Current Orthopaedics (2008) 22, 434e441

available at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/cuor

TRAUMA

Tibial non-union: a review of current practice

Elizabeth Moulder, Hemant K. Sharma*

Orthopaedic Department, Hull Royal Infirmary, Anlaby Road, Hull, HU3 2JZ, United Kingdom

KEYWORDS Summary
Tibia; Diaphyseal tibial fractures are common and generally heal well. However, non-union is
Fractures; a frequent consequence, can require prolonged treatment with unpredictable results and lead
Non-union; to chronic disability. This article describes the management of non-unions and provides an
External fixation; algorithm for current management techniques including the challenges of bone loss, deformity
Internal fixation; and infection and an overview of the role of biological augments in non-union surgery.
Infection Crown Copyright ª 2008 Published by Elsevier Ltd. All rights reserved.

Introduction vascular supply. As the tibia is a weight-bearing bone,

Each year in the USA there are approximately 580,000 tibial
fractures, resulting in 3.5 million visits to casualty and 11
million visits to out patients’ departments.1 One British
trauma unit, covering a population of 750 000, reported
managing an average of 174 tibial shaft fractures per year.2
Treatment varies, depending on local resources, surgeon
preference and expertise, fracture configuration and soft
tissue integrity. Current surgical treatments include intra-
medullary nailing, open reduction and internal fixation and
external fixation with monolateral or circular frames.
Most tibial fractures heal satisfactorily over 3 to 6
months with conservative or simple operative manage-
ment. However in 22 combined series including 5517 frac-
tures the prevalence of delayed or non-union was 6.95%.3
The tibia is especially susceptible to a failure in the
biological healing process because of the large subcuta-
neous border, with sparse soft tissue cover and a precarious
* Corresponding author.
E-mail address: hksorth@yahoo.co.uk (H.K. Sharma).
morbidity of a non-union is high.
This paper highlights the risk factors for non-union, the
commonly used classifications and gives a management
algorithm for this difficult problem. Management of infec-
tion or extensive bone loss is discussed as is a brief outline
of new and experimental surgical adjuncts.
Normal fracture healing
A meta-analysis of 2886 closed tibial fractures showed the
median time to union was 14.7 weeks after immobilization
in a cast, 20.0 weeks after fixation with an intramedullary
rod and 13.0 weeks after open reduction and internal
fixation.7 Normal fracture healing occurs in three phases;
the initial phase of fracture healing, haematoma forma-
tion, involves inflammatory cells and signalling molecules
with generalised increased cell division around the fracture
site. During the subsequent reparative phase the fracture
haematoma is organised by collagen fibres and matrix to
form soft callus which is then mineralized and undergoes
osteogenic process of replacement and repair, remodelling
the new bone according to Wolff’s law.4

