BACKGROUND: Treating tibial non-unions efficiently presents a challenge for orthopaedic trauma surgeons. The established gold standard involves implanting autologous bone graft with adequate fixation, but the addition of biologicals according to the so-called diamond concept has become increasingly popular in the treatment of non-unions. Previous studies have indicated that polytherapy, which involves implanting mesenchymal stem cells, bioactive factors and osteoconductive scaffolds, can improve bone healing. This study aims to evaluate the efficacy of polytherapy compared with monotherapy in treating tibial non-unions of varying severity.
METHODS: Data from consecutive tibial non-unions treated between November 2014 and July 2023 were retrospectively analysed. The Non Union Scoring System (NUSS) score before non-union surgery, and the Radiographic Union Score for Tibial fractures (RUST), scored at 1, 3, 6, 9, 12 and 18 months post-surgery, were recorded. Initially, a comparison was made between the polytherapy and monotherapy groups. Subsequently, patients receiving additional surgical non-union treatment were documented, and the frequency of these treatments was tallied for a subsequent per-treatment analysis.
RESULTS: A total of 34 patients were included and divided into a polytherapy group (n = 15) and a monotherapy group (n = 19). The polytherapy group demonstrated a higher NUSS score (44 (39, 52) versus 32 (29, 43), P = 0.019, z = -2.347) and a tendency towards a higher success rate (93% versus 68%, P = 0.104) compared with the monotherapy group. For the per-treatment analysis, 44 treatments were divided into the polytherapy per-treatment group (n = 20) and the monotherapy per-treatment group (n = 24). The polytherapy per-treatment group exhibited a higher NUSS score (48 (43, 60) versus 38 (30, 50), P = 0.030, z = -2.173) and a higher success rate (95% versus 58%, P = 0.006) than the monotherapy per-treatment group. Within the monotherapy per-treatment group, the NUSS score displayed excellent predictive performance (AUC = 0.9143). Setting the threshold value at 48, the sensitivity and specificity were 100.0% and 70.0%, respectively.
CONCLUSIONS: Polytherapy is more effective than monotherapy for severe tibial non-unions, offering a higher success ratio. The NUSS score supports decision-making in treating tibial non-unions.
METHODS: Level III.

UNASSIGNED: Non-unions have been traditionally classified as atrophic, oligotrophic and hypertrophic and their management was primarily dictated by that. In our Unit, we have based our treatment rationale mainly on the stability of the metalwork and the presence of symptoms rather than the radiologic appearance of the non-union or the presence of infection. The aim was to present the treatment algorithm for lower limb long bone non-union following operative fixation.
UNASSIGNED: All patients treated for a femoral or tibial non-union following fixation between 2014 and 2020 in our unit and with a minimum follow-up of 2 years were included. Non-union was defined as having no evidence of fracture healing in any cortices six months after the index procedure. Union was defined as bridging callus in at least three cortices visualized on at least two orthogonal radiographs. Information retrieved included demographic and fracture characteristics, presence of infection, evidence of metalwork stability and treatment. Outcome measures included union rate, time to union and complications. Data were analysed with the Statistical Program for Social Sciences (SPSS) using contingency tables and linear regression. A p-value of less than 0.05 was considered statistically significant.
UNASSIGNED: Seventy-seven consecutive patients were included in the study. Union was achieved in 91% of the cases, while union was noted in all the patients treated non-operatively. The mean time to union was 14.49 months (9.98). Complications were encountered in 20 of the patients and the most common were docking site non-union and metalwork breakage. Infection was the only factor that affected time to union in a statistically significant manner (p = 0.006).
UNASSIGNED: The results of our study suggest that in cases of long bone non-union following operative fixation using signs of metalwork instability and the presence of clinical symptoms as the main indication for surgical intervention provides a satisfactory outcome. This approach prevented operative management in a large proportion of patients.
UNASSIGNED: This article presents an algorithmic approach that could aid clinicians in their decision-making in long-bone non-union management.
UNASSIGNED: Therapeutic level III.
UNASSIGNED: Poutoglidou F, Krkovic M. The Cambridge Experience with Lower Limb Long Bone Non-union Following Fixation and the Treatment Algorithm. Strategies Trauma Limb Reconstr 2023;18(2):100-105.

