NON-UNION SURGERY: THE RESULTS AND LESSONS AFTER 380 CONSECUTIVE CASES

Abstract

The results of the first 100 consecutive patients treated in our tertiary referral non-union practice have been previously reported. The purpose of this report is to review this group together with a further 280 cases treated between 1991 and 2000. The principles of management remain the same, namely restoration of alignment, stabilisation and stimulation, however in the more recent cases increasing use of distraction, bone transport and bifocal techniques as well as single stage lengthening and correction of soft tissue contractures have been used to eliminate limb strength discrepancies. A total of 380 consecutive established non-unions treated between 1987 and 2000 were reviewed. Twenty-nine patients were lost to follow up (five deceased). There were 159 atrophic, 89 hypertrophic and 103 infected cases, with 319 cases as a result of trauma, and 32 cases as a consequence of planned surgery. The majority involved the tibia with 162 cases, followed by femoral non-unions with 51 cases and the remainder involving upper limb and smaller bones. At the time of review, 8 had abandoned treatment and 25 remained ununited. Twenty-one cases ended with amputations: 14 infected, 4 atrophic and 3 cases due to excessive pain following patients request.

Union was achieved in 297 cases (85% overall union rate), representing 90% of atrophic, 89% of hypertrophic and 73% of the infected non-unions. A comparison is made between the first hundred previously unreported series of 280 cases. The overall union rates have improved from 80% to 85%, with an increase in union rates noted predominantly in the atrophic group. Infected cases remain more of a problem and challenging with lower healing rates. There was no statistical difference in union rates between smokers and non-smokers, but slower times to union and increased complication rates were noted in the heavy smokers (< 40/day). The non-union profiles, pathogenesis and change in treatment options are discussed.