Acta Chir Orthop Traumatol Cech. 2016; 83(6):367-374 | DOI: 10.55095/achot2016/059

Treatment of Tibial Non-Unions - State of the Art and Future ImplicationsCurrent concepts review

S. MÄRDIAN1,*, M. GIESECKE1, F. HASCHKE1, S. TSITSILONIS1, B. WILDEMANN2, P. SCHWABE1
1 Charité - University Medicine Berlin, Centre for Musculoskeletal Surgery, Berlin, Germany
2 Charité - University Medicine Berlin, Julius Wolff Institute for Biomechanics and Musculoskeletal Regeneration, Berlin, Germany

Although fracture healing disturbances could be decreased due to successful concepts for fracture treatment, bone healing disturbances occur in 5-10% of the cases. The anatomical region of the lower limb predisposes the tibia for bone healing disturbances. Reports about the incidence of non-unions of the tibial shaft are inhomogeneous. Different treatment strategies have been published which depend on the type of non-union as well as the history of the patient. These range from conservative approaches to complex procedures including segmental resection and bone transport. This review aimed to summarize the state of the art treatment of tibial non-unions and report about recent basic research results that may improve bone healing.

Keywords: tibial non-unions, treatment strategies, bone healing

Published: December 1, 2016  Show citation

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MÄRDIAN S, GIESECKE M, HASCHKE F, TSITSILONIS S, WILDEMANN B, SCHWABE P. Treatment of Tibial Non-Unions - State of the Art and Future Implications. Acta Chir Orthop Traumatol Cech. 2016;83(6):367-374. doi: 10.55095/achot2016/059. PubMed PMID: 28026731.
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    References

