Cutting Edge Orthopedics - Issue 3

Distal Tibia and Ankle Nonunions • 5  that have caused a disruption of the normal vascular supply to the bone. They have had a cessa- tion of the regeneration process, resorption of the bone ends, and in many instances, closure of the endosteal canal of the bone. These nonunions are mobile; patients usually are unable to bear weight and may require external immobilization for comfort. A special case of the atrophic non- union is a true pseudarthrosis in which a false joint has been created between the two ends of the bone. These fractures need biological stimulation in addition to skeletal stability. Bone grafting and other adjuvants often play a role in their treatment. Oligotrophic nonunions are somewhere in between these two extremes. They have very little callous formation, but the bone ends are vital. They often require both biological and mechanical augmentation. Ilizarov described nonunions as stiff or mobile [11–13]. Stiff nonunions, those with less than 7 degrees of motion at the fracture site, are thought to be biologically viable and thus equivalent to the hypertrophic nonunion. They require stability to heal, are biologically viable, and can be a source of new bone formation if distracted. In many instances, they can be treated closed. Lax nonunions have more than 7 degrees of motion and are equivalent to the atrophic nonunion of Weber. They not only require stability to heal, but also require open debridement of the nonunion site to stimulate the bone and the addition of bone graft or other biological stimulus. They are not a source of new bone with pure distraction, but instead require compression. The evaluation of the patient with a nonunion, just as with an acute injury, requires a thor- ough look at more than just the fracture pattern and the radiographs. One must determine the “personality of the fracture,” as coined by Schatzker and Tile [14]. This involves a complete history of the events of the injury, the fracture, the host, the treating physician, and the institution at which the treatment will occur. Only with this kind of analysis can one do proper preoperative planning and optimize the chance for success. Clinical Evaluation A comprehensive history is essential, as a complete picture of the fracture and the host must be obtained. Was the initial injury open or closed? Was there a high-energy mechanism such as a motorcycle accident or a lower energy trip and fall? Were there any neurovascular issues at the time of initial injury or after treatment? A determination of the type and number of previous surgeries is essential, as is the presence and treatment of previous infection. If there is retained hardware at the fracture, old operative notes can be helpful in identifying the hardware type and manufacturer for planned removal. Have previous fractures healed in a timely fashion? Patients with recreational drug habits or other substance abuse may have compliance issues. Smokers are at risk because of the well-documented relationship between nicotine use and delayed healing. Patients using nicotine gum are not immune to this problem. The occupation of the patient is important, as treatment that requires a non-weight bearing gait will cause a longer period off work for a laborer than for a patient with a more sedentary occupation. The knowledge of the avocations and hobbies of your patient are also important, as it rounds out the level of activity to which the patient must return. Hospital discharge planning often begins before surgery. The patient’s living situation, amount of support from family or friends, their financial resources, the location of their home, and what type of dwelling in which they reside is helpful in planning successful aftercare.