Eighty-five percent of bone fractures heal. But what about the other fifteen percent?
Generally, bones fail to heal for two reasons. Malunions are comprised of fractures that have either healed in a rotated or deformed position; or nonunions are fractures that have failed to heal or mend.
"Most broken bones want to heal," explained Samir Mehta, MD. "When you have a situation where a fracture or some kind of trauma hasn't healed, there is an underlying reason why."
Dr. Mehta and his colleagues, plastic surgeon Stephen J. Kovach, III, MD, and ortho-plastic surgeon L. Scott Levin, MD, co-direct the Penn Orthoplastic Limb Salvage Center.
This team of Ortho-Plastic surgeons and trauma physicians, based in the Philadelphia area, are specifically devoted to treating these types of fractures, as well as other complex issues, such as:
- malunion and nonunion fracture repair
- complex soft tissue repairs
- advanced limb lengthening
- reconstructive microsurgery
- osteotomies
- living bone transfers
"Often, patients whose bones haven't healed need a plan," Dr. Mehta said. "They need some kind of algorithmic approach to their care, and it often requires multiple sets of input to do it right."
Penn Medicine is able to provide that personalized plan and intensive treatment.
The Center is unique for having experts like Dr. Mehta (who is also Chief, Orthopaedic Trauma and Fracture Care), cutting edge technology and a high volume of patients. In a recent video, Drs. Mehta and Levin discuss the unique systematic approaches and tools they use at Penn's Orthoplastic Limb Salvage Center.
Treating Malunion and Nonunions
Caused by complications imposed upon the original injury, non-healing fractures, such as malunions and nonunions, require intensive treatment and rehabilitation — often with treatment that is fundamentally different than the treatment for the patient's initial injury.
"A malunion typically occurs when a fracture has not been aligned in a way that optimizes healing," said Dr. Mehta. He explained that if the misalignment results in rotation (or shortened limb), the malunion becomes a mechanical issue that interferes with normal function. Hardware issues or bone alignment during healing can also result in limited function.
The standard therapy for malunions is to reset the bone and hardware for proper healing.
The lack of adequate blood flow to the bone in a nonunion can cause bone tissue to degrade, and even result in osteonecrosis (bone death).
Nonunions are typically treated as if they are new fractures.
Four Factors for Fracture Healing
Typically, the reasons an injury did not properly heal can be narrowed down quickly. "Usually, the problem is in one of four domains, or some combination thereof," Dr. Mehta explained. "Infection, the blood supply to the bone, the biomechanics of the fracture, and the patient's own host factors."
Infection is common when the soft tissue envelope hasn't been restored. Infection must be removed before addressing other morbidities or reconstruction.
"What sets us apart as a program is that we have skilled plastic surgeons able to undertake complex soft tissue repairs," Dr. Mehta said.
Inadequate blood flow can cause bone tissue breakdown and osteonecrosis (bone death).
Biomechanics can play a role in malunions and nonunions.
"Instability at the fracture site months after injury is a clear sign of biomechanical failure," says Dr. Mehta.
Penn Medicine physicians developed a surgical fixation strategy to ensure stability in complex fracture repair. The personalized plan is created after an evaluation of the patient's musculoskeletal structure. The team troubleshoots the origin of the hardware failure, and the patient leaves with a blueprint for follow-up care.
Patient biology can greatly impact healing.
Reviewing patient biology allows us to gauge the body's capacity to repair bone. Penn patients undergo metabolic panels and other lab evaluations, such as body chemistry, metabolism and immune response. Medical history and lifestyle factors also contribute to healing potential. The result of these panels can determine direction before and after malunion and nonunion repair.
Heather's Tibia: A Nonunion Case Study
Heather, an athletic woman in her mid-thirties, broke her tibia during a roller derby match. The break was severe, and she had a rod inserted in the bone in a local hospital.
Eight weeks later, was on her skates again. But she was still in pain — 2400 mg of prescription-strength ibuprofen per day pain.
Heather circled back to her community hospital's surgeon, who, finding nothing wrong, referred her to the Penn Orthopaedic Limb Salvage Center.
