During fracture repair, a number of growth factors and cytokines are present at elevated levels at the fracture site such as Transforming Growth Factor Beta (TGF-), Fibroblast Growth Factor (FGF) and Platelet Derived Growth Factor (PDGF). The aim of the study was to investigate the presence of these growth factors in healing fractures and fracture non-unions, in order to test the hypothesis that atrophic non-unions express a lower level of growth factors than hypertrophic non-unions and healing fractures. Biopsies were taken from the fracture site of 23 patients (mean age 46) with uninfected non-unions, 12 patients with hypertrophic (mean 13.8 months after fracture) and 11 patients with atrophic (mean 16.5 months after fracture). A comparison group of biopsies from early fracture callus (one to four weeks after fracture) in five patients with healing fractures was also included. Five-micron paraffin sections were immunohistochemically stained for TGF-, FGF-II and PDGF. Growth factors were then assessed in six different cell types. Fibroblasts, endothelial cells and macrophages were found to express TGF-, FGF-II and PDGF in all three-fracture groups. Osteoblasts, osteoclasts and chondrocytes were not present in the healing fracture group. The growth factor expression in osteoblasts, osteoclasts and chondrocytes in the non-union groups were found to be variable, however, the expression of these growth factors appeared to be less in the atrophic non-unions than hypertrophic non-unions. The expression of these growth factors was found to be less in the atrophic non-union group than the hypertrophic non-union group in osteoblasts, osteoclasts and chondrocytes. These results may have relevance for new therapies that can be aimed at delivering growth factors to treat fracture non-unions. By further investigation of the differential expression of these growth factors it may be possible to determine which factors are likely to stimulate fracture healing

Aims. Occult (clinical) injuries represent 15% of all scaphoid fractures, posing significant challenges to the clinician. MRI has been suggested as the gold standard for diagnosis, but remains expensive, time-consuming, and is in high demand. Conventional management with immobilization and serial radiography typically results in multiple follow-up attendances to clinic, radiation exposure, and delays return to work. Suboptimal management can result in significant disability and, frequently, litigation. Methods. We present a service evaluation report following the introduction of a quality-improvement themed, streamlined, clinical scaphoid pathway. Patients are offered a removable wrist splint with verbal and written instructions to remove it two weeks following injury, for self-assessment. The persistence of pain is the patient’s guide to ‘opt-in’ and to self-refer for a follow-up appointment with a senior emergency physician. On confirmation of ongoing signs of clinical scaphoid injury, an urgent outpatient ‘fast’-wrist protocol MRI scan is ordered, with instructions to maintain wrist immobilization. Patients with positive scan results are referred for specialist orthopaedic assessment via a virtual fracture clinic. Results. From February 2018 to January 2019, there were 442 patients diagnosed as clinical scaphoid fractures. 122 patients (28%) self-referred back to the emergency department at two weeks. Following clinical review, 53 patients were discharged; MRI was booked for 69 patients (16%). Overall, six patients (< 2% of total; 10% of those scanned) had positive scans for a scaphoid fracture. There were no known missed fractures, long-term non-unions or malunions resulting from this pathway. Costs were saved by avoiding face-to-face clinical review and MRI scanning. Conclusion. A patient-focused opt-in approach is safe and effective to managing the suspected occult (clinical) scaphoid fracture. Cite this article: Bone Jt Open 2024;5(2):117–122

Aims: We wanted to study the outcome of bone transport by Ilizarovñs method in simple and complicated gap non-unions where other conventional methods have little role to play. Methods: Sixty-six consecutive patients with an age range of 23–64 years (58 males and 8 females) were included in this study. Forty-four patients (67%) had associated problems like infection, deformity and shortening along with gap non unions of varying length. All the patients were treated with ring þxators and the principles of Ilizarovñs treatment were adopted. Corticotomy was carried out in all the cases. Appropriate arrangement of apparatus assembly was done according to the requirement of individual gap non-unions. Follow up ranged from 6 to 46 months. Results: In all but three cases, union was achieved along with satisfactory correction of other associated problems. In one case the patient had previously undiagnosed hypothyroidism and showed signs of callus at corticotomy site after treatment with thyroxine. This patient lost to follow-up. Two other cases needed further surgery (Ilizarovñs ring þxator). In one case, cancellous bone grafting had to be carried out. In six tibial gap non-unions, residual equinus deformity persisted. Conclusions: Ilizarovñs method of bone transport is quite effective in treatment of gap non-unions associated with complex problems, where other methods have proven to be less successful

