protein). Other labs to consider as more rare causes include the following: basic chemistry including calcium, magnesium, phosphorous, alkaline phosphatase, thyroid function tests, parathyroid hormone, iron studies, growth hormone, cortisol, and testosterone.
E. When to intervene operatively?
1. This is a difficult question to answer with a large subjective component; however, it is the most important decision on which all others are based.
2. Nonoperative treatment is always an option.
3. Ultimately, each case is unique and must be examined independently.
4. Several factors can help determine when to intervene:
a. How much does the malunion/nonunion impact the patient’s daily life?
b. How much patient function can you improve with surgery?
c. Is there a surgical option which can increase that function without exposing the patient to extreme risk?
d. Does the surgeon have the skills and equipment necessary to complete the operation and deal with any potential intraoperative complications, or should it be referred to a specialist?
e. Investigation of patient support system and motivation.
II. Treatment of Nonunions
A. The critical factor in finalizing a treatment plan is determining the cause of the nonunion and trying to counteract it.
1. Nonunion repair requires both the appropriate biology and the necessary mechanical stability for fracture healing.
2. The cause of nonunion can be multifactorial.
B. A comprehensive treatment is necessary to maximize chances of a successful outcome and minimize risks of complications.
C. If needed, it is imperative to consult with other specialists including infectious disease, general medicine, and endocrinology, among others.
D. Preoperative planning
1. Adequate imaging will be the foundation of the treatment plan.
2. From the imaging and previous records, it is critical to determine what, if any, implants are retained.
3. If the types of implants are unknown, the surgeon must be equipped to deal with any removal necessary to achieve the objectives of the operation.
4. With that in mind, it is important to minimize the destruction of the surrounding bone and soft tissue, if removing an implant is not critical to the success of the operation. Operative principles for most nonunions include:
a. Exposure and debridement at the fracture site (may not be required if hypertrophic).
b. Supplementation with biologic augments as needed. Autogenous bone graft, demineralized bone matrix, bone marrow aspirate.
c. Rigid fixation—IM nails, plates and screws, or multiplanar external fixator.
d. Preservation of soft tissues.
e. Adequate treatment of known risk factors to provide an optimal chance at recovery.
f. A frank understanding of the surgeon’s limitations and abilities so that the patient is not subjected to undue risk.
g. As a general rule:
i. Hypertrophic nonunions require increased stability and rarely any biological augmentation.
ii. Atrophic nonunions require biologic augmentation and typically some adjustment in mechanical stability such as compression at the fracture site to reduce gaps (▶Fig. 7.2).
5. Biologic augments:
There are three basic properties:
a. Osteoconductive—the graft acts as a structural frame for bone growth.
b. Osteoinductive—stimulates bone growth by the induction of stem cells.
c. Osteogenic—contain cells that promote bone healing.
Classes of Bone Graft (Refer to Chapter 8, Biologics, for additional information).
III. Malunion
Many of the principles discussed above in relation to nonunion also apply to malunion, particularly, the evaluation of when to intervene. For surgical correction to be considered, the malunion must be causing an unacceptable functional or cosmetic deformity.
A. Assessment
1. History:
a. How much does the malunion affect the current activities of daily living, employment, and desired activities of the patient.
b. What is the psychologic effect of the deformity on the patient is important to determine, yet treatment should be directed towards functional gain.
c. Were there any issues during the previous injury or surgery which may have interfered with healing or which may have contributed to forming a malunion?
2. Physical exam—the evaluation of adjacent structures and functional impacts of malunion is critical. When evaluating and deciding whether to address a malunion with operative intervention, there are several characteristics to consider which are as follows:
a. Limb length discrepancy (typically > 2 cm in lower extremity, 3 cm upper extremity).
b. Clinically relevant malrotation (typically > 15–20 degrees).
Fig. 7.3 (a) A 29-year-old male with a congenital 14-degree valgus deformity and 2 cm of shortening. (b) Osteotomy and application of circular ring fixator to gradually fix both length (via distraction osteogenesis) and alignment.
c. Angular alignment of the deformed limb (> ~10 degrees for lower extremity and higher for upper extremity).
d. Adjacent joint range of motion, particularly if there are contractures present.
3. Imaging:
a. For lower extremity deformity correction, full-length standing radiographs (anteroposterior and lateral) are extremely helpful in the evaluation and treatment planning stages.
b. Computed tomography is particularly helpful in assessing rotation/torsion. It may be necessary to have both the affected and contralateral extremity in the scanner to provide comparison to the normal side.
B. Treatment
1. Treatment protocols are site specific.