0268-0890/$ - see front matter Crown Copyright ª 2008 Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.cuor.2008.07.005
Tibial non union: a review of current practice
This process is affected by movement at the fracture
site. A rigidly fixed fracture will form little or no callus, and
will unite with endosteal callus, with remodelling across
the fracture site as the cortical cells re-establish bony
continuity. This is primary healing and can be a slow process
and if the gap between the rigidly fixed fracture ends is too
great, primary union cannot occur.
If there is movement at the fracture site, secondary
bone healing occurs. This is much more common than
primary healing. Gaps are bridged by callus and subsequent
ossification.5 In fact Goodship and Kenwright demonstrated
that micromotion across an experimental sheep tibia frac-
ture accelerated the healing process and formed increased
external callus radiographically.6
A fracture is considered to be clinically united when it
is stable and pain-free. This can be a difficult diagnosis if
the fracture has been surgically managed and the diag-
nosis may rely on x ray findings, e.g. when bone
trabeculae or cortical bone can be seen crossing the
fracture site.
Risk factors for non-union
Every non-union is different and results from many variable
factors affecting this careful balance of biological and
mechanical factors. They can be considered as factors
specific to the patient, their injury and their treatment.
Patient factors
Many patient factors can influence fracture healing, as
endogenous insulin and steroids have a direct effect,8 it is
unsurprising that diabetes appears to retard bone healing
and systemic steroids have been shown to delay bone
healing in rats.9 Other drugs such as anticoagulants and
non-steroidal anti-inflammatories are thought to impede
union10 as can malnourishment, anaemia, increasing age
and poor soft tissue. However it less clear why fracture
consolidation is delayed in the elderly, as the vascular
response does not change with age.11
Special mention should be made of the effect of nicotine
on fracture healing; one study specifically studying tibial
shaft fractures showed the time to clinical union almost
doubled in smokers.12
Injury factors
The energy expended at the time of injury influences both
fracture configuration/ comminution, and the degree of
damage to the soft tissue envelope which affects local
vascularity and hence influences the development of
infection and non-union.
Multiply injured patients, irradiation of bone, interrup-
tion to the blood supply, associated nerve injuries, open
fractures and compartment syndrome have all been shown
to predispose to non-union.
Metaphyseal fractures heal better than diaphyseal
fractures and distal third and segmental tibial fractures are
less likely to unite,13 due to the relatively poor blood supply
and the poor soft tissue cover in this area is an additional
factor.
435
An intact fibula, either at the time of injury or because it
healed before the tibia, can ‘strut’ the injured tibia,
increasing the risk of non-union as well as leading to varus
deformity.14
Treatment factors
Mishandling of the tissues, particularly unnecessary peri-
osteal stripping during stabilization, will exacerbate soft
tissue damage and increase the risk of infection and/or
non-union.
Lack of contact between the bone ends, be that
secondary to poor reduction, distraction, soft tissue inter-
position, bone loss or failure of fixation is associated with
non-union.13
The stability conferred by a fixation device has consid-
erable impact on the likelihood of union. If the fracture is
rigidly anatomically stabilised then primary union can
occur. While secondary union is encouraged by a degree of
micromotion across the fracture site, too much motion and
insufficient stability can lead to non-union.
Diagnosis of non-union
The diagnosis of tibial non-union is not based purely on
time. While activity related pain is the usual complaint
from a patient whose tibial fracture has failed to unite,
a pseudoarthrosis has formed or an intact fibula prevents
movement, with intact fixation the patient may be
symptom-free.
On examination there may be local tenderness and pain
on stressing the fracture site.
The clinical and radiological findings should be observed
over a period of time and if there is no radiological
progression of healing after 6 months, non-union should be
considered. If plain films are inconclusive, CT scanning may
be helpful to show the fracture site in more detail.15
When non-union is suspected concomitant infection must
be excluded; it not only predisposes to non-union but
complicates the subsequent treatment. Inflammatory
markers and MRI scanning may be helpful in confirming
infection.
Classification of non-union
The radiological appearance of any callus is commonly used
to describe non-union. In hypertrophic non-unions there is
a large volume of callus around the fracture site, and little
or no callus with atrophic non-unions and usually bony
resorption at the fracture site.
Ilizarov enthusiasts classify non-unions as ‘stiff’ or ‘lax’,
depending on the clinical and mechanical findings.16 The
former shows no evidence of clinical movement, and callus
formation is usually of the hypertrophic type with a large
area of bony contact. A lax-non union has little inherent
mechanical stability, and is defined as moving more than
seven degrees in any plane. There is likely to be bone loss,
with atrophic changes seen on x-ray and little callus or bony
contact. It must not be forgotten that the laxity of a non-
union may not be apparent until fixation is removed and/or
a fibular osteotomy performed.
436 E. Moulder, H.K. Sharma