Humerus non-unions are difficult to treat, especially those with infected non-unions, bone loss, deformity, previous multiple surgeries and/or broken hardware. This paper presents our experience with the use of the Ilizarov frame with humerus non- unions. Eight consecutive humerus non-unions were treated using the Ilizarov frame. Only loose or infected hardware was removed. The Ilizarov frame was applied using safe zones principles of Ilizarov, Catagni and Paley. Aspetic non-unions were treated with deformity correction, sequential compression and distraction, bone grafting and intramedullary stabilisation for diaphyseal nonunions. Infected diaphyseal non-unions were treated intra-medullary reaming with or without excision of infected necrotic bone segment, followed by insertion of antibiotic cement rod and compression. Elbow spanning frames were avoided for supracondylar non-unions. Fine wire fixation of the distal fragment was preferred instead. Free elbow movement was allowed. There were two infected (diaphyseal) and six aseptic non-unions (four diaphyseal and two supracondylar) treated with this technique. Broken hardware was left in-situ in five cases. The average time from the index injury was 14 months, with each case having had an average of 3.2 procedures, prior to the application of the Ilizarov frame. Union was obtained in all cases. The average humerus shortening was 1.5 cm. There was no residual angular or rotational deformity. Infection was eliminated in both the infected non-unions. Primary bone grafting was used in all aseptic nonunions. Additional bone grafting was needed as a secondary procedure in four cases prior to frame removal. T he average time spent in the frame was 4.5 months. The Ilizarov method is a useful option for the management of complex humerus non-unions. Patients learn to tolerate the fixator and can achieve functional shoulder and elbow range with the fixator

The purpose of this study was to review the outcomes and complications of all circular external fixators (frames) used for the management of sterile and infected fracture non-unions in the lower limb in our institution over a twenty year period. We retrospectively reviewed a prospectively compiled database of all frames applied in our institution and identified all frames which were applied for acute lower limb trauma. We identified 76 non-unions in 76 patients. There were 22 femoral non-unions and 54 tibial non-unions. Five femoral non-unions and 12 tibial non-unions were confirmed infected. The mean time in frame was 281 days for a sterile non-union and 457 days for an infected non-union. There was a union rate of 87% for sterile non-unions and 71% of infected non-unions at cessation of treatment. Factors associated with persistent non-union included cigarette smoking, soft tissue complications, and excessive pin-site toilet by the patient. Lower-limb fracture non-unions can be extremely difficult to treat. The patients included in our study had previously undergone more traditional treatments in an attempt to establish union. The results presented demonstrate that circular frames are an excellent treatment modality in non-unions resistant to other forms of treatment. We would recommend this as a first line treatment for patients at higher risk of developing fracture non-union

Proximal humeral non-unions are uncommon, but when they occur they are disabling and often present a surgical challenge. We have treated 55 cases of proximal humeral fractures by internal fixation from March 2002 to March 2004. Of these, 18 were non-unions out of which 16 were treated using AO Cannulated blade plate and bone grafting. Results of these patients are presented in this report. 14 out of 16 were available for follow up, which ranged from 18–30 months. Patients were regularly reviewed clinically and radiologically and had constant and DASH scoring at final follow up. Average Constant score was 64 and DASH score was 35.3. Range of movement recovered to 50% or more in every patient but only 3 had full range of movements. Maximum recovery in the strength of shoulder muscles measured with myometer was about 75% as compared to other side. Although X-rays showed sound bony healing in all but one case, none of the patients was completely symptom free at final review. However, they were all satisfied with the outcome of their operation. Stable internal fixation is the key to success of surgical treatment of non-unions. We are satisfied with the usefulness of AO cannulated blade plate in providing a rigid fixation in our cases. However, it is difficult to achieve perfect results in terms of pain relief and recovery of normal function due to various reasons, which would be highlighted in our presentation. The report would also discuss the technical difficulties encountered in using this implant

