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Nonunion and Bone Defects
Posted: Jan 30 2020 #(C101373)
A

Proximal Third Tibia Fx Nonunion in 62F

HPI

A 62-year-old female presents for evaluation of nonunion of a left proximal 1/3 tibial shaft fracture. She sustained the initial closed injury in April 2018 and underwent IMN placement. Post-operative CT Scan revealed nonunion and she underwent nonunion takedown with nail removal and revision ORIF with a 3.5mm plate and screw construct and bone grafting. Interval healing was noted on subsequent films, and she was allowed to weight bear. Unfortunately, following a period of weight-bearing, she sustained hardware failure. CT scan again revealed incomplete union at the fracture site. She then underwent a second revision with a larger 4.5mm plate and screw construct with bone grafting. She continued to have pain with weight-bearing, and there was no evidence of definitive union in subsequent months. CT scan again revealed nonunion with varus malalignment. She presented to the office for an opinion regarding her treatment options.

PMH

No prior medical history. Denied regular alcohol use, tobacco products, or illicit substance abuse. Works as a restaurant owner. Labs: calcium, vitamin D, pre-albumin, albumin, CBC, CRP, and ESR had all been normal in previous workups.

PE

A focused physical exam of the left lower extremity reveals well-healed incisions without any drainage or erythema. She has clinical varus deformity of her lower extremity. She has tenderness to palpation of her nonunion site with gross motion at her nonunion site. She is neurovascularly intact

Poll
1 of 10
1. Would you perform any additional workup to guide further management at this time?
No - additional work-up would not affect my management
17%
178/1046
Yes - repeat metabolic work-up only (includes Vitamin D, TSH, etc.)
4%
44/1046
Yes - repeat infectious work-up only (includes CBC, ESR, CRP, etc.)
22%
234/1046
Yes - repeat metabolic + infectious work-up
53%
563/1046
Outside my area of expertise - best if I don't vote
2%
27/1046
2. Given the negative infectious work-up, how would you classify this persistent nonunion?
I would not use a classification system
4%
45/1020
Hypertrophic
33%
343/1020
Oligotrophic
34%
348/1020
Atrophic
23%
238/1020
Outside my area of expertise - best if I don't vote
4%
46/1020
3. How would you manage the patient's persistent nonunion at this time?
Nonoperative
3%
37/1001
Operative
93%
939/1001
Outside my area of expertise - best if I don't vote
2%
25/1001
4. If you choose Operative management, in addition to possible hardware removal, what surgery would you perform?
I would not choose Operative management
0%
5/1004
External fixation only (includes monoplanar, ringed circular fixation, etc)
29%
293/1004
Intramedullary nail (IMN) fixation
30%
304/1004
Open Reduction Internal fixation (ORIF) with plate and screws (includes MIPO)
18%
187/1004
ORIF + IMN
18%
184/1004
Outside my area of expertise - best if I dont vote
3%
31/1004
5. If you choose Intramedullary nail (IMN) fixation, would you perform a fibular osteotomy?
I would not choose IMN fixation
12%
123/967
No
12%
120/967
Yes
70%
685/967
Outside my area of expertise - best if I don't vote t
4%
39/967
6. If you choose Intramedullary nail (IMN) fixation, how would you address the nonunion site?
I would not choose IMN fixation
9%
89/936
I would not do anything specifically with the nonunion site
10%
94/936
Debridement + acute bone grafting
59%
557/936
Debridement + placement cement spacer for staged grafting (Masquelet technique)
17%
168/936
Outside my area of expertise - best if I don't vote
2%
28/936
7. If you choose Acute bone grafting of the nonunion site, what type of graft would you use?
I would not choose Acute bone grafting
3%
32/926
Allograft only
6%
57/926
Autograft only
53%
499/926
Allograft + autograft
33%
313/926
Outside my area of expertise - best if I dont vote
2%
25/926
8. If you choose Autograft, what source would you use?
I would not choose Autograft
2%
22/915
Reamer-Irrigator-Aspirator (RIA)
23%
217/915
Iliac crest bone graft (ICBG)
68%
626/915
Proximal tibia
2%
19/915
Other
1%
12/915
Outside my area of expertise - best if I don't vote
2%
19/915
9. If you choose Intramedullary nail (IMN) fixation, would you supplement with biologics?
I would not choose IMN fixation
7%
67/886
No
32%
291/886
Yes - rhBMP-2
22%
201/886
Yes - rhBMP-7
18%
161/886
Yes - Other
3%
31/886
Outside my area of expertise - best if I dont vote
15%
135/886
10. If you choose Operative management and attained the final construct shown below, would you prescribe a post-operative bone stimulator?
I would not choose Operative management
0%
5/845
No
38%
325/845
Yes
53%
456/845
Outside my area of expertise - best if I don't voteWide excision
6%
59/845
PROCEDURE #1

Nonunion repair of left tibia with placement of intramedullary nail following hardware removal and fibular osteotomy

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OUTCOMES
Post-procedure P1
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