What to do if Your Bone Didn’t Heal
A non-union is the permanent failure of a bone to heal following a fracture. A delayed union is the failure of a fracture to heal within a normally expected time. Non-unions and delayed unions may occur after traumatic fractures, or osteotomies (in which a bone is cut to correct deformities). However, they are most common in fusion surgery.
How are They Treated?
My #1 job is to figure out why the fracture didn’t heal the first time. Most doctors don’t like to treat patients that didn’t heal the first time, but I enjoy it and treat it like a detective game.
These patients require careful and extensive history and physical examination. I look for clues of risk factors for not healing. I also intently study the x-rays and try to determine why the first treatment didn’t work. I have a serious advantage this time as I get to see what didn’t work the first time. I evaluate the alignment from the spine down to the foot to determine if there are nerve problems or biomechanical malalignment that could be predisposed to failure. A careful assessment of blood supply is also essential. You cannot grow crops without water and you cannot grow bone without blood. Sometimes we need to bring in Vascular specialists and even plastic surgeons to help improve the vascularity of the bone.
What Causes Delayed Unions and Non-Unions?
There are 2 main categories of causes for delayed and non-unions.
- Failure to obtain or maintain adequate stabilization. This is characterized by thick excessive bone callus (hypertrophic nonunion) as the body desperately attempts to self stabilize.
- Failure to line up the two ends of the bone or accidental interposition of soft tissue in between the fractured bone ends.
- Avascular necrosis (loss of blood supply). Occasionally the trauma of a fracture, the nature of the bone fractured (high risk bone with poor blood supply), or even surgery interrupts the blood supply to the bone. If there is no blood, the fracture cannot heal until the blood supply returns from either end.
- Infection in a fracture is called osteomyelitis. More often associated with open (compound) fractures or fractures with delayed skin wound healing, infection may block bone healing
- Metabolic causes. Diabetes with poor sugar level control, smoking, Vitamin D Deficiency, and other metabolic/endocrine deficiencies can delay healing.
Complications with Diabetes
Diabetics require the greatest amount of attention. It makes no sense to do a second surgery in a patient with blood sugar levels that are out of control. Some doctors nickname that surgery a “pre-amputation surgery,” and loss of a limb is nothing to joke about.
My second job is to plan how to redo the work and make it heal the second time. I have to reverse all the negative factors inhibiting healing that I can by doing the following:
- Improving the mechanical environment (increasing or replacing the stabilization of the bone)
- Removing interposed soft tissue
- Realigning the fractured ends
- Using specialized hardware to help create rigid compression between the bone ends
- Adding growth factors to encourage healing. I use a combination of autogenous (from the patient), allograft (cadaver donation), and artificial bone substitutes.
Often in a revision (second time) surgery, I pull out all the stops and will use bone stimulators, either intra-operatively or post-operatively. A bone stimulator sends a signal to the bone cells and encourages the formation of bone. Usually the device causes no symptoms (other than annoyance to put it on every day for several hours).