AIM: We present the results of scaphoid non-unions treated with open reduction, bone grafting and internal fixation with biodegradable implants on active heavy labour workers. MATERIAL AND METHODS: Between 2002 to 2004, 20 patients with scaphoid non-unions were treated by open reduction, bone grafting and internal fixation using self-reinforced poly-L-lactic acid screws. The mean prospective follow-up was 24 months (range, 12–38 months). The mean age was 28 years (range, 18–42 years). All patients were male and heavy-labour workers. The patients were assessed clinically (modified Mayo wrist score) and radiograhically. The grip and pinch strength were also studied. RESULTS: We find 13 excellent results, good in 5 cases and poor in 2 cases. A Matti-Russe group patient was revised 6 months after the first intervention. Any fragment displacement, implant loosening or adverse reaction was found. Most of the patients (90%) return to the same work and the same level without complications. CONCLUSION: Both groups are a good alternative for the scaphoid non-unions treatment. However, biodegradable implants disappears in the time, the removal are no necessary, facilitate the revision surgery, if necessary, and permitted MRI studies to evaluated the graft viability

Objective. To investigate the outcomes of patients following the chipping procedures as an alternative to bone grafting in treatment of femoral non-unions. Design. Retrospective evaluation of prospectively collected data. Setting. University hospital. Level IV, therapeutic case series. Patients. Eleven patients with femoral non-union were included. The median age of patients was 37 years (range, 19–73 years). The median follow-up was 24 months (range, 12–60 months). Intervention. Non-unions were treated by the chipping procedure and re-install of an intramedullary nail or locked plate(s). Main Outcome Measurements. Radiographic bone union, walking ability, and complication were evaluated. Results. All non-unions clinically and radiographically healed with a median time of 7.5 months (range, 6–12 months). All patients were able to walk without walking aids within 9 months after surgery. Pre-existing deformities (e.g., varus and mal-external rotation) were anatomically corrected after the revision surgery for non-union. There were no superficial or deep infections, but post-operative temporal anemia and swelling of the thigh were common complications after surgery. Conclusions. Chipping the non-union site was likely to enhance fracture healing, and this technique was useful as an alternative to bone grafting in treatment of femoral non-union, especially for both atrophic and hypertrophic non-unions with deformities

Background:. Delay in fracture healing is a complex clinical and economic issue for patients and health services. Established non-unions are debilitating and often difficult to treat. Bone morphogenic proteins (BMPs) may play an important role in bone and cartilage formation, fracture healing and the repair of other musculoskeletal tissues. There is, however, a paucity of data on the use of BMPs in fracture healing and to date its role remains unclear. Objectives:. To describe the 9-year experience of the Limb Reconstruction Team, Belfast in using BMP 2 for fracture non-unions. Methods:. This is a 9-year retrospective review of 66 episodes of BMP 2 application in 63 patients for fracture non-unions by two surgeons across two sites. Rate of union was calculated as the primary outcome measure. Secondary outcome measures were: time to fracture union, complication rate and re-operation rate. Time to radiological and clinical union was assessed by serial outpatient follow-up. Results:. 63 patients had been treated for an average of 12.7 months (range 2–61) for a variety of fracture non-unions with an average 2.2 operations each (range 0–6) prior to their definitive BMP implantation. 46% were open fractures. A union rate of 89% was achieved in an average of 5 months following BMP application to 45 tibial fractures, 16 femoral fractures, 4 humeral fractures and 1 radial fracture. There was an overall complication rate of 12%: 6% further non-union, 4.5% osteomyelitis and 1.5% heterotopic ossification at the BMP site. Overall there was an 11% re-operation rate, with repeat grafting required in 3 patients. Following repeat BMP grafting in these patients an overall union rate of 95% was achieved. Discussion:. High bony union rates are achievable through the use of the osteo-inductive agent BMP 2 for fracture non-unions. It can provide a reliable intervention for delayed fracture healing in circular frame patients where established non-union is deemed likely

