What is a Non-Healing Fracture?
A fracture area that has not healed is called a Non-Union or Un-United Fracture.
This area may have metalwork present, either along the fracture in the form of a plate with screws, or an internal rod within the bone called an Intra-Medullary nail. Intra-Medullary means within the Medulla or Canal of the bone.
Why may the Fracture not heal?
There are many reasons why a fracture may not heal:
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It may be that the current fixation has broken.
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There may be an infection at the fracture area, which has prevented the fracture from healing.
At the time of your surgery, tiny samples of the fracture area may be taken and sent to the Bacteriology Laboratories to determine if there is an infection present. Infected bone is called Osteomyelitis.
How does Plastic Surgery help?
If a large area of Osteomyelitis or soft tissue has to be removed using surgery, then a second procedure may be required to fill the space left by the surgery and improve the blood circulation.
Dependent on the bone and soft tissue area involved and the strength requirements of the bone affected, a variety of methods may be used. Please discuss this further with Mr Khan and team.
Examples of this second procedure involving plastic surgery reconstruction are:
1. Small areas with surrounding healthy tissue can be left and will fill and heal eventually with no other intervention required.
2. Muscle flaps can be used to fill and correct both soft tissue and bone gaps within the body. These flaps are not visible externally on the limb. They improve the circulation to the area therefore assisting the antibiotics to penetrate the area. Mr Khan will remove a muscle from another area of your body, usually from an area local to the surgical area. (Mr Khan always attempts to transfer a muscle that by its removal alone should not affect your day-to-day performance)
3. Muscle flaps can be used to fill soft tissue gaps in a limb where infected skin and muscle have had to be removed. This not only improves the circulation but ensures that the operated area is completely protected with the new soft tissue, improving the blood supply, filling the gap and preventing secondary infection from the outside (atmosphere) into the surgical area. When used this way the muscle flap is covered with a layer of skin graft. The skin graft is usually taken from your thigh. Mr Khan tries to take into account the final resulting shape and appearance of the area of the limb but it often takes a few months for the muscle flap to flatten to the same shape as your limb.
4. Plastic Surgery may also involve using bone transferred from one area of your body to another to fill a gap in the bone. This may involve using bony chips usually taken from the part of your hip called the Iliac Crest. This is the area of your hips that stick out at the front, above your groins. The bony chips are then used to fill small gaps in bone.
5. The second procedure involves using larger sections of bone. This procedure is used in Limb Reconstruction when the amount of lengthening required is more than we can offer by using the frame alone. An example of this procedure is explained. A larger piece of bone is taken (usually from the fibula, the smaller leg bone, below the knee) and transferred with its own blood supply into the area of your limb where you need living bone. This is called live bone transplant. It involves “plumbing” the transplanted bone (usually the fibula) arteries and veins together into the new area requiring bone.
Different aspects of Non-Healing Fracture Surgery
Removal of Metalwork at Infected Non-Union sites: A non-union site is where your original fracture (sometimes held with metalwork) has not healed. This may be due to a variety of reasons, but at the time of surgery Mr Khan will take samples of the bone at the non-union site to look for signs of infection. If the non-union site has metalwork present, Mr Khan may need to remove this metalwork at the time of surgery.
Non-Union Site Surgery: The non-union site is Debrided. Debridement of bone involves scraping away diseased bone until healthy bone is reached. If there is any obviously infected bone, this is also Debrided or removed completely. Dead or infected bone may need to be removed completely. Depending on the bone involved and the strength requirements of the bone, the limb may need to be supported, protected or held in a secure position after the operation.
How does the frame help to heal a Non-Union?
The majority of patients Non-Union sites are merely held in the frame until united or healed. However, if necessary we can stimulate the area if we feel that it is not healing as it should do. The method is similar to leg lengthening. Using spanners to make tiny movements to the frame we can compress (squash) the 2 ends of the bone or distract (pull apart) the ends. This is used when we think that the fracture site needs stimulating or exciting.
What is the progression with a Fixtator Treatment?
First Stage: During the first few weeks you are gaining confidence about your treatment. You are learning to adapt to the fixator and the changes in your normal routine. You begin to see progress, whether it is a lessening deformity or leg lengthening being achieved.
Middle Stage: At this stage you have adapted to the fixator and new routine, you seem to have more time on your hands and physio or exercises become tedious.
You may have been off work for a long time and life may have become pretty boring.! You are half way through treatment and the end seems a long way off. You may have encountered a problem that has delayed your treatment by a few weeks. You may feel despondent or depressed. This is a completely normal response to the treatment at this stage and please remember that these feelings will pass.
At this stage it is extremely important to attend your clinic appointments. Take the time to talk to other patients. It may be useful to exchange telephone numbers with other patients who are going through the same problems.
Try and think about activities or people that usually cheer you up. Take some time to organise one activity or visit each week. Maybe taking up a new activity to occupy your time would help. Some examples are drawing, painting, writing or photography.
Final Stage: You are nearing the end of your treatment and removal of the fixator. The frame is driving you mad, but you are able to see the light!
We begin to neutralize the frame in clinic so that more weight is being put through the bone and less through the frame. The timing and actual removal of the frame will be discussed with you by your team of doctors at your clinic appointments. Some parts of your frame may be able to be removed at a clinic appointment. Removal of the frame occurs under a general anaesthetic. This takes from 10 minutes to one hour. This is usually treated as a day case and you are able to go home the same day. Many patients require a plaster of paris cast applied following removal of the fixator. (Some patients have light-weight splints) The length of time spent in this plaster varies depending on your condition, but most patients spend 4 to 6 weeks in the plaster cast.
All patient’s experiences are different.
Everyone had different coping mechanisms. We aim to support you throughout your treatment and offer advice and support 24 hours a day, 7 days a week before and after surgery. We are very interested in your comments and experiences during your fixator treatment. Please feel free to write down any information that you feel is important for us to know so that we can pass this information on to our future patients.
Recovery after Non-Healing Fracture
You may be asked not to put any weight through the limb for a period of time. If your surgery is on your leg, you may be asked to use elbow crutches or another walking aids. If your surgery is to your arm, you may be asked not to carry anything heavier than a piece of paper.
If the bone is unstable Mr Khan will apply an external fixator device to your limb.