Introduction of a new management algorithm for tibial non-union in developing countries

INTRODUCTION

The definition of non-union remains heterogeneous in the literature,^[1,2] although most authors agree on a common concept: Failure of fracture healing within 6–9 months despite appropriate management.^[3-5] We adopt the definition proposed by Antonova, according to which non-union is a fracture incapable of healing spontaneously without further intervention after 6–9 months.^[2] Non-unions account for 1–12% of complex long-bone fractures^[6] and remain challenging to treat,^[7,8] particularly when associated with bone loss or infection.^[9,10] Recognized extrinsic risk factors include smoking, alcohol consumption, and diabetes^[7,11,12]; in African countries, additional factors include inadequate initial surgical management, infection from open fractures, and frequent use of traditional medicine.^[2,13,14]

The therapeutic strategy depends on the non-union. Hypertrophic forms usually respond to Judet periosteal decortication, which stimulates local biology,^[15] whereas atrophic forms require bone grafting to restore healing potential.^[8,16] For major bone defects, several techniques have emerged: Masquelet’s induced membrane technique (IMT),^[10,17] Ilizarov distraction-compression or lengthening methods,^[15,18,19] the “Diamond concept” using reaming by-products to optimize biological environment,^[20,21] and Huntington’s fibula-pro-tibia procedure for extensive defects.^[9,22] More recent approaches – magnetic fields, bone marrow injections, osteoinductive proteins – are still under evaluation.^[23,24]

Septic non-unions require a two-stage approach: Radical debridement and infection control before reconstruction through delayed grafting, intertibio-fibular grafting (ITFG), or IMT.^[17,25]

Given the increasing incidence of tibial diaphyseal non-union in our setting and the lack of local data on risk factors and outcomes, we conducted this study to describe the epidemiological features of tibial diaphyseal non-union and to evaluate outcomes following the application of a precise algorithm. We hypothesized that strict adherence to a standardized protocol ensures satisfactory results even under limited technical conditions.

MATERIALS AND METHODS

A prospective multicenter study was conducted between January 2017 and December 2021 on all tibial non-unions managed in the department. Patients ≥16 years old who consented to treatment and completed at least 12 months of follow-up were included. Septic non-unions or defects >10 cm were excluded. Management followed a predefined algorithm adapted to local resource constraints, integrating the Weber-Cech classification^[26] and Catagni’s classification of bone defects.^[27,28]

Weber-Cech distinguishes vital (hypertrophic, slightly hypertrophic, and oligotrophic) from avital (atrophic, partially necrotic, necrotic, or with bone loss) non-unions. Bone defects were classified into three types per Catagni: Bone loss without shortening, shortening without bone loss, or both. The algorithm-guided treatment is based on three essential parameters: Septic status, biological vitality, and defect size.

Aseptic non-unions, whether vital or avital, were treated with Judet decortication with or without bone grafting, according to established recommendations.^[15,22] Septic non-unions or those with bone loss were treated sequentially. The first stage consisted of oncologic-type debridement followed by targeted antibiotic therapy. Infection control was confirmed by repeated C-reactive protein (CRP) measurements, with CRP <5 mg/L required before reconstruction. The second stage involved bone grafting, IMT, or ITFG, depending on the defect and septic status. Reoperation was planned systematically for persistent non-union or lack of union progression. The results of these reoperations are shown in the results section.

The union was assessed clinically (absence of pain and abnormal mobility) and radiologically (mature callus). Functional and bone results were analyzed using the Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria [Table 1].^[28,29] Data were collected using a standardized form and analyzed using Epi-Info 2008 version 3.5.2. Chi-square test was used for comparisons, with significance set at 5%.

RESULTS

DISCUSSION

This study shows that despite limited technical resources, rigorous adherence to a therapeutic algorithm yields excellent outcomes in both aseptic and septic tibial non-unions [Figure 1]. The chosen principles rely on validated approaches widely described in the literature,^[23,30-34] notably oncologic-type debridement for septic cases and Judet decortication for aseptic cases,^[15] with bone grafting depending on residual biological potential. These techniques are effective and require minimal specialized equipment, except for IMT, which requires bone cement.

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Figure 1:

Algorithm for the management of leg non-union. OMD: Osteomuscular decortication, CMN: Intramedullary nailing, ITFG: Intertibio-fibular grafting, and IMT: Induced membrane technique.

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The systematic two-stage approach to septic non-unions enabled effective infection control prior to reconstruction. Plaster immobilization, widely used in our series, helped prevent the need for internal implants in a septic environment. Our results confirm this strategy: 52 of 55 septic non-unions dried after initial debridement [Table 4]. No secondary infection occurred in initially aseptic cases.

Persistent infections occurred only in immunocompromised HIV-positive patients, consistent with previous findings on their increased susceptibility.^[11] Despite this, the union rate of 97.1% and low residual infection rate (2.8%) highlight the value of treatment standardization, consistent with Western^[18,35,36] and African series.^{[10,11,24,25]}

The high prevalence of non-union (18.5%) in our study exceeds international reports (2.5–12%),^[2] likely due to delayed management of open fractures, limited emergency equipment, and a high risk of infection.^[34] For vital non-unions, decortication alone was sufficient in most cases, consistent with the literature, which shows that grafting is unnecessary when biological potential is preserved.^[14,15] Conversely, avital or bone-loss cases required reconstructive techniques. ITFG was particularly effective for septic non-unions with limited defects, confirming other authors’ observations.^[25] IMT proved valuable in larger defects, as widely documented.^[10,17]

Limitations include a lack of a control group, a monocentric design, and 11 (9.5%) cases lost to follow-up. Single-surgeon procedures and single-observer evaluations may introduce bias but also ensure methodological homogeneity. Overall, our findings confirm that, even in resource-limited environments, a structured strategy grounded in established principles can achieve outcomes comparable to those of well-equipped centers.

CONCLUSION

Strict adherence to a codified therapeutic protocol is essential for the successful management of tibial non-union, even in low-resource settings. Judet periosteal decortication remains the reference technique for vital or aseptic non-unions, with bone grafting indicated when biological potential is insufficient. For septic forms and significant bone loss, staged treatment combining radical debridement and delayed reconstruction is indispensable. Techniques such as ITFG or IMT provide high union rates while limiting complications. Despite limited resources, our results are encouraging and suggest that this structured approach can be implemented in similar healthcare environments. Standardization of therapeutic pathways, rigorous infection control, and adaptation of techniques to biological vitality and septic status underpin effective and reproducible management of non-unions.