Essential Insights For Managing Nonunions

By Jesse B. Burks, DPM, FACFAS

Nonunions can be a troubling condition for both the patient and the podiatric physician. Failed unions can result from a host of factors arising from the patient, surgeon or both. In many surgical cases, one primary cause is difficult to identify and the end result may actually result from a combination of various etiologies. As with any surgical complication, it is important to emphasize preventive efforts. However, even with diligent efforts, a nonunion may still occur. In my opinion, there are three different perspectives that dictate how one should treat. There is the academic perspective, the patient perspective and the podiatric physician’s perspective. From a purely academic point of view, a non-union is classically described as a fracture, osteotomy or arthrodesis site that has failed to show progressive signs of radiographic healing over an eight-month period. However, almost every surgeon will agree this is more of a guideline than a concrete statement. When a fracture, osteotomy or arthrodesis site fails to progress toward a successful union, surgeons will often treat this aggressively prior to the conclusion of an eight-month time frame. From the patient’s perspective, the condition may not even require treatment. In many cases, a surgical or traumatic non-union may not cause pain or alter function, and is simply a radiographic finding. If there is appropriate discussion with the patient and documentation, one may forgo treatment of the nonunion. The perspective of the podiatric physician is most important as he or she is considering what is the most beneficial thing for the patient in the long term. For example, a nonunion of a first metatarsocuneiform arthrodesis may not be symptomatic but gradual elevation of the first ray can lead to transfer pressure and lesser metatarsal complications. In such cases, even a pain-free nonunion may require treatment in order to prevent long-term sequela. Emphasizing Patient Compliance In Preventing Nonunions Despite a surgeon’s (and the patient’s) best efforts, nonunions can still occur. However, there are several factors that surgeons and patients can address during the pre-operative or pre-treatment period that will reduce the risk of a failed union. For the sake of simplicity, one may divide these factors into patient factors and surgeon/physician factors. Obesity is a common dilemma and can contribute to a myriad of health problems. Any type of bony injury or reconstruction can be significantly influenced by a patient’s weight. The added weight can make it difficult for the patient to remain compliant in treatments that necessitate complete non- or protected weightbearing. Postoperative or post-traumatic edema can also be exacerbated by the increased weight. It has also been my experience that fitting overweight patients in non-custom devices for the purpose of offloading or immobilization is difficult. Concurrent health problems such as diabetes do not always preclude surgical intervention but one should strive to do what he or she can to minimize the potential effects of these conditions. In particular, when patients have diabetes, one should emphasize the importance of strong glucose control even if the clinician is initiating conservative treatment. Patients on chronic steroid therapy and other immunosuppressive medications may also need to have adjustments to their dosages. Compliance is difficult and, at times, impossible to control. Early or excessive weightbearing can displace internal fixation or increase micromotion of bony fragments, and increase the chances of nonunion. Casting, bracing or in-patient admission, if warranted, can dictate some of the patient’s activities but, ultimately, having a frank discussion with the patient about possible adverse outcomes is the most influential way to facilitate compliance. Revisional surgery is not a pleasant proposition for the surgeon or patient. Key Preventive Measures For Reducing Nonunion Risk Conservative treatment and the choice of surgical procedure will vary among physicians and surgeons. However, there are certain principles we typically adhere to when attempting to prevent or reduce the incidence of nonunion. In my opinion, immobilization can be overzealous. Most surgeons will agree that immobilization is needed for fracture treatment and many arthrodesis or osteotomy procedures. Of course, the question is “How much immobilization is enough?” This can vary among surgeons.

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