.This form of external fixation providesfree wound access, allows stabilizationof bone fragments at a distance fromthe lesion, permits motion of adjacent

Fig. 2-A

Figs. 2-A, 2-B, and 2-C A closed comminuted fracture of the tibial shaft with as-

sociated compartment syndrome was treated with fasciotomies and reamed in-

tramedullary nailing in a fifty-two-year-old man. Fig. 2-A Initial postoperative

anteroposterior and lateral radiographs.


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joints, and encourages patient mobility.Pin-track drainage, reported to occur inassociation with 5% to 10% of all pinsand to be responsible for removal or al-teration of one of thirty frames, may beminimized with fastidious local care81,82.

There has been some controversyconcerning the role of internal fixationfollowing previous external fixation.Because of the risk of infection, we do

not recommend insertion of plates orperformance of reamed tibial nailingfollowing prolonged external fixation(for longer than ten to fourteen days),regardless of the condition of the softtissue. After short periods (shorter thanten to fourteen days) of external fixa-tion with dry pin sites, reamed nailingmay be performed, but it must beclearly understood that the risk of infec-tion is increased even in the absence ofprevious pin track infection. We avoid

performing reamed intramedullarynailing whenever an external fixator hasbeen in place for more than two weeks.

Compression Plates

Use of compression plates for thetreatment of closed tibial nonunionshas been advocated by Muller andThomas83,84, Rosen85, and Weber andBrunner86. Success rates with compres-

sion plates alone have been reportedto be high in the treatment of hyper-trophic nonunions, but supplementarybone-grafting is required for atrophicnonunions. Weber and Brunner re-ported union of 126 of 127 uninfectedtibial nonunions treated with compres-sion plates. Like most other forms of in-ternal and external fixation discussed inthis lecture, compression plates allowmotion of adjacent joints and preventfracture disease. Although proven

successful for the treatment of unin-fected tibial nonunions, compressionplates are load-bearing devices and donot tolerate weight-bearing until heal-ing has occurred. The risk of infectionassociated with compression plates isslightly higher than that following sim-ple cancellous bone-grafting for thetreatment of uninfected tibial non-unions and is unacceptably high for the

treatment of previously infected tibialnonunions87. We therefore preferreamed intramedullary nailing or pos-terolateral bone-grafting to compres-sion plates for the treatment of tibialnonunions that are in acceptable align-ment, but we recognize that use ofplates with or without grafting is an ac-ceptable alternative to bone-grafting.

The greatest application of com-pression plates is in the treatment ofuninfected angulated delayed unions of

Fig. 2-B

Fig. 2-B Anteroposterior and lateral radiographs made five months postoperatively demonstrate a delayed union of the tibia. Fig. 2-C Anteroposte-

rior and lateral radiographs made two months after exchange reamed intramedullary nailing demonstrate fracture union.

Fig. 2-C


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the tibia. The plate may be used to re-align the fracture if it is positioned onthe tension side of the nonunion,placed under additional tension with

an independently placed distractor,and then used as a template for fracturerealignment.

Ilizarov Technique

The Ilizarov technique has been usedfor the treatment of angulated mal-unions and failures of union associatedwith malalignment. There is consider-able enthusiasm for this approach,although the need for frequent postop-erative visits as well as a relatively highrate of pin track problems may temperenthusiasm for the technique for lesscomplicated cases. Because of its versa-tility, however, this method may be thesalvage procedure of choice for difficulttibial delayed unions that would otherwise not be amenable to functionallimb salvage. The technique may beespecially useful when shortening orcompromised soft tissues complicatethe more readily approachable simpleangulated delayed union. Considerablepreoperative planning is recommendedwhen the Ilizarov technique is used. Pa-tients requiring the Ilizarov technique

should be treated by a surgeon who isexperienced with the method.

