Simpson A Hamish R W, Tsang S T Jerry
Department of Trauma and Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK.
Department of Trauma and Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK.
Injury. 2018 Jun;49 Suppl 1:S78-S82. doi: 10.1016/S0020-1383(18)30309-7.
Approximately a third of patients presenting with long-bone non-union have undergone plate fixation as their primary procedure. In the assessment of a potential fracture non-union it is critical to understand the plating technique that the surgeon was intending to achieve at the primary procedure, i.e. whether it was direct or indirect fracture repair. The distinction between delayed union and non-union is a diagnostic dilemma especially in plated fractures, healing by primary bone repair. The distinction is important as nonunions are not necessarily part of the same spectrum as delayed unions. The etiology of a fracture non-union is usually multifactorial and the factors can be broadly categorized into mechanical factors, biological (local and systemic) factors, and infection. Infection is present in ~40% of fracture non-unions, often after open fractures or impaired wound healing, but in 5% of all non-unions infection is present without any clinical or serological suspicion. Methods to improve the sensitivity of investigation in the search of infection include the use of; sonication of implants, direct inoculation of theatre specimens into broth, and histological examination of non-union site tissue. Awareness should be given to the potential anti-osteogenic effect of bisphosphonates (in primary fracture repair) and certain classes of antibiotics. Early cases of delayed/non-union with sufficient mechanical stability and biologically active bone can be managed by stimulation of fracture healing. Late presenting non-union typically requires revision of the fixation construct and stimulation of the callus to induce fracture union.
约三分之一因长骨骨不连就诊的患者，其初次手术采用的是钢板固定。在评估潜在的骨折不愈合时，了解外科医生在初次手术中想要采用的钢板固定技术至关重要，即其是采用直接还是间接骨折修复方式。延迟愈合与不愈合之间的区分是一个诊断难题，尤其是在通过一期骨修复愈合的钢板固定骨折中。这种区分很重要，因为不愈合不一定与延迟愈合属于同一范畴。骨折不愈合的病因通常是多因素的，这些因素大致可分为机械因素、生物学（局部和全身）因素以及感染。约40%的骨折不愈合存在感染，通常发生在开放性骨折或伤口愈合不良之后，但在所有不愈合病例中，有5%的感染在没有任何临床或血清学怀疑的情况下存在。提高感染检查敏感性的方法包括：对植入物进行超声处理、将手术标本直接接种到肉汤中以及对不愈合部位组织进行组织学检查。应注意双膦酸盐（在一期骨折修复中）和某些类别的抗生素可能具有的抗成骨作用。对于具有足够机械稳定性和生物活性骨的早期延迟愈合/不愈合病例，可通过促进骨折愈合来处理。晚期出现的不愈合通常需要对固定结构进行翻修，并刺激骨痂以诱导骨折愈合。
