What is the best course of treatment for an elderly patient with a non-union fracture, possibly complicated by underlying conditions such as diabetes, osteoporosis, or a history of smoking?

Management of Non-Union Fractures in Elderly Patients

For elderly patients with non-union fractures, surgical revision with stable internal fixation (preferably plate and screw osteosynthesis) combined with autogenous cancellous bone grafting is the definitive treatment, followed by comprehensive osteoporosis management and rehabilitation to prevent subsequent fractures. 1, 2, 3

Surgical Management Algorithm

Revision surgery is necessary in the majority of non-union cases to achieve osseous healing. 2 The surgical approach should prioritize:

• Stable internal fixation using plates and screws as the primary fixation method, which provides the mechanical stability essential for healing 3, 4
• Autogenous cancellous bone grafting should be added when there is a fracture gap or bone defect, as these fractures have excellent intrinsic healing capability due to abundant circulation in metaphyseal-epiphyseal regions 3
• Debridement of infected non-unions must be performed first, followed by external fixation or plate fixation with bone grafting once infection is controlled 3

Expected healing time after appropriate surgical revision averages 6-7 months 2, 3

Risk Factor Modification in Elderly Patients

Critical Risk Factors to Address

• Smoking cessation is mandatory, as smoking is a well-established risk factor for non-union 5, 4
• Infection control must be achieved before definitive fixation, particularly in high-energy trauma or open fractures 6, 4
• Adequate mechanical stability from the implant is essential—inadequate initial fixation is a primary cause of non-union 4
• Post-surgical fracture gaps significantly increase non-union risk and must be addressed with bone grafting 4

Special Considerations for Comorbidities

• Diabetic patients require specialized offloading techniques and careful soft tissue management to prevent complications 6
• Osteoporotic bone in elderly patients necessitates careful surgical planning due to frail bone quality, but should not preclude operative intervention 6

Comprehensive Osteoporosis Management

All patients over 50 years with fragility fractures require systematic evaluation and treatment for osteoporosis to prevent subsequent fractures. 5, 7

Pharmacological Treatment Protocol

• First-line agents are alendronate or risedronate (oral bisphosphonates) due to proven efficacy in reducing vertebral, non-vertebral, and hip fractures, low cost, and extensive clinical experience 5
• Alternative agents include zoledronic acid (IV) or denosumab (subcutaneous) for patients with oral intolerance, dementia, malabsorption, or non-compliance 5
• Teriparatide (anabolic agent) should be considered for patients with very severe osteoporosis 5
• Treatment duration is typically 3-5 years, extended longer in patients who remain at high risk 5

Essential Supplementation

• Vitamin D 800 IU daily plus adequate calcium intake (1000-1200 mg/day total) is associated with 15-20% reduction in non-vertebral fractures and 20% reduction in falls 5
• Avoid high-pulse dosages of vitamin D, which paradoxically increase fall risk 5

Rehabilitation and Fall Prevention

Early mobilization with comprehensive rehabilitation is critical for regaining pre-fracture mobility and independence. 5, 8

• Physical training and muscle strengthening should begin early after fracture stability is achieved 5, 8
• Long-term balance training and multidimensional fall prevention must continue to reduce subsequent fracture risk 5, 8
• Range-of-motion exercises should begin within the first postoperative days, but overly aggressive therapy may increase fixation failure risk 5

Implementation Through Fracture Liaison Service

• Systematic follow-up using the Fracture Liaison Service (FLS) model achieves up to 90% adherence to osteoporosis treatment, substantially higher than standard care 5, 7
• The FLS five-step plan includes: identifying patients, inviting for fracture risk evaluation, differential diagnosis, therapy initiation, and systematic follow-up 5

Common Pitfalls to Avoid

• Failure to address underlying osteoporosis leads to subsequent fractures—every patient over 50 requires systematic evaluation 5, 8
• Inadequate initial mechanical stability is a primary cause of non-union and must be corrected with revision surgery 4
• Overlooking soft tissue injuries associated with the fracture can lead to complications 6
• Neglecting smoking cessation and alcohol limitation perpetuates risk factors for non-union 5, 4
• Insufficient rehabilitation and fall prevention in elderly patients results in poor functional outcomes and increased subsequent fracture risk 5, 6