Bone-GraftingBone-grafting techniques deal with thebiologic issues of delayed union aftermechanical stability has been ad-dressed. Bone formation is a processconsisting of osteogenesis, osteoinduc-tion, and osteoconduction. Graft os-teogenesis refers to the synthesis of newbone at the recipient site by the cellularelements within a donor graft that sur-

vive transplantation. Graft osteoinduc-tion is the process by which hostmesenchymal stem cells from the sur-rounding tissue differentiate intobone-forming osteoblasts as a result ofthe presence of proteins or chemotacticfactors within the graft that attract vas-cular ingrowth and healing. Graft os-teoconduction is the process by whichthe graft provides a scaffold on whichnew bone growth can occur. Autoge-nous bone graft, typically from the iliac

crest, remains the gold standard withwhich all other grafts and graft substi-tutes must be compared. It incorpo-rates all of the above-mentioned

properties with no associated risk ofviral transmission, but there are prob-lems with donor-site morbidity88.

Many methods of bone-graftingfor tibial defects have been described.These include multiple forms of slidingonlay grafts89-92, inlay grafts93, nonvas-cularized fibular transplants94,95, freevascularized fibular grafts96, and othertechniques for creating a tibiofibularsynostosis97,98. Cortical bone grafts havedemonstrated weakness due to the de-velopment of internal porosity. Theyincorporate within six weeks aftergrafting but remain weak for at leastsix months99. In comparative series,cortical grafts have required a longertime to achieve union and have beenassociated with more complicationsthan cancellous grafts91,100. Proposed al-ternatives to cancellous bone-graftinginclude the use of percutaneousmarrow injections101, human bonemorphogenetic protein102, platelet con-centrates103, and synthetic bone-graftsubstitutes104. Although promising, theprecise role of each of these alternatives

in a general orthopaedic practice hasyet to be defined.

Anterolateral grafting of the tibiahas been used in the past, but the prox-imity to traumatic anterior woundsincreases the rate of wound complica-tions; also, only limited amounts ofbone graft can be inserted because ofthe risk of the development of a com-partment syndrome. Posterolateralgrafting is the preferred technique inthe middle and distal thirds of thetibia105,106, whereas posteromedial bone-

grafting is preferable in the proximalthird of the tibia because of the prox-imity to the neurovascular structureswith the posterolateral approach107.Several large series in which cancellousbone-grafting had been used for tibialnonunions have demonstrated unionrates of 87% to 100%5,19,108-114. Similarrates of success might be anticipatedfor the treatment of delayed unions,but the results for delayed unions havenot been as extensively documented.

Complications of posterolateral bone-grafting, which are uncommon, in-clude stiffness, deformity, and loss ofankle motion. These complications

have been ascribed to the initial injury,but they may be aggravated by theadditional, prolonged immobilizationassociated with bone-grafting. Pares-thesias on the sole of the foot and de-layed vascular impairment have alsobeen reported but seem to be rare5,111.Formation of a synostosis has been as-sociated with, but is not clearly thecause of, ankle pain9. Because thesecomplications are uncommon and theunion rate after posterolateral bone-grafting is high, the procedure is usedin conjunction with other proceduresto treat angulated or infected delayedunions.

Posterolateral Bone-Grafting

The posterolateral approach to the tibiacan be performed with the patient inthe lateral or prone position. Either po-sition allows a two-team approach; onesurgeon can begin harvesting the bonegraft from the iliac crest while the otherbegins the approach to the tibia. Thistwo-team approach decreases the oper-ating time and provides maximum ex-

posure of the posterior iliac crest andposterior part of the tibia.

A generous skin incision is made10 cm proximal to and 10 cm distal tothe level of the nonunion. The dissec-tion proceeds longitudinally, medial tothe palpable border of the fibula, be-tween the gastrocnemius-soleus andflexor hallucis longus and the peronealmuscles. After the fascia of the soleushas been entered, a fixed palpable fasciaon the anteromedial border of the fib-ula provides a landmark for the next

level of dissection. Lateral stripping ofthe peroneal muscles from the fibulashould be avoided as this unnecessarilycompromises the regional blood supply.The soleus and flexor hallucis longusmuscles are reflected with use of a peri-osteal elevator. The posterior compart-ment is elevated free from the fibulawith care taken to avoid inadvertent en-try into the posterior tibial compart-ment, which could injure the posteriortibial neurovascular bundle. Once the


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appropriate plane has been entered, thedissection extends to the nonunion site,which frequently is encased in scar tis-sue. At this point, the posterior tibial

compartment is lifted off of the in-terosseous membrane with a periostealelevator, exposing the nonunion site.