Background: Fracture non-union remains a severe clinical problem. The methods of Ilizarov allow a new approach using a tensioned fine wire circular frame to construct cylinders around limb segments that are then manipulated with respect to each other with deformity correction using hinges. Ilizarov introduced the concept of bone formation in distraction. The use of fine wires and non-invasive techniques minimise bone and soft tissue damage. Method: Two hundred consecutive non-unions treated by the use of an Ilizarov frame were studied prospectively. The first 100 cases to have finished treatment were analysed. The mean time from fracture was 22.8 months (range: six months to 37 years) and the mean number of surgical procedures was four (range: one to 122). Eighty-eight percent affected the tibia. Unifocal compression was also used where bone loss was not a problem. Results: Ninety-three fractures united. There were two amputations for overwhelming infection, four refractures and one defaulter. Infection, present in 56 cases at presentation was eradicated in all successful cases. Time in the frame for unifocal distraction (n=6) was 6.0 months (2.5-13), for unifocal compression (n=36) was 8.4 months (2.8-20), for bifocal compression distraction (n=33) 10 months (2.9–17.4) and for bifocal excision distraction (n=24) 19 months (6.5–41). Comparing times in frame for tibial bifocal cases, compression/distraction was 9.1 months (2.9–17.4), excision with shortening and relengthening was 15.7 months (6.5–23.6) and excision/transport was 23.5 (12.6–41.5), indicating increasing time required for more radical treatments. Conclusion: The Ilizarov method provided an excellent technique for the treatment of non-unions. The technique was initially difficult for the surgeon and the patient but, with increasing experience, treatment times were reduced and the frames became progressively more manageable and less painful. In our hands, the Ilizarov frame has become the treatment of choice for all but the simplest non-unions

Introduction Infected non-unions of long bones with failure of internal fixation are difficult problems with a high amputation rate. Infection following intra-medullary nail fixation is associated with medullary osteomyelitis throughout the length of the bone. We present the results of management of these infected non-unions with intra-medullary lavage, antibiotic cement rod and Ilizarov bifocal transport. Methods Pre-operative management included management of limb dystrophy and planning for soft tissue cover including angiography. The first stage consisted of removal of the infected hardware, intra-medullary lavage, excision of the necrotic bone with acute (or gradual) shortening, soft tissue coverage including muscle flaps, stabilisation with the Ilizarov device and insertion of a custom-made antibiotic cement rod. The second stage consisted of removal of the rod at six to eight weeks, with a proximal (or distal) lengthening osteotomy for bifocal transport. The docking site was grafted when necessary. Outcome measures used were union, time for treatment completion and the Baltimore/ASAMI bone and functional scores. Eleven consecutive infected non-unions with failure of internal fixation at three tertiary teaching hospitals were treated with staged salvage. All cases had been offered an amputation by their original treating teams. Nine cases had infected intramedullary nails, one had a plate and one an external fixator for an infected nail. There were 10 tibial and one femoral non-unions. Four cases required muscle flaps. The average length of bone resected was 4.8 cm (range 3 to 8). Results The average time for completion of treatment was 9.8 months (range 5.5 to 11.3). All eleven cases went on to solid union, both at the resection site and the lengthening osteotomy site. The mean post-treatment radiographic leg-length-discrepancy was less than 0.5 cm. All cases had an excellent to good functional score and an excellent to good bone score. Conclusions Antibiotic cement rod and Ilizarov bifocal transport offer a viable alternative to amputation in salvaging infected non-unions following internal fixation of long bones. Treatment is long and difficult, but a functional limb is salvaged as the end result

