Non-union
What is Non-union?
Non-union refers to a situation where a fractured bone fails to heal despite appropriate treatment. There are several reasons why bones do not go on to heal. The factors that may result in failure of bone healing can be mechanical and biological. Mechanical factors include way the fracture is fixed, and the stiffness of the implants used. Bone heals best when the mechanical environment is optimised. Non-union may result may if the construct does not provide enough stability or if the construct is too stiff. Another important factor in bone healing is the biology of the fracture. If there is damage to the bone’s blood supply from the injury or subsequent surgery, the bone may not be able to heal without surgery. Other important biological factors include the presence of infection, poor soft tissues around the fracture or a lack of the essential building blocks needed for healing, for example due to poor dietary intake or vitamin deficiencies. In reality there are usually a combination of reasons that prevent bone healing, and we term this interplay between the two element as biomechanical factors.
How to manage non-union
Non-union can be very frustrating for patients as they often report feeling stuck, unable to make progress in their recovery. Furthermore, they often report that when their recovery does not progress as expected sometime their treating team is a but unsure about what to do. Managing non-union requires a comprehensive approach aimed at addressing the underlying causes of delayed or failed bone healing and promoting bone union. Here’s an overview of the strategies the Oxford Limb Reconstruction and Infection Clinic uses for the management of non-union:
Evaluation and Diagnosis
Clinical Assessment: We perform a comprehensive evaluation of the the medical history, including details of the initial injury and prior treatments to ensure we identify all risk factors that need to be addressed to achieve a successful outcome. Pre-operative optimisation is a crucial element to getting go outcomes from surgery.
Imaging Studies: We will recommend what imaging studies might be helpful in guiding management. Often, we can organise the transfer of images taken in other centres to avoid duplication of these tests. X-rays are the most useful imaging test in the assessment of non-union and can give a lot of useful information about the progress of healing, the alignment of the bone and the state of the implants used to fix the fracture. Sometimes other test might be useful, such as CT scans, or MRI to assess the extent of bone healing, or look for signs of bone infection. If these are thought to be necessary, we can discuss this at your initial assessment review.
Addressing Contributing Factors
Correcting Biomechanical Issues: Addressing malalignment, instability, or inadequate fixation that may hinder bone healing.
Optimizing Nutrition: Ensuring adequate intake of nutrients essential for bone healing, such as protein, calcium, vitamin D, and vitamin C.
Managing Systemic Factors: Addressing underlying medical conditions (e.g., diabetes, osteoporosis) or lifestyle factors (e.g., smoking) that may impair bone healing.
Surgical Interventions
There are several different surgical options which are based on the circumstances of each case. We will be able discuss the various options with you in the clinic and decide together the best way of moving forward.
Excision of non-vital tissue: Removal of fibrous tissue, necrotic bone, or non-viable tissue from the fracture site to promote a healthy environment for bone healing. We aim to improve the blood supply to the fracture end to support healing.
Stabilization: Providing stable fixation of the fracture using internal fixation devices (plates, screws, rods), external fixators, or intramedullary nails to facilitate bone union.
Bone Grafting: Adding bone graft material to the fracture site to stimulate new bone formation and enhance healing. This may involve autografts (from the patient’s own bone), or synthetic bone substitutes.
Biological Augmentation: Use of growth factors, bone morphogenetic proteins (BMPs), or other biologically active substances to stimulate bone healing.
Addressing bone gaps: In cases of segmental bone loss when there is a gap in the bone following excision, there are several options to address this. One option is the use of bone transport techniques using external fixators or internal devices that allow gradual lengthening of the bone which results in regeneration bone and bridge the defect. We also use other techniques, such as microvascular transfer of bone, but all options will be discussed to support your decision-making in choosing the best option for you.
Postoperative Care and Rehabilitation
Physical Therapy: This is a key element for successful outcome, and we work hard with you to initial early mobilization and range of motion exercises to prevent joint stiffness and promote functional recovery.
Weight-bearing: We try and achieve early weight-bearing in most cases we treat. Almost all our patients can bear at least 50% of their body weight through the limb after surgery, but each case will receive a bespoke guide to their recover following surgery.
Wound Care: Initial follow up will focus on ensuring there is good ongoing wound healing this allow us to address any problems promptly and avoid bigger issues caused by undue delay.
Multi-disciplinary follow up: In all non-union surgery we will look to exclude associated risk factors, such as infection. Therefore, additional tests to exclude infection are performed during surgery. Follow-up will look to ensure this issue is fully addressed and monitored.
Monitoring and Follow-Up
Radiographic Evaluation: Regular follow-up imaging is undertaken (usually using X-rays) to monitor bone healing progress and assess the stability of fixation devices.
Clinical Assessment: Monitoring of symptoms, signs of infection, and functional outcomes to ensure successful bone healing and rehabilitation.
Follow-up until healing achieved: We would usually continue follow-up until healing has been achieved. In some situations, the implants used for fixation might cause some ongoing issues and these can be removed if requested.
Managing non-union requires a systematic approach tailored to the individual patient’s needs, addressing contributing factors, providing stable fixation, promoting bone healing, and facilitating rehabilitation. The Oxford Limb Reconstruction and Infection Clinic can deliver good outcomes for patients with non-union, even in complex cases, through its close collaboration between the surgical team, physical therapists, and other healthcare providers.
Contact Us
If you’re concerned about symptoms or need more information, please don’t hesitate to contact the Oxford Limb Reconstruction and Infection Clinic. We’re here to help you understand your condition and explore the best treatment options.