This classification influences the treatment as a stiff non-

Table 2 Factors contributing to the non-union personality
union contains fibrocartilage which will ossify if stabilised,
unlike the amorphous fibrous tissue of a lax non-union. Local Factors
When describing a non-union, the condition of the soft  Host condition
tissues and presence or absence of infection should also be  Previous treatment
included. Paley’s classification of non-union includes  Soft tissue
degree of bone loss and limb deformity as this will also status i,e, skin,
influence the management (see Table 1).17 scar tissue
 Bone loss,
apposition and deformity
Aims of treatment  Neurovascular status
 Stability
The objective is a fully functional, mechanically well  Infection
aligned, healed limb with equal leg lengths. Obviously,  Intact fibula
functional recovery is the most important objective,
especially important in the presence of infection. If func- be a painless pseudoarthrosis which may even be sufficient
tional recovery is unlikely, the option of amputation should for weightbearing.
be discussed with the patient as appropriate.
Low-intensity ultrasound
Treatment
Low-intensity ultrasound, commercially available as Exogen
To prevent unnecessary pain and the social and psycho- (Smith and Nephew), may be beneficial, and may counter-
logical morbidity associated with a delayed tibial union, balance systemic risk factors such as smoking.18 Animal
early intervention is recommended. The average ortho- studies indicate the callus formed is stiffer and stronger,
paedic surgeon may only see 4e5 severe tibial fractures and the endochondral ossification process is accelerated
every year.2 Even with a non-union rate of 10%, the average due to an angiogenic, chondrogenic, and osteogenic effect
district general hospital surgeon will not accumulate of the ultrasound. There appears to be no risk to the
enough experience to deal with these complex problems. patient, so this should be considered in most cases whilst
Circular frame techniques and the availability of biological
adjuncts demand further specialist knowledge from clini-
cians. It may be appropriate to refer the patient to
a specialist centre with sufficient accumulated experience
at an early stage to ensure optimal care.
The type of non-union will dictate the treatment, i.e.
a hypertrophic or stiff non-union will heal if stabilised but
an atrophic or lax non-union is hampered by poor vascu-
larity and will require biological stimulation. The treating
surgeon must consider these and many other factors,
summarised in Table 2.

Conservative /minimalistic management

Not all tibial non-unions will require surgery. Occasionally,

watchful waiting (Fig. 1) is the most appropriate option, for
example a painless non union, in an elderly, infirm or
incapacitated patient as the final stage of a non union may

Table 1 Paley’s classification of Non-unions, adapted

from Paley D, Catagni MA, Argnani F et al. Ilizarov treat-
ment of tibial non-unions with bone loss. Clin Orthop
1989;241:146-165
TYPE A TYPE B
Less than 1cm of Bone Loss More than 1cm of Bone Loss
A1 Lax B1 Bony defect,
A2 Stiff no shortening
A2-1 No deformity B2 Shortening, no bony
A2-2 Fixed deformity defect Figure 1 A e Painless non-union (intact fibula) treated
B3 Bony defect conservatively, wait and watch policy with Exogen, low
and shortening intensity ultrasound. Patient continued to walk and participate
in daily activities. B e Healed after 2 years.
Tibial non union: a review of current practice
further options or opinions are considered. It is also advis-
able to use ultrasound early in complex fractures, when the
potential of non-union is high.
Dynamisation
Dynamisation of an intramedullary nail by removing the
locking bolts will facilitate compression and loading across
the non-union site, potentially accelerating the healing of
a delayed union. The Edinburgh group suggest that nail
dynamization has no effect on the time to union.19 However
it is our opinion this low risk procedure should be considered.
Fibulectomy
Delee reported a tibial union rate of 77% after partial
fibulectomy,20 although a stable non-union is a prerequi-
site. Fibulectomy can be combined with other treatment
methods, and is mandatory for deformity correction.
Operative management
Stiff or hypertrophic non-union
These non-unions require stability but do not require bone
grafting, and may go on to unite with the minimum of
disturbance. By avoiding intervention at the fracture site
Figure 2 A & B e Grade 3 open fracture with intact fibula, resulted in stiff, sterile, non-union with deformity. C & D e Treated
with Taylor spatial frame and fibular osteotomy. Gradual distraction and deformity correction, without opening the non-union site.
Secondary deformity (distal valgus) due to injury to distal growth plate.
437
the vascularity is preserved, which is especially advanta-
geous if there were soft tissue cover problems.
Exchange nailing
If the tibia was previously nailed, renailing with a larger
diameter nail confers further stability, and disseminates
biological material across the fracture site. It is a well
established technique, with a reported union rate of over 90 %
in the first and 100 % in the second exchange nailing.21 There
is, however, an infection rate reported of up to 12 %.21,22
Internal fixation
If the original fracture was internally fixed, the plate should
be removed with minimal soft tissue damage. Replating is an
option although fixation can be difficult due to the previous
screw holes and stress shielding around the non-union site.
Circular frame fixation
A fine wire circular frame will provide stability along with
continuous compression or distraction as appropriate.
Circular frame treatment directed at a single site within the
bone is termed ‘‘monofocal’’.16 If there is less than 2 cm of
shortening, with or without bony deformity, there is also the
option of manipulating the non-union site by gradual
distraction to correct deformity and restore length (Fig. 2).
The tension osteogenesis effect will also accelerate fracture
healing. As the non-union site itself is not invaded, the risk of
introducing infection here is eliminated.
438 E. Moulder, H.K. Sharma

