Treatment of bone fragments nonunion after dyaphiseal fracture

Abstract

According to the Kharkiv interregional MSEC occurrences of nonunion fractures requiring additional surgical treatment ranges from 12.5 to 26 %. Treatment of such complication appeared requires weighed approach which might take into consideration its causes and clinical features in order to repeated surgery to be the last one.

Purpose: to evaluate clinical, radiological, morphological and mechanical features of the regenerate in patients with nonunion diaphyseal fractures, and to substantiate choice of their treatment and methods of stimulation of bone regeneration.

Methods: an experience of treatment of 73 patients with nonunion diaphyseal fractures of the extremities is presented. Among them 14 patients have had femur nonunion, 39 – shin bones nonunion, 14 – humerus nonunion, and 6 patients have had forearm bones nonunion. Terms passed after trauma or surgery amounted from 4 to 23 months. Nonunions was determined in 56 % patients after open reduction of bone fragments and internal osteosynthesis, in 33 % patients after extrafocal osteosynthesis with different apparatus of external fixation, and in 11 % patients after conservative treatment. Patients were subdivided into clinical groups based on the assessment of regenerate deformation: 1^st — 16 patients with bone-cartilagenous healing; 2^nd — 22 patients with free mobility of bone fragments sometimes combining with angular deformation, restriction of adjacent joint function, and considerable violation of the support function of the segment; 3^rd — 35 patients with nonunion due to failure of internal fixation device.

Results: indications for using of closed compression osteosynthesis as well as of various types of plastic materials (small cancellous autologous bone grafts alone and in combination with platelet-rich plasma, autologous fibrin gel and other drugs containing fibrin) were clarified. Original external fixation devices allowing functional loading of the extremity were used for juxtapositioning of bone fragments. Positive outcomes were obtained in 95 % of cases.

Conclusions: deformation of soft-tissue regenerate in cases of nonunions was determined by its tissue structure. Forcible deformation is typical for bone-cartilagenous regenerate, and free one is typical for regenerate with prevalence of connective tissue. In case of dense bone-cartilagenous regenerate there were recommended creation of correct axial loading after closed elimination of its angular deformity by the external fixation device. It is a necessary to resect fibula fragment. Functional plaster dressing may be used in some cases. In case of nonunion with free type of deformation treatment has to be added with open surgery including decortication and removal of connective tissue from interfragmental area. Forming defect and subperiosteal area has to be filled with cancellous autologous bone grafts, autologous fibrin or fibrin-containing products. In case of nonunion diaphyseal fractures the use of the external fixation device is biomechanically substantiated. It allows dosage correction of the position of the fragments and thereby maintains axial vector of tension of the regenerate.