Reconstruction for nonunion or malunion fractures

Nonunion and malunion fractures are the result of an initial bone fracture that didn’t heal properly. A fractured bone that fails to heal after an extended time—up to a year after injury—is a nonunion fracture. A malunion fracture occurs when a broken bone heals in an abnormal position, making it look “bent” and impeding the normal functioning of the bone or limb.

Reconstruction surgery can repair these complex fractures, which are fundamentally different than the original fracture and require specialized techniques to restore function. Each reconstruction case is different and diagnosing the cause of the malunion or nonunion is essential to creating the best treatment plan. Prompt evaluation and diagnosis often lead to the best outcomes.

At the Penn Orthoplastic Limb Salvage Center, orthopaedic trauma surgeons work closely with microvascular surgeons, plastic surgeons, and other surgical providers to correct nonunion and malunion fractures. Our services include advanced techniques, like custom, 3D implantable devices for more complex reconstruction cases. Specialists at the center create and coordinate a systematic, individualized plan of care to target the specific cause of your fracture, restore your movement, and help you return to your regular daily activities with confidence.

To determine if you might benefit from fracture reconstruction, your doctor will perform a physical exam, review your medical history, order imaging tests (x-rays, MRIs, or CT scans), and discuss your initial fracture and its healing. They’ll pay special attention to symptoms that may signal a nonunion or malunion fracture, including:

• A bent or misshapen appearance
• Impaired function, such as the inability to flex your body normally or bear weight
• Persistence stiffness, pain, tenderness, or swelling

Once your orthopaedic team has identified a nonunion or malunion fracture and its characteristics, they’ll evaluate the best surgical approach. They’ll assess many factors including whether an infection is present, if there is an active blood supply to the bone, and if there is an adequate musculoskeletal structure in the target area to support healing. They’ll discuss the treatment plan with you, including which bones and soft tissues are affected and any hardware required, like flexible screws or metal plates. You’ll have time to discuss the risks and get answers to any questions you have.

Prior to your reconstruction surgery, you’ll have preoperative tests to be sure your body can undergo the surgery and heal well. Your orthopaedic team will identify whether an infection is a factor in your fracture’s poor healing and use antibiotics to clear the infection before performing surgery. They’ll also run blood tests to identify adequate levels of thyroid, calcium, phosphorous, and other elements that can impact healing. If there are any imbalances, you’ll be treated to bolster your health before reconstruction surgery. Your doctor will discuss anesthesia options with you to ensure you are comfortable and pain-free throughout the procedure.

While every treatment strategy is individualized, it’s likely that your reconstruction surgery will include one or more of these techniques:

• Fracture fixation: A fracture fixation is a surgical procedure that stabilizes the affected limb. It includes aligning pieces of bone into their proper position.
• Debridement: This procedure removes dead or damaged tissue, which is essential for proper wound healing.
• Soft tissue coverage: Local tissue or grafts of ligaments, tendons, muscle, or other supportive tissues are used to cover injuries and create a healthy area around the fracture.
• Revascularization: Microvascular techniques may be used to restore blood flow to the affected area and help avoid more severe and extensive removal of damaged tissue.
• Internal fracture reconstruction: Metal screws, rods, or plates may be used to hold the bone in place as it heals. Dynamic screws and plates can be used for fractures that require more flexibility for optimal healing, such as those around major joints. Penn Medicine also uses 3D printed implants for custom reconstruction.
• External fixation: This frame on the outside of your body may be used for stabilization on its own or in addition to internal hardware.

Once the bones and soft tissues are stabilized and any internal hardware is applied, your surgeon will close the wound. The length of the surgery depends on many factors including the complexity of the procedure and the area of the body being treated. Talk with your surgeon about the expected timeframe for your procedure.

No two reconstruction surgeries are the same, and recovery timeframes can vary widely depending on the part of the body affected and the complexity of the fracture. You’ll want to discuss your recovery plan with your orthopaedic team to learn what to expect from your surgical recovery and rehabilitation.

Generally, people have some common experiences while recovering from surgery for nonunion and malunion reconstruction:

• You may feel pain near the surgery site for the first few weeks after surgery. Your doctor will create a pain management plan for you, including prescription medications or over-the-counter drugs. Over time, you’ll be able to decrease your medication usage.
• You may need assistive devices, such as splints or crutches, as you heal.
• Your orthopaedic team will create a physical therapy plan for you, which you’ll start as soon as your progress dictates.
• Working with your doctor and physical therapy team, you’ll have a step-by-step plan to return to your regular daily activities.

It may take a few months or longer for you to recover fully and return to your regular activities. If you follow the recommendations of your surgical team and physical therapists, you’ll have the best chance for full recovery. Our goal is to provide you with the full range of surgical follow-up and rehabilitation services to support your recovery.

Like many surgeries, there can be complications and risks associated with fracture reconstruction surgery. These risks can depend on your overall health, age, and complexity of the surgery. They may include:

• Infection at the site
• Bleeding
• Blood clots
• Wound healing issues
• Persistent pain

Talk with your doctor if you have questions about risks associated with your reconstruction surgery.

Penn Medicine’s orthopaedic team is uniquely equipped to provide the comprehensive care you need for reconstruction surgery. We offer advanced techniques, surgical expertise, and rehabilitation options for even the most complex nonunion and malunion reconstruction treatment.

Our specialized approaches include:

• Advanced imaging for superior visualization: We use sophisticated imaging like 3D CT scans and digital tomography to provide the best possible view of the fracture when planning for treatment.
• Custom, 3D-printed fracture solutions: Our orthopaedic surgeons combine 3D printing and radiologic studies to create personalized, implantable metal devices for patients with challenging and complex reconstructions.
• Dynamic stabilization: We use state-of-the-art flexible screws and plates that allow for movement, providing the relative stability required for certain bones or joints to heal most effectively.
• External ring fixation: Unlike other centers, Penn Medicine often uses this less invasive approach, which eliminates the need for internal implants or metal hardware, reducing the risk of implant infection.
• More effective healing options: We offer implants impregnated with antibiotics for patients at high risk of infection, as well as biologic techniques to help patients optimize bone growth.