The purpose of this study was an experimental assessment of changes in bone fragment position in patients with non-union of the tibia treated with a hexapod fixator.
We hypothesized that the use of hexapod fixators leads to differences between the planned and actual position of bone fragments.
The study was conducted in physical models of the hexapod fixator-bone fragment system. Bone fragment displacement was measured using the Optotrak Certus Motion Capture System. We assessed differences between the planned and actual position of bone fragments.
Assessment of bone fragment compression demonstrated a difference between the target and actual correction ranging from 1.5% to 13.2% (depending on the force applied to bone fragments) for configuration 1, from17% to 21.3% for configuration 2, and from 13.2% to 17.9% for configuration 3. The achieved varus deformity correction constituted 93.7-98.4% of the target correction for configuration 2 and 98.3-98.9% of the target correction for configuration 3. Torsional deformity correction showed considerable discrepancies between the target and achieved correction, ranging from 65.6% to 83%.
The value of the applied compression force had no marked effect on the differences between the target and achieved correction or on the magnitude of unintended rotational and transverse displacement of bone fragments. The use of hexapod fixators helped achieve complete correction of the simulated varus deformity; however, complete correction of torsional deformities was not achieved. Deformity correction in physical models with the use of a hexapod fixator yielded instances of unintended rotational and transverse bone-fragment displacement. The use of hexapod fixators in physical models leads to differences between the planned and actual position of bone fragments.
IV, case series.

Intertibiofibular graft (ITFG) bridges tibial non-union, but blocks bimalleolar mortise opening, leading to loss of ankle dorsiflexion. The aim of the present study was to assess dorsiflexion loss and to determine whether it was associated with secondary osteoarthritis. Material and method A 2-center retrospective study included cases of tibial non-union, without initial involvement of the ankle, treated by ITFG with more than 2 years\' consolidation. Clinical, functional and radiographic parameters were analyzed. Dorsiflexion stiffness was defined as<10° flexion. Symptomatic osteoarthritis was defined by radiologic joint impingement and/or osteophytosis associated with pain>4/10 on visual analog scale (VAS) restricting walking distance to less than 1 kilometer.
Thirty-one cases were analyzed at a mean 7±2.8 years\' follow-up. Mean pain on VAS was 3±2.6. Mean AOFAS score was 62.3±20.5 and mean SEFAS was 28.3±10.5. Mean dorsiflexion was significantly lower on the ITFG side, at 6.6±7.9° versus 15.1±4.8° on the healthy side. There was dorsiflexion stiffness in 26 cases. No correlation emerged between dorsiflexion stiffness and onset of osteoarthritis.
Dorsiflexion was the most severely impacted motion. The rate of osteoarthritis was too low for any implication of dorsiflexion loss to be demonstrated, especially in traumatic contexts.
IV; retrospective study.

OBJECTIVE: Exchange nailing is widely used for the management of aseptic femoral and tibial non-union. Compressive forces markedly reduce strain, increasing rate and incidence of union. Additional compressive forces can be applied to the non-union site by using the design features of some modern nailing systems. This study hypothesises that the use of additional compression in exchange nailing results in faster time to union.
METHODS: All femoral and tibial shaft non-unions were identified over a 4-year period between 2014-2018. Intraoperative compression during exchange nailing was either applied or not applied with a dedicated active compression device through the intramedullary nail. An initial \'radiographic union score for tibia\' (RUST) score was calculated from preoperative lateral and AP radiographs and compared with the postoperative radiographs at 6-8 weeks. Healing was defined as bridging callus on at least three cortices (RUST > 10).
RESULTS: A total of 119 patients were identified. Following application of exclusion criteria, we analysed data for 19 patients, 10 undergoing exchange nailing with intraoperative compression and 9 without. The pre-exchange RUST score was comparable between the compressed group and standard exchange group with mean of 7.11 versus 7.5 (p = 0.636). At 6-8 weeks post-op, there was a significant difference between the median RUST score in the compressed group vs standard exchange group, 11 compared to 8.39 (p = 0.001).
CONCLUSIONS: Our study shows that time to union was accelerated when additional compression was applied to exchange nailing, resulting in reduced follow-up visits and number of radiographs required.

