Surgical treatment of aseptic nonunion in long bones: review of 193 cases

The surgical treatment of aseptic nonunion often represents a more challenging situation for the orthopaedic surgeon than treatment of the primary fracture. In fact, it may be necessary not only to "rivitalize" the nonunion area, but also to exchange the bone fixation devices and to place some refill material in the bone gap. Several surgical techniques and different kinds of bone gap refills have been reported in the literature for the treatment of long bone nonunion. We present the results of 193 cases of long bone nonunion that have been treated in a period of 11 years (1992–2003) by a mostly open approach to the nonunion site with or without autologous bone graft interposition. The site (27 humerus, 44 forearm, 48 femur, 74 tibia) and the type of nonunion (179 atrophic, 19 hypertrophic) were considered in the surgical planning as were the mechanic and biological problems. New osteosynthesis was performed in 139 cases: with plate and screws in 82 cases, with intramedullary nails in 31 cases, with external fixators in 15 cases and with other devices in 11 cases (e.g. interfragmentary screws, k-wires). Cancellous or corticocancellous bone graft, always autologous from the iliac crest or from the anterior tibial tuberosity, was used in 183 cases (94.8%). Healing of the nonunion was successful in 179 cases (92.7%) in a mean time of 5.8 months. 14 patients (7.2%), all atrophic nonunion, healed with further surgery in a mean time of 19.2 months. Best results were obtained by the use of the intramedullary nail (31 cases): 99% healed in 5.2 months for the lower limb and 100% healed in 7.4 months for the upper limb. Good results have been achieved by plate (82 cases): 89.5% healed in 4.5 months for the lower limb and 94.1% in 6 months for the upper one. The worst results were observed with external fixation (15 cases). However, this device was used in the most complex situations, when severe soft tissue sufference was present. In this group, the mean healing time was 7.1 months (69.2% of cases) in the lower limb and 8 months (50%) in the upper one. Bone graft alone (54 cases) led to healing in 34 of 35 cases (97%) in the lower limb in 6 months and in 17 of 19 cases (89.4%) in 6.4 months in the upper limb.