Figure 3 A e Lax, sterile non-union. Treated with debridement of bone ends, acute shortening and proximal corticotomy and
lengthening. B & C eFinal X rays.

Lax or atrophic non-union

To encourage union, a lax non-union requires biological

stimulation, which invariably requires the non-union site to
be opened. Any internal fixation should be removed and the
bone ends debrided back to bleeding bone ensuring that all
fibrous tissue is excised. This will encourage the production
of biological factors for bony healing. The use of bone graft,
bone graft substitutes and other biological adjuncts should
be considered before stabilisation.
If the expected shortening is minimal, the fracture can
be stabilised with a plate or nail with bone grafting. Plating
was a popular option previously, but latterly internal
fixation has fallen out of favour owing to the increased
infection rate and circular frames are now preferred. These
are ideally suited to cases with deformity or significant
shortening as the distant corticotomy enables increased
vascularity and restoration of length (Fig. 3). Corticotomy
also activates surface cells by 500% and therefore assists
the healing of the non-union,23 and bone grafting is not
usually necessary.

Bone graft
Autologous cancellous bone graft, taken from the iliac
crest, can be used to fill bony defects at the non-union
site. Cancellous bone does not confer any structural
support but has the three characteristics required of an Figure 4 A e Quiescent, infected, stiff non-union with varus
adjunct, providing the osteogenetic stem cells and deformity. B e Treated with Taylor spatial frame, fibular
osteoinductive biological factors to encourage union, as osteotomy and gradual distraction, correcting the deformity
well as an osteoconductive scaffold for the ingrowth of without opening the non-union site.
Tibial non union: a review of current practice
new bone. While this is still the ‘gold standard’, its
potential disadvantages include limited volume and the
donor site morbidity.
Demineralised bone matrix
An alternative to autologous graft is demineralised bone
matrix which provides an osteoconductive scaffold with
variable osteoinductive content. There is variability
between products and concerns have been raised about the
source of donor bone.23
Bone morphogenic proteins
Bone morphogenic proteins are osteoinductive chemical
mediators of bone formation. The most widely researched
are BMP-2 and BMP-7 (also known as OP1-). While only
BMP-7 is approved for the treatment of tibial non-unions,
both have been used with success,24 indeed BMP 7 has
been shown to be as good as autogenous bone grafts,
without the donor site morbidity and with a lower infec-
tion rate, 3% versus 21 %.1 Research is continuing into an
optimal delivery method for the exogenous application of
BMPs and other growth factors which may enhance the
union of fractures.
Bone marrow injection and implantation
Bone marrow contains all the progenitor and supporting
cells for osteogenesis. Successful healing of non unions
Figure 5 A e Lax non-union with active infection. B e Treated with removal of nail, segmental excision, proximal corticotomy
and lengthening, along the principles described. C e Healed non-union, no infection and restoration of length.
439
after the percutaneous injection of bone marrow has been
described25 but the clinical use is limited.
It is now possible to increase the concentration of
osteogenic cells through tissue engineering, and it is hoped
that combining implantation of these cells with a scaffold
will provide structural support at the non-union site as well.
A recent article reported successful healing of a long
standing tibial non-union after implantation of a culture
expanded bone marrow cell population, loaded on to
a calcium sulphate scaffold.26
Recently platelet rich plasma has been used in jaw
reconstruction and long bone non-unions, but more data
are needed before widespread clinical application can be
recommended.
Corticotomy
Corticotomy of the tibial shaft at a point distant to the non-
union site can increase vascularisation of the whole limb. The
advocates of Ilizarov techniques use it in the management of
non-unions and infections. The increased vascularity
improves the biological environment, encouraging union, and
is also thought to play a role in preventing infection.