The purpose of this study was to evaluate the efficacy of autologous cancellous bone grafting (ABG) for the treatment of long bone fracture non-unions. Patients who were treated with ABG for fracture non-unions of the lower extremities were identified from our prospectively entered database. Non-union was defined as failure of the fracture to unite within a period of 9 months. Demographics, comorbidities, medications, complications and surgical outcomes were all recorded and subsequently analysed. Chi square test was used to analyse the results. In total 82(54 male) patients met the inclusion criteria. The mean age was 43.6 years (range 18–78). Ten patients were diagnosed with femoral and 72 with tibial fracture non-unions. Fifty three (64.6%) were open fractures at presentation. In the tibial non-union group, initially, 67 fractures were stabilised with IM nailing and 5 with plating. During revision surgery, 33 patients underwent exchanged nailing and ABG whereas 34 received ABG without revision of the metal work. All five tibial plantings required re-plating and ABG. In the femoral non-union group, five fractures were initially stabilised with IM nailing and the rest with plating. During revision surgery, six patients underwent change of fixation (exchange nailing) and ABG and four received only ABG. Overall 73/82 patients progress uneventfully to union and the success rate was 89%. A second and a third attempt of ABG was made for 6/86 patients (7.31%) and 2/82 patients (2.44%) respectively, till clinical and radiological union. All but one of the patients united their fractures. One patient underwent amputation due to underlying osteomyelitis. The mean time to union following the ABG procedures was 8.4 months (range 3–18). Autologous bone grafting is an effective method of treating fracture non-unions. Success rates of as high as 89% can be achieved as seen in this series of patients

Treatment of scaphoid fractures continues to be a difficult problem for both acute unstable fractures and non-unions. In our study, the results of a consecutive series of symptomatic non-unions of scaphoid fractures treated with Herbert screw and bone graft during period between July 1996 and June 2000 are studied. Out of a total of 66 patients (one bilateral), 61 (91.04%) cases who had symptomatic non-unions (type D) were treated with Herbert screw plus iliac crest bone graft while 6 (8.95%) cases were treated for acute unstable fractures (type B) with Herbert screw only (these are excluded from the study). All fractures were classified according to Herbert classification. Russe approach was used in 50 patients while dorsal approach was used in 11 cases with proximal pole fracture non-union. The time interval between injury and surgery was 12.2 months (range 2–72 months). Patients were followed up for radiological evidence of union and clinically for range of movement of wrist, grip strength and outcome score. The site of fracture, type, screw placement, the time interval between the original injury and non-union surgery, and age of the patient, were investigated to assess whether they influenced outcome. Results: Total No. 61 – union 47 (77.1%), persistent non-union 14 (22.9%). We found site of fracture (p=0.044), type of fracture (p=0.028) and screw placement (p=0.019) as statistically significant factors influencing outcome. No statistically significant influence on outcome was found with patient’s age (p=0.983) and also with time interval to non-union surgery (p=0.749). Forty-six (75%) patients were available for clinical follow-up. Seven (15.2%) had persistent non-unions of which four had proximal pole fracture non-unions. Using the scaphoid outcome score, an assessment scale based on pain, occupation, wrist motion, strength and patient satisfaction, functional results were graded as excellent in 19 cases, good in 12 cases, fair in 10 cases and poor in 5 cases. We recommend axial placement of Herbert screw with bone grafting via Russe approach and for difficult proximal pole non-unions dorsal approach is recommended

Introduction: In 1995 we started using, at the G. Pini Orthopaedic Istitute of Milano, a system for bone healing stimulation based on low intensity pulsed ultrasound. Advantages of the method are: home therapy (20 minutes per day); no side effects, even in the presence of metallic devices or infection; ease of use. Indications of low intensità pulsed ultrasound are bone healing after fresh frarctures, in which a significant bone healing accelation can be observed, delayed and non-unions. We share our experience in a challenging field of application: septic non-unions. Materials and methods: We retrospectively evaluated 30 patients, treated from 1996 to 2003, affected by septic non-unions (a fracture that, in the presence of infection, did not show any significant increase in callus formation at 8 months from the time of fracture). The patients had a mean 1.7 ± 2 previous failed intervention. Patients were treated, in the absence of other medical or surgical treatment (excluding antibiotic therapy), with low intensity pulsed ultrasound (EXOGEN S.A.F.H.S. or, since year 2002, IGEA F.A.S.T.). The treatment was applied, after the necessary instructions, directly from the patient, at home, 20 minutes per day. Failures of the treatment were considered need for further surgery to stimulate bone healing, persistence of non-union at follow-up. Exclusion criteria included: evident instability of the synthesis, soft tissue loss and bone exposure, wide bone loss (> 2 cm). Results: 24 bone healing (86 %), 4 failures (need for surgery), 2 treatment discontinuation. Mean treatment duration: 123 ± 43 days (minimum 90, maximum 240 days). No side effects local or general were observed. In 18 cases a bone debridment and/or hardware removal intervention had been performed after bone healing. At follow-up, 28 patients are free from infection, while two showed infection recurrence. Conclusions: Low intensity pulsed ultrasound is an effective options in the treatment of septic non-unions, without side effects. An accurate indication and patient selection provide an advantageous cost/benefit ratio