    1. Altman RD, Latta LL, Keer R, Renfree K, Hornicek FJ, Banovac K. Effect of nonsteroidal antiinflammatory drugs on fracture healing: a laboratory study in rats. J Orthop Trauma. 1995;9:392-400. Go to original source... Go to PubMed...
    2. Amanat N, McDonald M, Godfrey C, Bilston L, Little D.. Optimal timing of a single dose of zoledronic acid to increase strength in rat fracture repair. J Bone Miner Res. 2007; 22:867-876. Go to original source... Go to PubMed...
    3. Bellabarba C, Ricci WM, Bolhofner BR. Results of indirect reduction and plating of femoral shaft nonunions after intramedullary nailing. J Orthop Trauma. 2001;15:254-263. Go to original source... Go to PubMed...
    4. Bhandari M, Guyatt GH, Swiontkowski MF, Tornetta P 3rd, Sprague S, Schemitsch EH.. A lack of consensus in the assessment of fracture healing among orthopaedic surgeons. J Orthop Trauma. 2002;16:562-566. Go to original source... Go to PubMed...
    5. Biasibetti A, Aloj D, Di Gregorio G, Massè A, Salomone C. Mechanical and biological treatment of long bone non-unions. Injury. 2005;36(Suppl 4):S45-50. Go to original source... Go to PubMed...
    6. Blokhuis TJ, Calori GM, Schmidmaier G. Autograft versus BMPs for the treatment of non-unions: What is the evidence? Injury. 2013;44(Suppl 1):S40-S42. Go to original source... Go to PubMed...
    7. Bodde EW, Kowalski RS, Spauwen PH, Jansen JA. No increased bone formation around alendronate or omeprazole loaded bioactive bone cements in a femoral defect. Tissue Eng Part A. 2008;14: 29-39. Go to original source... Go to PubMed...
    8. Bode G, Strohm PC, Südkamp NP, Hammer TO.. Tibial shaft fractures - management and treatment options. A review of the current literature. Acta Chir Orthop Traumatol Cech. 2012;79:499-505. Go to original source... Go to PubMed...
    9. Bosemark P, Isaksson H, McDonald MM, Little DG, Tägil M.. Augmentation of autologous bone graft by a combination of bone morphogenic protein and bisphosphonate increased both callus volume and strength. Acta Orthop. 2013;84:106-111. Go to original source... Go to PubMed...
    10. Bowen CV, Botsford DJ, Hudak PL, Evans PJ. Microsurgical treatment of septic nonunion of the tibia. Quality of life results. Clin Orthop Relat Res. 1996;332:52-61. Go to original source... Go to PubMed...
    11. Brinker MR, Hanus BD, Sen M, O'Connor DP. The devastating effects of tibial nonunion on health-related quality of life. J Bone Joint Surg Am. 2013;95:2170-2176. Go to original source... Go to PubMed...
    12. Brinker MR, O'Connor DP. Nonunions: Evaluation and treatment. In: Browner BD, Jupiter JB, Levine AM, Trafton PG (Eds). Skeletal trauma: Basic science management and reconstruction. 2009, Philadelphia, Saunders W. B., pp.615-708.
    13. Calori GM, Albisetti W, Agus A, Iori S, Tagliabue L.. Risk factors contributing to fracture non-unions. Injury. 2007;38(Suppl 2): S11-18. Go to original source... Go to PubMed...
    14. Calori GM, Phillips M, Jeetle S, Tagliabue L, Giannoudis PV. Classification of non-union: need for a new scoring system? Injury. 2008;39(Suppl 2):S59-63. Go to original source... Go to PubMed...
    15. Carofino BC, Lieberman JR. Gene therapy applications for fracture-healing. J Bone Joint Surg Am. 2008;90(Suppl 1):99-110. Go to original source... Go to PubMed...
    16. Coles CP, Gross M. Closed tibial shaft fractures: management and treatment complications. A review of the prospective literature. Can J Surg. 2000;43:256-262.
    17. Day SM, DeHeer DH. Reversal of the detrimental effects of chronic protein malnutrition on long bone fracture healing. J Orthop Trauma. 2001;15:47-53. Go to original source... Go to PubMed...
    18. Dimitriou R, Carr IM, West RM, Markham AF, Giannoudis PV.. Genetic predisposition to non-union: evidence today. Injury. 2013;4(Suppl 1):S50-53. Go to original source... Go to PubMed...
    19. Einhorn T.A. Enhancement of fracture-healing. J Bone Joint Surg Am. 1995;77:940-956. Go to original source... Go to PubMed...
    20. Finkemeier CG, Schmidt AH, Kyle RF, Templeman DC, Varecka TF. A prospective randomized study of intramedullary nails inserted with and without reaming for the treatment of open and closed fractures of the tibial shaft. J Orthop Trauma. 2000;14:187-193. Go to original source... Go to PubMed...
    21. Fong K, Truong V, Foote CJ, Petrisor B, Williams D, Ristevski B, Sprague S, Bhandari M. Predictors of nonunion and reoperation in patients with fractures of the tibia: an observational study. BMC Musculoskelet Disord. 2013. 14:103. Go to original source... Go to PubMed...
    22. Frolke JP, Patka P. Definition and classification of fracture non-unions. Injury. 2007;38(Suppl 2):S19-22. Go to original source... Go to PubMed...
    23. Gao KD, Huang JH, Li F. Treatment of aseptic diaphyseal nonunion of the lower extremities with exchange intramedullary nailing and blocking screws without open bone graft. Orthop Surg. 2009;1:264-268. Go to original source... Go to PubMed...
