Single-Stage Treatment Protocol for Presumed Aseptic Diaphyseal Nonunion.

INTRODUCTION

This article describes the general surgical technique for treating presumed diaphyseal nonunion with a one-stage procedure involving intraoperative removal of specimens for culture, revision open reduction and internal fixation (ORIF) with a plate or nail, and bone-grafting.

STEP 1 PREOPERATIVE EVALUATION: Take a careful history, evaluate the extremity and wound, and note comorbidities and medications.

STEP 2 PREOPERATIVE PLANNING: Preoperative planning is essential before revision nonunion surgery.

STEP 3 DEBRIDEMENT IMPLANT REMOVAL AND CULTURES: Debride the nonunion site, remove all failed and loose implants, and take specimens for culture; withhold antibiotics until all culture specimens have been obtained.

STEP 4 OPEN REDUCTION AND INTERNAL FIXATION: Reduce the fracture and use interfragmentary fixation and/or compression, or a bridging plate.

STEP 5 POSTOPERATIVE CARE: If any of the five cultures are positive, consult an infectious disease specialist with experience in treating musculoskeletal infections.

RESULTS

We have used this protocol at our institution for patients with prior fracture surgery who subsequently developed a nonunion, with or without implant failure, that had no obvious infectious etiology.IndicationsContraindicationsPitfalls & Challenges.