Management of resistant pseudarthrosis of long bones

A retrospective review was undertaken of 15 patients with long-bone pseudarthrosis with long-standing nonunion. These patients were referred to a tertiary care center after their fractures failed to unite after numerous surgical attempts as well as a course of electrical stimulation. Fourteen patients had nonunion of the tibia, and one had nonunion of a humerus fracture. Twelve were originally Gustillo Grade II or III fractures, and four sustained multiple injuries. The average duration of nonunion before presentation to the clinic was 22.5 months. Five patients presented as infected nonunions. Each nonunion was analyzed with specific reference to injury mechanism, skin and bone conditions, presence of infection, primary treatment protocol, and selection criteria for treatment with electrical stimulation. Review of the data revealed that the most common factor associated with failure of electrical stimulation treatment was inappropriate patient selection, according to criteria previously published for the use of these techniques. Treatment modalities consisted of intramedullary fixation in three, open reduction and internal fixation using Arbeitsgemeinschaft fur Osteosynthesefragen (AO) technique in nine, and external fixation in three. All patients were bone grafted. The mean follow-up duration was 1.5 years. Nonunions were healed in fourteen patients. Twelve were fully weight bearing at six months, and one at 12 months. Success was defined as restoration of a functional extremity, giving a success rate of 87%. A thorough reevaluation of the original treatment regimen and a return to basic principles of operative fracture management and bone grafting can yield excellent results, even in patients with recalcitrant nonunion.