    24. Garrison KR, Shemilt I, Donell S, Ryder JJ, Mugford M, Harvey I, Song F, Alt V. Bone morphogenetic protein (BMP) for fracture healing in adults. Cochrane Database Syst Rev. 2010(6): CD006950. Go to original source...
    25. Giannoudis PV, Einhorn TA, Marsh D. Fracture healing: the diamond concept. Injury. 2007;38(Suppl 4):S3-6. Go to original source... Go to PubMed...
    26. Giannoudis PV, Einhorn TA, Schmidmaier G, Marsh D. The diamond concept-open questions. Injury. 2008;39(Suppl 2):S5-8. Go to original source... Go to PubMed...
    27. Giannoudis PV, Gudipati S, Harwood P., Kanakaris N. Long bone non-unions treated with the diamond concept: a case series of 64 patients. Injury. 2015;46(Suppl 8):S48-54. Go to original source... Go to PubMed...
    28. Giannoudis PV, Kanakaris NK, Dimitriou R, Gill I, Kolimarala V, Montgomery RJ. The synergistic effect of autograft and BMP-7 in the treatment of atrophic nonunions. Clin Orthop Relat Res. 2009; 467(12):3239-3248. Go to original source... Go to PubMed...
    29. Giannoudis PV, MacDonald DA, Matthews SJ, Smith RM, Furlong AJ, De Boer P. Nonunion of the femoral diaphysis. The influence of reaming and non-steroidal anti-inflammatory drugs. J Bone Joint Surg Br. 2000;82(5):655-658. Go to original source...
    30. Greiner S, Wildemann B, Back DA, Alidoust M, Schwabe P, Haas NP, Schmidmaier G. Local application of zoledronic acid incorporated in a poly(D L-lactide)-coated implant accelerates fracture healing in rats. Acta Orthop. 2008;79(5):717-725. Go to original source... Go to PubMed...
    31. Guarniero R, de Barros Filho TE, Tannuri U, Rodrigues CJ, Rossi JD. Study of fracture healing in protein malnutrition. Rev Paul Med. 1992;110(2):63-68. Go to PubMed...
    32. Gustilo R., Anderson JT. JSBS classics. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones. Retrospective and prospective analyses. J Bone Joint Surg Am. 2002;84:682. Go to original source... Go to PubMed...
    33. Harding AK, Dahl AW, Geijer M, Toksvig-Larsen S, Tagil M. A single bisphosphonate infusion does not accelerate fracture healing in high tibial osteotomies. Acta Orthop. 2011;82:465-470. Go to original source... Go to PubMed...
    34. Hausman MR, Schaffler MB, Majeska RJ. Prevention of fracture healing in rats by an inhibitor of angiogenesis. Bone. 2001;29:560-564. Go to original source... Go to PubMed...
    35. Heckman JD, Ryaby JP, McCabe J, Frey JJ, Kilcoyne RF.. Acceleration of tibial fracture-healing by non-invasive low-intensity pulsed ultrasound. J Bone Joint Surg Am. 1994;76:26-34. Go to original source... Go to PubMed...
    36. Ilizarov GA. Ledyaev VI. The replacement of long tubular bone defects by lengthening distraction osteotomy of one of the fragments. 1969. Clin Orthop Relat Res. 1992;280:7-10. Go to original source...
    37. Johnson EE. Buckley RC. Chronic infection and septic nonunion. In: Ruedi T, Buckley RC, Moran AG (Eds). AO principles of fracture management. 2007, Georg Thieme Verlag: Stuttgart New York.
    38. Khatod M, Botte MJ, Hoyt DB, Meyer RS, Smith JM, Akeson WH. Outcomes in open tibia fractures: relationship between delay in treatment and infection. J Trauma. 2003;55:949-954. Go to original source... Go to PubMed...
    39. Kloen P, Lauzier D, Hamdy RC. Co-expression of BMPs and BMP-inhibitors in human fractures and non-unions. Bone. 2012;51:59-68. Go to original source... Go to PubMed...
    40. Macey LR, Kana SM, Jingushi S, Terek RM, Borretos J, Bolander ME. Defects of early fracture-healing in experimental diabetes. J Bone Joint Surg Am. 1989;71:722-733. Go to original source... Go to PubMed...
    41. Manolagas SC, Weinstein RS. New developments in the pathogenesis and treatment of steroid-induced osteoporosis. J Bone Miner Res. 1999;14:1061-1066. Go to original source... Go to PubMed...
    42. Mardian S, Schaser KD, Duda GN, Heyland M. Working length of locking plates determines interfragmentary movement in distal femur fractures under physiological loading. Clin Biomech. (Bristol Avon) 2015;30:391-396. Go to original source... Go to PubMed...
    43. Masquelet AC, Begue T. The concept of induced membrane for reconstruction of long bone defects. Orthop Clin North Am. (table of contents) 2010;41:27-37. Go to original source... Go to PubMed...
    44. Matos MA, Tannuri U, Guarniero R. The effect of zoledronate during bone healing. J Orthop Traumatol. 2010;11:7-12. Go to original source... Go to PubMed...
    45. McKee MD, Ochsner PE. Aseptic nonunion. In: Ruedi T, Buckley RC, Moran CG (Eds). AO principles of fracture management 2007, Stuttgart, New York, Georg Thieme Verlag.
    46. Minkwitz S, Fassbender M, Kronbah Z, Wildemann B. Longitudinal analysis of osteogenic and angiogenic signaling factors in healing models mimicking atrophic and hypertrophic non-unions in rats. PLoS One. 2015;10:e0124217. Go to original source... Go to PubMed...
    47. Moghaddam-Alvandi A, Zimmermann G, Büchler A, Elleser C, Biglari B, Grützner PA, Wölfl CG. [Results of nonunion treatment with bone morphogenetic protein 7 (BMP-7)]. Unfallchirurg. 2012;115:518-526. Go to original source... Go to PubMed...
