Transfocal Osteotomy to Treat Shear (Oblique) Non-union of Tibia

Abstract

Aseptic non-unions of tibial shaft fractures often need surgical treatment which carry significant socio-economic implications. The causes for non-union include patient co-morbidities, high energy trauma, open fractures and fracture geometry. Oblique fractures are subject to shear forces and, if not adequately neutralised, will fail to unite. Experiments have shown that callus formation is poor in oblique fractures due to local shear stresses. We report a technique of minimally invasive transfocal transverse osteotomy and compression in a hexapod circular fixator, Taylor Spatial Frame (TSF) for 12 patients treated with a shear non-union of tibia between 2010 and 2019. There are four female and eight male patients. The average age is 49 years (range from 26 to 72 years). The fracture pattern was oblique (30-45°) in all cases. Healing of the non-union occurred in 12 cases with one case needed additional treatment with bone marrow aspirate and demineralized bone matrix. The technique of creating a minimally invasive transfocal transverse osteotomy through the oblique non-union of tibia and the use of a hexapod circular fixator to compress the osteotomy is described and adds to the range of treatments available for aseptic non-union of tibia.

How to cite this article: Lahoti O, Abhishetty N, Al-Mukhtar M. Transfocal Osteotomy to Treat Shear (Oblique) Non-union of Tibia. Strategies Trauma Limb Reconstr 2022;17(2):117-122.

Keywords: Aseptic non-union; Biomechanics; Cohort study; Compression force; Fracture geometry; Osteotomy; Shear force; Taylor Spatial Frame; Tibia.

Figs 1A to D

(A) A 55-year-old male patient sustained a lower tibia and fibula fracture. At initial surgery, fibular was fixed and the long oblique tibial fracture was fixed with two screws and a spanning external fixator because of extensive blistering and swelling. The fibular wound broke down due to swelling and needed split skin grafting. The external fixator was removed at 4 months. X-rays at presentation, 6 months after the injury, showed an oblique (shear) non-union. The soft tissues were stable but the limb was oedematous and the ankle stiff; (B) Image intensifier sequence. Osteotomy level identified. Incomplete osteotomy of tibia with frame in situ. Osteotomy completed; (C) Progression in frame. Early callus formation seen at 8 weeks; (D) AP and oblique views show full healing of the non-union. Note that the healing has progressed above and below the transverse osteotomy level

Figs 2A and B

(A) Pre-operative X-rays show an oblique non-union with plate failure. The image intensifier shows the transverse osteotomy and TSF in place; (B) Healing of osteotomy and non-union. Note the healing of entire oblique plane non-union above and below the osteotomy

Figs 3A to C

(A) A case of failed fixation with an intramedullary nail (two prior attempts to heal with exchange nailing with a total of three reaming procedures including the initial nailing) showing a long oblique atrophic non-union; (B) Transfocal osteotomy (black line) and application of the Taylor Spatial Frame; (C) Final result