Intra-medullary osteosclerosis of the tibia is a rare condition characterised by chronic pain due to diaphyseal hyperostosis with no detectable triggering factor. The main differential diagnoses are stress fracture and osteoid osteoma. Of the few cases reported to date, most were in adults. The objective of this study was to assess paediatric patients with intra-medullary osteosclerosis to determine whether the first visit provides sufficient information to establish the diagnosis and rule out both osteoid osteoma and stress fracture, whether a biopsy is required, and which treatment is optimal.
The diagnosis of intra-medullary osteosclerosis of the tibia can be made at the first visit.
Seven paediatric patients, 4 males and 3 females, with a mean age of 11 years, were included in this retrospective study. We evaluated the clinical features, findings from imaging studies (standard radiographs, computed tomography, magnetic resonance imaging, and bone scintigraphy), and treatment outcomes.
At the first visit, all patients had a painful swelling at the middle of the shin and imaging study evidence of antero-lateral tibial cortical thickening extending into the medullary cavity; in 5 patients, a linear lucency was visible. No other bone abnormalities were seen. Treatments included non-operative measures, pinning, and nailing. None of these treatments provided permanent bone healing or pain relief, although transitory freedom from pain with or without radiological bone healing was achieved.
Intra-medullary osteosclerosis of the tibia is rarely reported and therefore probably underdiagnosed. Distinctive characteristics of the cortical and endosteal thickening include location at the antero-lateral mid-diaphysis and, in some cases, the concomitant presence of a linear lucency that can provide the early diagnosis. The distinctive radiological features allow differentiation from a stress fracture. The management is challenging.
IV, retrospective observational study.

A good long-term outcome following a total knee arthroplasty relies on restoration of the mechanical axis and effective soft tissue balancing of the prosthetic knee. Arthroplasty surgery in patients with secondary osteoarthritis of the knee with an extra-articular tibial deformity is a complex and challenging procedure. The correction of mal-alignment of the mechanical axis is associated with unpredictable result and with higher revision rates. Single-staged deformity correction and replacement surgery often result in the use of constraint implants. We describe our experience with staged correction of deformity using a Taylor Spatial Frame (TSF) followed by total knee arthroplasty in these patients and highlight the advantage of staged approach. The use of TSF fixator for deformity correction prior to a primary total knee arthroplasty has not been described in the literature. We describe three cases of secondary osteoarthritis of the knee associated with multiplanar tibial deformity treated effectively with a total knee arthroplasty following deformity correction and union using a TSF. All patients had an improved Knee Society score and Oxford Knee score postoperatively and were satisfied with their replacement outcome. Staged deformity correction followed by arthroplasty allows the use of standard primary arthroplasty implants with predicable results and flexible aftercare. This approach may also provide significant improvement of patient symptoms following correction of deformity resulting in deferment of the arthroplasty surgery.

The need for an ideal approach for the nonunion of the tibial shaft with anteromedial soft tissue scarring has long baffled surgeons. Many different approaches have been suggested in the past, but all those approaches were haggled by a multitude of problems. We have described a novel \'transfibular approach\' for this selective situation. An appropriate patient with a mid-shaft tibial non-union was selected. After preoperative workup, the patient underwent an open reduction internal fixation (ORIF) with lateral tibial plating, bone grafting, and partial fibulectomy. In this new approach, the plane between tibialis anterior and extensor hallucis longus was used combined with a conventional posterolateral approach using the same incision. Subsequently, the patient was followed up for adequacy of the fixation and wound-related problems with a convincing outcome.

BACKGROUND: Non-union of the tibia complicated by osteomyelitis is one of the most challenging problems in orthopaedic surgery. There remains a significant amount of debate and controversy regarding the optimal medical management of infected tibial non-union. There are few articles which have reported the outcomes of treatment for infected non-union of tibia from single-stage reconstruction with open bone grafting plus vacuum-assisted closure (VAC).
METHODS: Our report covers experience between March 2007 and February 2010 of open bone grafting plus VAC in one stage for patients with infected tibial non-union. The time for bone union and wound healing to occur, the duration of hospitalisation, and the rate of resolution of infection were all analysed. The main outcome measures were based on a clinical scoring system that assessed functional ability, range of knee and ankle motion, shortening, infection and pain. Fifteen patients were involved in this study.
RESULTS: All patients were followed up for an average of 22.6 months (range: 14-42 months). Bone union was achieved in 93.3% (14/15) of patients after a mean of 5.93 months (range: 3-10 months). All wounds healed within an average period of 5 weeks (range: 3-10 weeks), and the function and appearance of all limbs were satisfactory.
CONCLUSIONS: Open bone grafting combined with VAC in a one-stage procedure can be a feasible alternative to the treatment of infected tibial non-union, especially for those wounds which are not good candidates for microsurgery; however, further studies are required to confirm the likely benefits.