What is the treatment for a non-union of an intact fellow bone, also known as a non-union of a fracture in an adjacent (intact) bone?

From the Guidelines

The most effective treatment for intact fellow bone non-union is surgical management, including complete excision of the pseudarthrosis site, sufficient autogenous bone graft, and proper method of fixation, as recommended by the recent study 1. In managing non-unions with an intact fellow bone, treatment decisions are influenced by the stability provided by the intact bone. The intact bone provides some structural support, which may allow for more conservative management options.

• Treatment for non-unions with an intact fellow bone typically begins with non-surgical approaches including immobilization, bone stimulation devices, and vitamin D and calcium supplementation.
• If conservative measures fail, surgical intervention may be necessary, including bone grafting, internal fixation with plates and screws, or intramedullary nailing.
• The presence of an intact fellow bone can be advantageous during surgery as it helps maintain alignment and length.
• The biological basis for non-union includes inadequate blood supply, infection, excessive motion at the fracture site, or metabolic factors.
• The intact fellow bone may sometimes mask symptoms of non-union, leading to delayed diagnosis, but it generally provides a more favorable mechanical environment for healing compared to non-unions in single bones. The use of intramedullary rods (IMR) alone is generally associated with high complication rates and low success rates, ranging from 54% to 90%, as reported in the study 1.
• The study found that the mean primary union rate was 67.7% and the mean primary union time was extended to 12.6 months, with a high non-union rate of 17% and a refracture rate of 48.1%.
• In contrast, the use of Fassier-Duval rods (FDR) had improved the primary union rate (85.7%) and no refracture has been reported based on recent studies 1.
• Therefore, it is recommended that IMR be combined with other techniques, such as external fixation, to enhance stability and reduce the risk of complications. Low-intensity pulsed ultrasound (LIPUS) has been studied as a potential treatment for non-unions, but the evidence is limited and inconclusive, as reported in the studies 1 and 1.
• The studies found that LIPUS may have some benefits in terms of functional recovery and pain reduction, but the evidence is not strong enough to support its use as a standard treatment for non-unions.
• Further research is needed to determine the effectiveness of LIPUS and other treatments for non-unions, and to develop de-implementation strategies for ineffective treatments.

From the Research

Definition and Causes of Non-Union

• Non-union represents a chronic medical condition where the healing process of a fractured bone fails due to inadequate immobilization, failed surgical intervention, insufficient biological response, or infection 2.
• The aetiology of a fracture non-union is usually multifactorial, including mechanical factors, biological (local and systemic) factors, and infection 3.

Treatment Options for Non-Union

• External fixation is currently used as the definitive mode of fracture stabilisation in the management of approximately 50% of long-bone non-unions 3.
• Teriparatide, a parathyroid hormone (PTH) analogue, has been found to induce union in those with delayed union and nonunion, with a systematic review showing that 95.3% of subjects developed complete union after treatment with teriparatide 20 μg/day 4.
• Teriparatide has also been used to treat postoperative non-union with internal fixation loosening of Garden IV femoral neck fracture, with a case report showing that bone non-union healed after 6 months of continuous subcutaneous injection of teriparatide at a dosage of 20 μg/day 5.

Use of Teriparatide in Non-Union Treatment

• Teriparatide has increasing supporting data for its use in the treatment of non-unions, with studies demonstrating its positive effect on fracture healing in both physiological and pathological conditions 6.
• The effect of teriparatide seems very useful in the non-unions consequent to an atypical femoral fracture after long-term administration of bisphosphonates 6.
• Further studies are needed to confirm the hopeful hypotheses regarding the use of teriparatide in non-union treatment 6, 4.