Non-union/Mal-union Surgery Consent
Introduction to Non-Union and Mal-Union of Fractures
Fracture are typically caused by direct trauma, or repetitive stress. In most cases, these fractures heal with conservative treatment, including immobilization, offloading, and regenerative therapies like stem cell injections. However, in some cases, the fracture fails to heal properly, resulting in either a non-union or a mal-union, both of which can cause chronic pain, deformity, and functional impairment.
Non-Union
This occurs when a fractured bone fails to heal within the expected timeframe (typically 6-12 weeks). Instead of new bone bridging the fracture site, fibrous scar tissue may form, preventing proper healing and leading to continued pain and instability.
Mal-Union
This happens when the fracture heals in a misaligned or incorrect position, causing deformities like shortening, or abnormal biomechanics that can lead to difficulty walking or wearing shoes.
In cases where conservative treatments—including immobilization, physical therapy, and regenerative medicine therapies like stem cell injections—have failed to stimulate healing, surgical intervention may be necessary. The goal of surgery is to refresh the fracture site, promote new bone formation, and stabilize the toe using internal fixation.
Definition of ORIF (Open Reduction Internal Fixation)
The procedure used in many cases of non-union or mal-union fractures is called ORIF (Open Reduction and Internal Fixation). This surgical technique is used to realign broken bones and secure them with internal fixation devices to allow proper healing.
Open Reduction
The surgeon makes a small incision to directly access the fractured bone, removing fibrous tissue from the non-union site or re-aligning the improperly healed bone in mal-union cases.
Internal Fixation
Once the bone is properly aligned, the surgeon stabilizes it using screws, plates, or pins to hold the fragments in place while the bone heals.
In cases where the fracture is too small or fragile for rigid fixation, bone grafting or prolonged immobilization may be necessary to support the healing process. The decision to use ORIF versus simple fracture refreshing and immobilization depends on the extent of the non-union/mal-union, the quality of the bone, and the patient's overall health status.
By addressing the non-union or mal-union surgically, the goal is to relieve pain, restore function, and prevent long-term complications, allowing the patient to regain normal foot mobility and comfort.
The Procedure
The surgical approach aims to refresh the fracture site, remove any fibrous tissue preventing healing, and stabilize the bone using internal fixation if possible. The key steps of the procedure include:
1. Preparation and Anesthesia
The procedure is typically performed under local anesthesia with or without sedation.
The foot is cleaned and prepped in a sterile manner.
Preoperative imaging is reviewed to confirm the location and severity of the non-union or mal-union.
2. Incision and Exposure
An incision is made over the fracture site. Care is taken to preserve soft tissue and minimize disruption to the surrounding structures, including tendons and neurovascular bundles.
3. Refreshing the Fracture Site
The surgeon identifies the non-union/mal-union site. Any fibrous scar tissue that has formed between the bone fragments is removed to allow proper bone healing. The bone ends are trimmed or drilled to create fresh, bleeding surfaces that will promote new bone growth and fusion.
4. Internal Fixation (If Possible)
If the bone can be properly realigned, internal fixation is used to hold the fragments together. The type of fixation depends on the size and stability of the fracture:
Small Screws: Used when the bone has adequate size to support a screw.
Pins or Wires (K-Wires): Often used to temporarily stabilize the fracture.
Mini Plates: Occasionally used for added stability in more complex cases.
If the fracture is too small or fragile for fixation, the surgeon may rely on immobilization alone for healing.
5. Bone Grafting (If Necessary)
If the bone appears to have poor healing potential, a small bone graft (from another part of the foot or a synthetic source) may be placed to encourage healing.
6. Closure and Dressing
The incision is carefully closed with sutures.
A sterile dressing and protective splint are applied to support the toe and limit movement during the healing process.
Postoperative Care
Weight-Bearing: Most patients will need to limit weight-bearing on the foot for several weeks. A surgical shoe is required, crutches and knee scooters can be used and are optional.
Wound Care: Keeping the incision clean and dry is essential for preventing infection.
Pain Management: Over-the-counter NSAIDs (like ibuprofen) or prescribed pain medications may be used for discomfort.
Follow-Up X-Rays: Regular imaging will be done to monitor the progress of bone healing.
Recovery Timeline:
First 2-3 Weeks: Protection of the surgical site with limited activity, and surgical shoe.
4-6 Weeks: Gradual increase in mobility, possible transition out of protective footwear.
8-12 Weeks: Most bones show significant healing, and normal shoes may be worn.
3-6 Months: Final bone remodeling occurs, and most patients achieve full recovery.
Long-Term Expectations:
Most patients experience pain relief and improved function after surgery. Those with underlying risk factors (such as diabetes, poor circulation, or smoking) may have slower healing times. To prevent future toe injuries, proper footwear, activity modification, and possible custom orthotics may be recommended.
Possible Complications Related to Non-union Surgery
Persistent Non-Union or Delayed Healing
In some cases, the bone may still fail to heal, even after surgical intervention. Risk factors include poor circulation, smoking, diabetes, or inadequate postoperative immobilization. If healing does not occur, additional surgery may be required.