Nonunion has been confirmed by CT scan after 9 months both in tibia and fibula. Patient is age thirty and suffered a high energy trauma in a car accident. Last month she complained of pain increase and a radiograph showed both plates are broken. The fracture site is too distal for a nail. Any advice?
I´d recommend circular frame - with foot plate if very distal
(with/without neutralizing frame for unloading the foot)
Best regards!
Peter H. Thaller
It would have been great to see the xrays. Nine months, implant failure: if atrophic nonunion with lot of sclerosis and closed medulla, need freshening, cancellous bone graft and LCP. If no atrophy, insitu ring fixator. If fibula # is very distal, needs refixation and bone graft. Best wishes
excision of non union,acute docking,application of ilizarov and corticotomy and bone lengthening would be ideal
Dependingon the quality of bone and involvement of the subtalar joint, my first choice would be to add autologous bone graft and redo the fixation if loose or broken hardware.
Difficult to be specific without seeing the X rays. However, the principles are:
1. Rule out infection - inflammatory markers, isotope bone scan
2. Optimise the patient's biology - stop smoking, avoid NSAIDs, control diabetes
3. Refixation with plate(s) is better if the soft tissues are good, if the fracture is oblique (can achieve absolute stability with lag screw + neutralisation plate). Refixation with frame is better if soft tissues are in poor condition and/or fracture is transverse.
4. You only need to take the fracture down / use bone graft or bone substitutes if it is an atrophic non-union. If it is hypertrophic you just need more mechanical stability. The CT will tell you this.
5. Make friends with your local plastic surgeon in case things go wrong with the soft tissues!
Hardware removal as well as debridement at the nonunion site along with sample collection for culture. Then, compressive osteosynthesis with ilizarov-type circular frame with the option of bone elongation in order to avoid any length discrepancy.
The most likely problem you will encounter is that there will be little bone left after debridement of the distal tibia. Ffixation of the distal fragment will be difficult or impossible. Be prepared for tibio-talar fusion using the circular fixator. Tthe foot will need to be incorporated into the fixator; you will need a foot plate
it's necessary to my opinion to see x rays and to have idea about tibio-talar joint, skin and soft tissues before to propose a solution.
It is a pity that no X-rays are available. However, I understand that this complex fracture could be classified as a "pilon" one with all the problems accompanying this severe injury. Additionaly, there is a plate debricolage and non-union. One can imagine that there are serious intrarticular canges in the talocrural joint. If this is the case, I would recommend removal of all plates and screws, debridement, autologous grafts and arthrodesis of the talocrural joint. The alignment should be maintained by fixateur externe (Ilizarov), including leg and foot.
If any infection is excluded bonegraft in combination with BMP might be helpful, as well as a good compression by using a combination of lag srew(s) and plate(s). The latter suggestion depends on the soft tissue-conditions.
Ilizarov external fixation with autologous bone grafting and evaluation of general conditions of the patient. If this is not successful talocrural arthrodesis.
There are so many options... But impossible to decide without seeing an X-Ray. But I would never use that kind of bone substitute in this area without autologous bone grafting / RIA
Usually we see a atrophied type of non union here. I would go for absolute stability with plating and bone grafting if soft tissue is good. Otherwise ilizarov is best.
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