This bifocal technique can be used to correct deformity
or lengthen the limb. When no lengthening is required, the
concertina technique (sequential compression and distrac-
tion) can be used. Alternate distraction and compression at
the corticotomy site will increase the cross-sectional area
and consolidation rate of the new bone.16
440
Special cases
Extensive bone loss
An Ilizarov frame with bone transport and lengthening is
ideally suited to significant shortenings or bone loss. Bone
transport is a variant of bifocal lengthening which enables
more extensive bony gaps to be bridged if the fracture ends
cannot be opposed. Corticotomy creates a free segment of
bone which forms new bone in its wake when moved, at the
usual rate of one mm per day, to meet the other end of the
non-union site.
In extreme cases or mid-diaphyseal defects, a trifocal
technique uses two corticotomy sites distal to the non
union site. A converging trifocal technique will enable two
transported segments to meet in the middle, or the
tandem variant moves two segments along the same axis
to close the non-union site. Both techniques can halve the
time required for union compared to a monofocal tech-
nique.16 It is recommended that the docking site should be
debrided and bone grafted, however this is contrary to the
original technique described by Ilizarov who suggested
compression and distraction to encourage union at the
docking site.
Transverse fibular transport or vascularised fibular
grafting can also be performed, to bridge the large bony
gap. In time, due to Wolff’s law, the fibula will tibialise,
widening to take the increased load.
Infection
Infection should be considered as a causative factor in any
non-union case, and can be difficult to exclude as inflam-
matory markers may be elevated or normal. X ray findings
Sterile
Stiff Lax
Debride bone
ends
Plate / IM Nail Significant
conservative shortening
Exchange
Nail
Circular frame Circular frame
Acute shortening
Distraction / Distant corticotomy
compression ? Bone grafting
E. Moulder, H.K. Sharma
may show periosteal elevation, sequestrae and mottling.
CT or MRI scanning may give more information and help to
define the limits of debridement preoperatively.
Quiescent infection
A stiff non-union with quiescent infection can be treated as
a sterile stiff non-union, using simple distraction or
compression without violating the non-union site (Fig. 4).
However, a lax non-union with quiescent infection
should be treated with debridement or segmental excision
followed by acute shortening with distant corticotomy and
lengthening. Bone grafting is not necessary.
Active infection
In the presence of active infection, multi-disciplinary
surgery with plastic surgeons is advisable to ensure soft
tissue cover is achieved as soon as possible to prevent
further infection. A transverse or lazy ‘S’ incision will allow
shortening of tibia, which will eliminate dead space. Any
existing internal fixation should be removed and adequate
debridement of the non-union site up to bleeding bone is
essential.27
Intra-operative antibiotics should be withheld until
sufficient microbiological samples are obtained, and then
broad spectrum antibiotics started according to the
previous cultures which are altered according to the
microbiology results of the intraoperative samples.
Stabilization in the actively infected case is best ach-
ieved with an Ilizarov frame, as this does not require the
insertion of metalwork into the infected area. Acute
shortening will require a distant corticotomy and distrac-
tion osteogenesis to equalise leg length (Fig. 5). This will
increase vascularity of the limb, aiding healing and antibi-
otic delivery to the area and remove the need for bone
grafting.
Non Union
Infected
Quiescent Active
Stiff or lax
Minimal shortening /
previous nail
Nailing
? bone grafting
Stiff Lax Circular frame
Debride Segmental excision
bone ends Acute shortening
Distant corticotomy.
No bone grafting
Tibial non union: a review of current practice
Conclusion
Tibial non-union is a common and complex problem. The
aim of treatment is to achieve a functional limb and to
minimise physical, social and psychological morbidity.
Treatment requires an understanding of fracture
biology, the contributory factors of non-union and a holistic
approach, summarised in our algorithm.
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