Evaluation at Penn Orthopaedic Limb Salvage Center
Heather was treated by Dr. Samir Mehta, an orthopaedic surgeon, fracture specialist and Co-Director of the Center. Upon evaluation, he quickly discovered that her tibia bone ends had failed to heal after her original injury.
Nonunions can be virtually invisible — even to highly trained specialists.
Fundamentally different from the original fracture, nonunions are treated as new fractures, as they require much more complex care. And none of the standard approaches to nonunions seemed to apply to Heather's fracture.
With the rod in place, and tests suggesting that Heather was otherwise healthy — with no signs of infection or blood supply impingement, the source of her nonunion was a mystery.
Something else was impeding the healing process. But what?
An Unconventional Approach to Healing
At this point, Dr. Mehta's suspicions turned to Heather's fibula, which had survived the accident that fractured its partner.
"The fibula isn't a load-bearing bone," Dr. Mehta recalled. "But because it was intact after Heather's accident, it struck me that it might be taking just enough of the load to prevent the tibia from compressing (and healing)."
Dr. Mehta's hypothesis was correct. And his method for treatment was unconventional: Surgically fracture the fibula. This would allow enough compression for healing to take place in the tibia.
Heather wanted her pain to end, and wanted to walk and skate again. She agreed to the procedure.
"When we did her surgery, we took out the existing rod, then did an osteotomy of her fibula to create a fracture there," Dr. Mehta said.
The Penn surgeons then put a new rod in the tibia, compressed the fracture in the operating room and placed new screws in the bone.
These adjustments brought about millimeters of bone compression. This allowed Heather to walk almost immediately.
Six weeks after surgery, Heather was without pain.
"For me, it was sort of a miracle," Heather said. "I got to skate again without pain. I got to live my life."
Consult with the Penn Orthopaedic Limb Salvage Center
It's our mission to restore patients like Heather back to their normal daily life.
Patients with lingering malunions/nonunions, persistent pain, unresolved infection, evolving scarring and bone or tissue defects as a result of cancer therapy, previous surgeries or trauma are the norm at Penn Orthopaedic Limb Salvage Center.
Our clinical team sees a high volume of patients with chronic injuries. We specifically treat these issues and severe functional limitations that other injuries cause.
Our Center is a resource of support to other physicians who may need assistance managing complex patient injuries.
- To refer a patient to the Center, call 215-294-9625, and we will coordinate your chronic trauma patient's care.
- For urgent or emergent management of a patient, please call 215-615-6978 to speak directly with a Penn Orthoplastic Limb Salvage Center surgeon.
Video Transcripts
Emerging Surgical Techniques for Malunions and Nonunions
Dr. Mehta: About 85 percent of all fractures heal. That really means that only 15 percent don't heal which means that it's not a common event. So, why didn't it happen?
A malunion of a fracture is really a fracture that is healed in a way that causes functional deficit.
One example I can give you is the malrotation of the femur. When the fracture was fixed, it was fixed in a way where the leg was rotated. And it's clear when you stand that the foot is really angled. Now, there are limits to that. The body can tolerate a certain amount of rotational deformity, but if it's too much, it's going to then cause a chain reaction of the body.
A non-union of a fracture is a fracture that has not healed. And the problem with a non-union is number one, they can be painful, and number two, they can limit your function... typically because of the pain, or the instability from the fracture still moving.
Usually, the problem is in one of four domains, or some combination thereof: Infection, the blood supply to the bone, the biomechanics of the fracture and the fracture healing, and then the patient's own host factors. Our approach is really to look at all four of those things, and address those in a very sort of systematic fashion.
Dr. Levin: We have very specialized techniques in reconstructive microsurgery, with the ability to transfer to transfer living bone with its blood supply. Osteotomies, in other words, re-breaking the bone, and using thin wire and external fixators, perhaps the ilizarov method.
We have very, very powerful tools that are not available in other centers around the country, and they're right here at Penn Orthoplastic Limb Salvage Center.
Dr. Mehta: Not all the fractures I take care of heal. It's the reality of the kind of work that we do.
But there are resources out there for providers who might see situations, clinical situations that they don't do on a regular basis.
And for those providers, a place like the Penn Orthopedic Limb Salvage Center is a great option, and we're always willing to have that conversation to figure out what the next best thing is for both the provider and the patient.