    48. Moghaddam-Alvandi A, Zimmermann G, Hammer K, Bruckner T, Grützner PA, von Recum J. Cigarette smoking influences the clinical and occupational outcome of patients with tibial shaft fractures. Injury. 2013;44:1670-1671. Go to original source... Go to PubMed...
    49. Moghaddam A, Zietzschmann S, Bruckner T, Schmidmaier G. Treatment of atrophic tibia non-unions according to 'diamond concept': Results of one- and two-step treatment. Injury. 2015;46 (Suppl 4):S39-50. Go to original source... Go to PubMed...
    50. Nadkarni B, Srivastav S, Mittal V, Agarwal S.. Use of locking compression plates for long bone nonunions without removing existing intramedullary nail: review of literature and our experience. J Trauma. 2008;65:482-486. Go to original source... Go to PubMed...
    51. Nolte PA, van der Krans A, Patka P, Janssen IM, Ryaby JP, Albers GH. Low-intensity pulsed ultrasound in the treatment of nonunions. J Trauma. 2001;51:693-702, discussion 702-703. Go to original source... Go to PubMed...
    52. Perlman MH. Thordarson DB. Ankle fusion in a high risk population: an assessment of nonunion risk factors. Foot Ankle Int.1999;20:491-496. Go to original source... Go to PubMed...
    53. Pneumaticos SG, Panteli M, Triantafyllopoulos GK, Papakostidis C, Giannoudis PV. Management and outcome of diaphyseal aseptic non-unions of the lower limb: a systematic review. Surgeon. 2014;12:166-175. Go to original source... Go to PubMed...
    54. Reed AA, Joyner CJ, Brownlow HC, Simpson AH. Human atrophic fracture non-unions are not avascular. J Orthop Res. 2002;20:593-599. Go to original source... Go to PubMed...
    55. Rosen H. Compression treatment of long bone pseudarthroses. Clin Orthop Relat Res. 1979;138:154-166.
    56. Roussignol X, Currey C, Duparc F, Dujardin F. Indications and results for the Exogen ultrasound system in the management of non-union: a 59-case pilot study. Orthop Traumatol Surg Res. 2012;98:206-213. Go to original source... Go to PubMed...
    57. Ruschke K, Hiepen C, Becker J, Knaus P. BMPs are mediators in tissue crosstalk of the regenerating musculoskeletal system. Cell Tissue Res 2012;347:521-544. Go to original source... Go to PubMed...
    58. Santolini E, West R, Giannoudis PV. Risk factors for long bone fracture non-union: a stratification approach based on the level of the existing scientific evidence. Injury. 2015;46(Suppl 8):S8-s19. Go to original source... Go to PubMed...
    59. Schmidmaier G, Moghaddam A. [Long Bone Nonunion]. Z Orthop Unfall. 2015;153:659-674; quiz 675-676. Go to original source... Go to PubMed...
    60. Schmidmaier G, Schwabe P, Strobel C, Wildemann B. Carrier systems and application of growth factors in orthopaedics. Injury. 2008;39(Suppl 2):S37-43. Go to original source... Go to PubMed...
    61. Schmitz MA, Finnegan M, Natarajan R, Champine J. Effect of smoking on tibial shaft fracture healing. Clin Orthop Relat Res. 1999;365:184-200. Go to original source... Go to PubMed...
    62. Schoierer O, Bloess K, Bender D, Burkholder I, Kauczor HU, Schmidmaier G, Weber MA. Dynamic contrast-enhanced magnetic resonance imaging can assess vascularity within fracture non-unions and predicts good outcome. Eur Radiol. 2014;24:449-459. Go to original source... Go to PubMed...
    63. Schwabe P, Greiner S, Ganzert R, Eberhart J, Dähn K, Stemberger A, Plank C, Schmidmaier G, Wildemann B. Effect of a novel nonviral gene delivery of BMP-2 on bone healing. Scientific-WorldJournal. 2012;2012:560142. Go to original source... Go to PubMed...
    64. Seeherman H, Wozney JM. Delivery of bone morphogenetic proteins for orthopedic tissue regeneration. Cytokine Growth Factor Rev 2005;16:329-345. Go to original source... Go to PubMed...
    65. Stafford PR, Norris BL. Reamer-irrigator-aspirator bone graft and bi Masquelet technique for segmental bone defect nonunions: a review of 25 cases. Injury. 2010;41(Suppl 2):S72-77. Go to original source... Go to PubMed...
    66. Urist MR. Bone: formation by autoinduction. Science. 1965;150:893-899. Go to original source... Go to PubMed...
    67. Weber BG, Cech O. Pseudarthrosis:Pathology biomechanics therapie results. 1976, Switerland, Hans Huber Medical Publisher
    68. Westhauser F, Zimmermann G, Moghaddam S, Bruckner T, Schmidmaier G, Biglari B, Moghaddam A. Reaming in treatment of non-unions in long bones: cytokine expression course as a tool for evaluation of non-union therapy. Arch Orthop Trauma Surg. 2015;135:1107-1116. Go to original source... Go to PubMed...
    69. White AP, Vaccaro AR, Hall JA, Whang PG, Friel BC, McKee MD. Clinical applications of BMP-7/OP-1 in fractures nonunions and spinal fusion. Int Orthop. 2007;31:735-741. Go to original source... Go to PubMed...
    70. Wozney JM, Rosen V, Celeste AJ, Mitsock LM, Whitters MJ, Kriz RW, Hewick RM, Wang EA. Novel regulators of bone formation: molecular clones and activities. Science. 1988;242:1528-1534. Go to original source... Go to PubMed...
    71. Wu CC, Shih CH. Treatment of 84 cases of femoral nonunion. Acta Orthop Scand. 1992;63:57-60. Go to original source... Go to PubMed...

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