Scaphoid non-union usually requires surgical treatment in form of reconstructive or salvage procedure. Imaging helps in planning the surgical procedure. Wrist arthroscopy may also be helpful in the pre-operative assessment. This study was conducted to find the usefulness of wrist arthroscopy in formulating a management plan to treat scaphoid non-union. We prospectively studied 17 patients of scaphoid non-unions by wrist arthroscopy. Non-union was assessed; and site and extent of any articular wear if present was noted. Some patients had additional procedures such as synovial debridement, removal of loose bodies or debridement of TFC tears. It was possible to formulate the further management plan at the same time. Our study included 14 men and 3 women with a mean age of 34.5 years (range 18 to 49). Arthroscopic findings included mild radiocarpal wear in 3 cases and severe articular wear in 1. Additionally, in two thirds of cases there was some degree of wear present over the radial styloid region. 6 cases had TFCC tears. 4 patients had synovial debridement and in 5 cases loose bodies were removed. Based on the arthroscopic findings, it was decided to proceed to a reconstructive procedure in 12 cases and a salvage procedure in remaining 5. We concluded that in scaphoid non-unions:. Articular surface wear is often less than suggested by imaging. Limited wear is often present at radial styloid area which could be debrided. Associate abnormalities such as loose bodies, synovitis and TFC tears are commonly present. State of union can not be accurately assessed due to presence of fibrocartilage at the non-union site

Introduction and Objectives: Non-unions of long bones represents a challenge for the orthopaedic surgeon due to the difficulty of treatment and high use of resources (human, surgical, etc.) which certainly raises health care costs. The development of morphogenetic proteins for the treatment of this clinical condition provides a powerful means of achieving the desired result: consolidation of the non-union. Materials and Methods: From June 2002 to May 2003, we treated 5 cases of non-union of long bones (2 of the humerus, 1 femur, 1 tibia, and one knee arthrodesis). The group included 3 males and one female, ranging in age from 23 to 71 years (mean 47.2 years). Three of the subjects had previously undergone surgery between 1 and 7 times. One case presented with a bone defect in the distal third of the humerus. All cases were treated using mechanical stabilisation of the fracture. In one case, a bone bank graft was used, and in another, an autologous graft was used. Results: Bone healing was achieved in all cases, except in one humerus. Discussion and Conclusions: BMP-7 (OP-1) appears to be an advance in the treatment of long bone non-unions. Though it does not eliminate the need for adequate surgical treatment of non-unions (resection of the focus, exposure until bleeding bone, and mechanical stabilisation), this method does favor osteogenesis at the fracture site and avoids the morbidity associated with extraction of autologous bone from the iliac crest

Background. The management of non-unions of subtrochanteric femoral fractures with associated implant failure is challenging. This study assessed the outcome of a cohort of patients treated according to the diamond concept. Methods. Between 2005–2010 all patients with subtrochanteric aseptic non-unions presented post implant failure (Gamma Nail breakage) were eligible in the absence of severe systemic pathologies and comorbidities. Demographics, initial fracture pattern, method of stabilisation, mode of failure of metal work, time to revision of fixation, complications, time to union, and functional outcome were recorded over a minimum period of follow-up of 12 months. The revision strategy was based on the “diamond concept;” optimising the mechanical and biological environment (revision of fixation, osteoinduction/BMP-7, osteoconduction/RIA harvested graft, and osteogenicity/concentrate of bone marrow aspirate). Results. Out of 280 nailing procedures 12 (4.3%) cases met the inclusion criteria. A consistent mode of metalwork failure was recorded with initial breakage of the proximal distal locking screw followed by nail breakage at the lag screw level. Biomechanical SEM analysis of the nails revealed no structural damage besides the standard fatigue striation. Varus mal-reduction was present in all cases, with an average of 7.3 degrees (5–11). The average time to screw failure was 4.3 months (2–6) and nail failure was 5.9 months (4–10). All but one of the cases were revised to a 95 degrees blade plate and one to an Affixus nail. Time to union was 6.5 months (5–10). All but one of the cases by 12 months have returned to their preinjury level of mobilisation. Conclusion. Varus mal-reduction must be avoided in the initial stabilisation of subtrochanteric fractures. Proximal distal screw failure is predictive of future fracture non-union and subsequent nail breakage. The diamond concept for optimising mechanics and bone biology is a successful method for managing complex sub-trochanteric non-unions with failed metalwork