After the nonunion has beenidentified, the tibia is assessed proxi-mally and distally to ensure that thereis viable bleeding cortical bone. Tis-sue from the nonunion site should besent for culture before systemic anti-biotics are initiated. Once all nonvia-ble tissue has been dbrided, theproximal and distal cortical bone canbe shingled with an osteotome toaid in revascularization, and the har-vested bone graft is packed into thenonunion site. After the bone graft isin place, a suction drain is placed, thesoleus fascia is loosely closed to theperoneal fascia to hold the bone graftin position, and the skin is closed.

Delayed Union Associatedwith Bone DefectsLarge segmental defects of the tibia areusually the result of severe open tibialfractures, the treatment of which is of-ten associated with severe contamina-

tion, neurologic and vascular injury,and polytrauma. One approach to theselarge segmental defects includes initialsurgical dbridement, stable externalfixation, and soft-tissue coverage withlate massive posterolateral cancellousbone-grafting. With this approach, asynostosis can be created proximallyand distally with internal fixation ofthe fibula to provide a strut for bone-grafting procedures. It may take two

years and multiple bone-grafting proce-dures to achieve a stable functional

union. Intramedullary nailing and tibialplate fixation are associated with ahigher risk of infection and are there-fore not used in this setting. Althoughtreatment is prolonged and multiplehospitalizations and bone-grafting pro-cedures are required, massive postero-lateral bone-grafting continues to be aviable alternative for the treatment ofsome patients with severe segmentalbone loss. It is the only technique withan acceptable rate of success that can be

used without specialized instrumenta-tion and training.

Ilizarov Technique

Recently, segmental defects have beentreated most effectively with theIlizarov technique of corticotomy andbone transport. Available reports of theresults of this technique have been en-thusiastic and promising115-117. Therehave been several reports on relativelysmall series with sufficient follow-upfor a critical evaluation of the out-comes and complication rate associ-ated with this technique115,118-121. Becausethe Ilizarov technique is substantiallydifferent from other available methodsfor treating segmental bone loss, asteep learning curve must be expected.It is recommended that a surgeon re-ceive formal training in the techniquebefore proceeding with any Ilizarovprocedure. A relatively high rate ofpin-track problems and other, poten-tially more serious complicationsshould be anticipated, and a good an-cillary medical support network ishighly recommended.

Adjuncts to Enhance Bone-Healingof Tibial Delayed Unions

Electrical StimulationElectrical stimulation has been pro-posed as a nonoperative alternative forestablished nonunions122,123. There isconsiderable laboratory and clinical ev-idence suggesting that electrical stimu-lation enhances fracture-healing. Threeforms of electrical stimulation havebeen used clinically. The method inwhich the stimulation device is totallyimplanted, championed by Paterson123,is the only form that permits weight-bearing. Two surgical procedures, one

for implantation and a second for re-moval, are required, and the union ratehas been reported to be 75% to 89% ofall nonunions, including those of thetibia. Complications have included de-layed wound-healing, infection, brokenwires, soft-tissue reaction around thegenerator, and protrusion of the cath-ode wire through the skin122,123.

The percutaneous, or semi-invasive, method developed by Brigh-ton et al.122,124,125 involves percutaneous

insertion of the cathode directly intothe nonunion site, which requires drill-ing across one bone cortex or fragment.Weight-bearing is prohibited during

the first twelve weeks of treatment

123

.Complications in Brightons series in-cluded pin-track infection (13.8%),broken wires (13%), recurrent osteo-myelitis (4.2%), cathode dislodgement(3.6%), and failure of the batterypack124. The corrected union rate(excluding patients for whom the elec-tricity was suboptimal or in whomthe nonunion gap was greater than halfthe bone diameter) was reported to be80% for tibial nonunions124.

Bassett et al. developed a nonin-vasive system for application of pulsingelectromagnetic fields126-128. The methodrequires non-weight-bearing and iscontraindicated for patients with a non-union gap of >1 cm126. The tibial unionrate was reported to be 82% to 87% af-ter the use of this technique. No com-plications other than those associatedwith prolonged non-weight-bearingand immobility were recorded.

