Thursday, August 25, 2011

Amir Matityahu, M.D. on Fractures That Don't Heal.

Unhealed Fractures after a standard trial of treatment are called bone "Non-Unions".

By Amir Matityahu, M.D.

Luckily, the body is very good at healing broken bones. As a matter of fact, bones heal without scarring. However, there are some bones that are more prone to not healing after a fracture. The most common is the tibia (leg bone).

The definition of a nonunion is a bone that has not healed after a length of time in which it should have been healed. For the tibia, if more then 6 months has elapsed before the bone is healed, and there is no change in healing on the x-ray over a three month period after that, then the bone will probably not heal.

The rate of bony non-union is around 5-10% depending on the bone and the the severity of the injury. Moreover, if there is complicated fracture patterns, open fractures, infection, poor nutrition, inadequate blood supply, diabetes, smoking, renal failure, metabolic bone diseases, or problems with fracture fixation stability or blood supply to  the fracture, then there may be a higher risk of the bone not healing.

The treatment of fracture nonunions should be done in an algorithmic fashion. The workup for any of the risk factors above should be performed to see if any risk factors are correctable. A thorough history to assess concomitant medical issues and previous treatments is critical. Analysis of the results from multiple tests such as labs, imaging studies, and biopsies (if needed), should be interpreted meticulously, with caution and experience. This initial step is critical for success in treatment. Moreover, patient and MD realistic treatment goals must be discussed in a frank manner. Each treatment protocol must be adjusted to the particular patient so that any the associated factors are remedied or optimized prior to surgical intervention.

The philosophy behind treating any unhealed bone is to create the correct environment for the bone to heal. This may include metabolic enhancement, infection eradication, treatment of chronic medical conditions, and mechanical stability. Moreover, smoking has been shown to have an association with bones not healing. Therefore, smoking cessation is critical.

Surgical treatment include removing any infected or avascular bone. Creating a good biological and mechanical environment for the bone to heal. Moreover, the use of antibiotic medication, if needed, can be critical. Small non-infected defects are usually treated with stabilization and bone grafting. Large bone defects can be treated in several ways such as bone transport with an external fixator or fixation with large bone grafts.  Fixation techniques vary depending on each individual case and may include plates and screws, intramedullary rods or external fixators.

Treatment of bone non-union can be done successfully but it takes expertise, algorithmic approaches and careful analysis. A multidisciplinary approach to treatment coordinated with an orthopaedic surgeon, plastic surgeon, infectious disease specialist, internist, and other specialists may be critical to success.

The questions I would ask my doctor are:
1) How many have you done? Were you trained to take care of these kinds of problems?
2) Have you taken care of a problem like mine before?
3) What workup do you plan on doing?
4) What kinds of surgery do you think I will need?
5) How long do you think it will take to treat this problem?

For more information visit Dr. Amir Matityahu’s website at or call (415) 206-8812.

About Dr. Matityahu:
Dr. Amir Matityahu is an orthopaedic surgeon specialized in complex orthopaedic trauma and reconstruction due to high velocity injuries. His areas of clinical interest are pelvic and acetabular fracture surgery, complex periarticular fractures and percutaneous and submuscular fracture fixation techniques.

His research interests include testing innovative implant design for fracture care and acetabular and periarticular fracture biomechanics.

Current Assignment:
Assistant Clinical Professor, Department of Orthopaedic Surgery, University of California at San Francisco.
Director of Pelvic and Acetabular Trauma and Reconstructive Surgery, Department of Orthopaedic Surgery at San Francisco General Hospital.

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