Purpose. Scaphoid non-unions can result in debilitating wrist problems. This study compared treatment of scaphoid non-unions using either a non vascularised (NVBG) or a vascularised bone graft (VBG). Method. Twenty one cases of scaphoid non-unions were treated by two surgeons between 2005 and 2008 using either a NVBG from the iliac crest or a VBG from the radius based on a 1,2 intercompartmental supraretinacular artery pedicle. Results. Of the 21 cases only 19 were available followed up at a minimum of 3 months with 12 cases available for clinical follow-up 2–5 years postoperatively. Union was achieved in 9 of 11 cases in the VBG group and in 6 of the 8 cases in the NVBG group with no statistically significant difference in average time to union. Wrist range of motion was compared at the time of consolidation and at the follow-up showing no significant difference between the two groups. 11 patients completed the Dash-score and the Mayo-wrist-score with similar results in both groups. Conclusion. This study could not demonstrate any significant differences in clinical and functional outcome at the time of confirmed fracture union or at a late follow-up

Objective. To investigate the outcomes of patients following the chipping procedures as an alternative to bone grafting in treatment of non-unions after long bone fracture. Patients. Sixteen patients with femoral or tibial non-union were included. The median follow-up was 24 months. Intervention. Non-unions were treated by the chipping procedure and re-install of an intramedullary nail or locked plate(s) without bone grafting. Main Outcome Measurements. Radiographic bone union, walking ability, and complication were evaluated. Results. Fourteen non-unions clinically and radiographically healed with a median time of 7.5 months. For these cases, patients were able to walk without walking aids within 9 months after surgery. Pre-existing deformities (e.g., varus and mal-external rotation) were anatomically corrected after the revision surgery for non-union. Radiographic consolidation could not been obtained for two cases within 12 months after chipping procedures; one nonunion after old osteomyelitis and another after supracondylar fracture. Lack of stability at chipping site may be one of the reasons for failure of the procedures. Post-operative temporal anemia and swelling of the thigh were common complications after surgery. Conclusions. Chipping the non-union site was likely to enhance fracture healing, and this technique was useful as an alternative to bone grafting in treatment of femoral non-union, especially for both atrophic and hypertrophic non-unions with deformities

The aim of this study was to identify risk factors for failure of exchange nailing in tibial diaphyseal fracture non-unions. The cohort comprised 99 tibial diaphyseal fracture non-unions treated by exchange nailing. The mean age of the patients at exchange nail surgery was 36 years. The median time from primary fixation to exchange nailing was 6.4 months. The main outcome measures were union, number of secondary fixation procedures required to achieve union and time to union. Univariate analysis and multiple regression were used to identify risk factors for failure to achieve union. Multiple causes for non-union were found in 31.3% cases, with infection present in 32.3%. Further exchange procedures were required in 35.4%, 7.1% required the use of other fixation modalities. Union was ultimately achieved in 97.8%. The median time to union was 8.7 months. Univariate analysis revealed that cigarette smoking, an atrophic pattern of non-union and infection were predictive for failure of exchange nailing (p<0.05). Multi-regression analysis found that only infection was statistically significantly predictive (p<0.05) of exchange nail failure. Exchange nailing is an effective treatment for tibial diaphyseal non-unions even in the presence of infection. Smoking, atrophic pattern of non-union and infection are associated with an increased risk of further fixation surgery