To our knowledge, only one pro-spective double-blind study of electri-cal stimulation has been published129,130.Although there is some evidence that

delayed unions show earlier radio-graphic evidence of union when anelectrical stimulator is applied, it hasbeen difficult to demonstrate the clini-cal benefit of a functioning electricalstimulator over a nonfunctioningstimulator129,130. The invasive approach,the only one that allows weight-bearing,requires a minimum of two operativeinterventions and its success rate islower than that associated with use of asingle posterolateral bone graft. Pend-ing proof of the clinical effectiveness of

electrical stimulation in a prospectivedouble-blind study, we cannot recom-mend electrical stimulation for treat-ment of tibial delayed unions.

Ultrasound

Ultrasound has been proven to en-hance the healing of fresh closed tibialfractures131,132, and it may be effective forthe treatment of some tibial delayedunions. Because ultrasound has notbeen proven to be effective for fractures


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stabilized with an intramedullary nail,however, it may have a diminished rolein the treatment of tibial delayedunions.

Biologic Adjuncts

In comparison with other currentlyavailable adjuncts, bone morphoge-netic protein (BMP) may have a moresubstantial role to play in the treat-ment of tibial nonunions and, perhaps,of delayed unions as well. Recombi-nant human bone morphogeneticprotein-7 (rhBMP-7) was shown topromote union in a prospective, ran-domized, controlled study of 122patients with a total of 124 tibialnonunions133. All of the nonunionswere at least nine months old and hadshown no progress toward healing forthree months. Each patient had beentreated with an intramedullary nail aswell as with rhBMP-7 in a type-1 col-lagen carrier or with autogenous bonegraft. At nine months postoperatively,81% of the patients treated with rh-BMP-7 and 85% of those treated withautogenous bone graft were judged tohave bone-healing according to clinicalcriteria and 75% and 85%, respec-tively, were judged to have radio-

graphic evidence of healing. Theseresults suggest that BMP is as effectiveas autogenous bone graft in the treat-ment of tibial nonunion and that itcould be similarly effective in the treat-

ment of tibial delayed union.Another recent, Level-I study

demonstrated evidence that BMP couldbe effective earlier in the treatment of

tibial fractures that have a relativelyhigh risk of nonunion. A series of 450patients with an open tibial shaft frac-ture were treated with recombinant rh-BMP-2 (0.75 mg/kg or 1.50 mg/kg onan absorbable collagen sponge) as wellas a locked intramedullary nail at thetime of wound closure and or weretreated with a locked intramedullarynail alone (control group)134. At twelvemonths, the group treated with thehigher rhBMP dose (1.50 mg/kg) had ahigher rate of fracture-healing, a 44%reduction in the risk of secondary in-terventions, fewer hardware failures,fewer infections, and faster wound-healing compared with the controlgroup. BMP has clearly shown promisewith regard to early enhancement ofhealing of problem tibial fractures. Bet-ter identification of patients who arelikely to benefit from the application ofBMP in the course of fracture-healingseems likely.

Overview

Delayed union of the tibia represents a

diverse group of clinical problems thatcan at times be challenging even in themost experienced hands. Early recogni-tion and treatment can save patientsfrom prolonged periods of pain and

disability. Although multiple treatmentoptions are available, most delayedunions can be managed by nonspecial-ist orthopaedic surgeons using simple

methods. Treatment must take into ac-count the biologic and mechanical fac-tors contributing to the delay infracture union.

Laura S. Phieffer, MDDepartment of Orthopaedic Surgery, TheOhio State University, N1037 Doan Hall, 410West 10th Avenue, Columbus, OH 43210

James A. Goulet, MDDepartment of Orthopaedic Surgery, Uni-versity of Michigan Medical School, 1500East Medical Center Drive, Ann Arbor, MI48109-0328

The authors did not receive grants or outsidefunding in support of their research for orpreparation of this manuscript. They did notreceive payments or other benefits or a com-mitment or agreement to provide such benefitsfrom a commercial entity. No commercial en-tity paid or directed, or agreed to pay or direct,any benefits to any research fund, foundation,educational institution, or other charitable ornonprofit organization with which the authorsare affiliated or associated.

Printed with permission of the AmericanAcademy of Orthopaedic Surgeons. This arti-

cle, as well as other lectures presented at theAcademys Annual Meeting, will be available inMarch 2006 in Instructional Course Lectures,Volume 55. The complete volume can be or-dered online at www.aaos.org, or by calling800-626-6726 (8 A.M.-5 P.M., Central time).

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Tibial Delayed Union