The process of healing after a fracture requires a precise balance and stabilization. Body mechanics, osteogenic cells, scaffolds, and other growth factors are the four pillars for adequate bone healing. However, in some cases, the healing process may not go as expected, and it requires additional intervention. This condition is called nonunions which affects the quality of a patient’s life and even causes additional health problems.

What Is A Nonunion Fracture?
After a fracture, if the broken bone doesn’t heal, then it is termed a “nonunion.” Nonunions might cause additional problems to the patient because they increase the risk of disability and are also associated with substantial pain. Sometimes it is also termed as delayed union fractures; that means the fracture takes more time to heal.

Nonunion Tibia Fracture
Nonunion fracture is a common complication of a tibia fracture; it means that the healing process after a fracture is not happening in a timely fashion. There is no standard procedure for nonunion fractures, some stated that tibia nonunion is a fracture that may not heal without additional surgical or nonsurgical treatment within 6–9 months. In contrast, others waited around six months to perform surgeries for correcting nonunions.

Factors That Increases Risk Nonunion Development
As mentioned, adequate treatment options and reduction techniques are key to complete fracture healing. Nonunion development is multifactorial, and the risk factors that involve in the development of a nonunion fracture include the following:

Fracture Associated With Injury-Related Factors

• High-energy fractures or complex fractures with significant comminution
• Type of fracture i.e. closed fracture or open fracture
• Location and pattern of the fracture (highly crushed or butterfly fragments)
• The range of soft tissue injury
• Loss of bone and fracture gaps greater than 3 mm
• Lack of cortical continuity
• Development of infection to the fracture

Biology and Patient-Related Risk Factors

• Lack of nutrition
• Diabetes
• Smoking and drinking
• Poor blood supply 
• Deficiency of vitamin D 
• Renal insufficiency
• Usage of certain medications like steroids, NSAIDs, opiates, etc.

After surgical treatment, inadequate stabilization of the fracture can also lead to nonunions.

Learn About Types Of Nonunion Fractures: https://www.drvasuortho.com/nonunion-fracture/

Treatment For Nonunion Tibia Fracture
Treatment of a tibial nonunion fracture is based on the type of fractures, location of the nonunion, alignment of lower-extremities, the stability of fracture, presence of infection, the extent of soft-tissue injuries (including nerve deficits), and patient general health conditions and other possible collateral injuries.

Generally, hypertrophic nonunions types of fractures are treated with rigid stabilization with or without compression. Atrophic nonunions type of fractures requires augmentation to initiate bone formation. The process involves bone grafting, soft-tissue, some other biologic stimulation factors like bone morphogenetic proteins or stem cells. Infected nonunions are treated by sterilizing the nonunion site.

Nonoperative Treatment For Nonunion Fractures
Nonoperative treatment methods are the first line of treatment options considered for nonunion fractures. Functional cast bracing is considered in selected cases. Geriatric patients, those who are not able to withstand major surgery, can be successfully treated with the help of cast brace.

In general, pediatric nonunions are a result of open fractures with soft-tissue damage and bone devascularization. Functional cast bracing is an efficient way to achieve union.

Pulsed electromagnetic stimulation is an effective way to treat nonunion fractures. Growth factors are stimulated by the electric and electromagnetic fields, particularly in the case of hypertrophic nonunions.

Low-intensity pulsed ultrasound (LIPUS) – Low-frequency ultrasound can promote bone healing and decrease fracture healing time.

Operative Treatment For Nonunion Fractures

The typically surgical treatment includes:

• Fibular osteotomy
• Removal of weak, broken, or infected hardware
• Use of biologic bone augmentation
• Bone stabilization
• Elimination of infection

Fibular osteotomy: This is a simple surgical technique performed when the fibula is thought to be compressing the tibial nonunion site. Usually, it is done along with other procedures. It is performed alone in case of a stable and noninfected hypertrophic nonunion type of fractures with limited or no deformity is present. Bony alignment and stability are crucial for the treatment of a tibial nonunion through the osteotomy method.

Compression Plating: Plating is also effective in treating tibial nonunions. In a study conducted over 49 patients with a tibial nonunion fracture, compression plating treatment after initial external fixation showed 92% healing rate within seven months without any further treatment. Compression plating is suitable anywhere along the nonunion tibia.

External Fixation: In this procedure small-wire and hybrid external fixation, is an exceptional choice to treat tibial nonunions. Particularly, it is effective if the fracture is proximal or distal, significant bone loss; the significant deformity is present. It provides stability to your fracture site, even in case of proximal or distal fractures. Infected bone fragments are removed and grafted, and shortening is also performed.

Limb-length equalization: This is done with transported bone. Adjunctive therapy like the use of antibiotic bone cement or incorporation of bone replacement beads is easy in case of stabilization with external fixation.

Bone Grafting: This is traditionally used when poor vascular supply is present. This treatment procedure helps to provide a new environment for the formation of bone.

Cell Therapy: It is a process where the mesenchymal cells are used within the fracture gap to create a healing environment.

However, some nonunion tibia fractures are challenging to handle and require experts to treat such cases. To know more about the nonunion fractures or if you or your family members experience any kind bone deformities consult Dr Vasudeva Juvvadi, Consultant Orthopaedic Surgeon at Sunshine Hospitals, Hyderabad. He has more than ten years of experience in treating various types of nonunion fractures, malunion fractures and other bone deformities.