Single-Stage Treatment Protocol for Presumed Aseptic Diaphyseal Nonunion

INTRODUCTION: This article describes the general surgical technique for treating presumed diaphyseal nonunion with a one-stage procedure involving intraoperative removal of specimens for culture, revision open reduction and internal fixation (ORIF) with a plate or nail, and bone-grafting. STEP 1: PREOPERATIVE EVALUATION: Take a careful history, evaluate the extremity and wound, and note comorbidities and medications. STEP 2: PREOPERATIVE PLANNING: Preoperative planning is essential before revision nonunion surgery. STEP 3: DEBRIDEMENT, IMPLANT REMOVAL, AND CULTURES: Debride the nonunion site, remove all failed and loose implants, and take specimens for culture; withhold antibiotics until all culture specimens have been obtained. STEP 4: OPEN REDUCTION AND INTERNAL FIXATION: Reduce the fracture and use interfragmentary fixation and/or compression, or a bridging plate. STEP 5: POSTOPERATIVE CARE: If any of the five cultures are positive, consult an infectious disease specialist with experience in treating musculoskeletal infections. RESULTS: We have used this protocol at our institution for patients with prior fracture surgery who subsequently developed a nonunion, with or without implant failure, that had no obvious infectious etiology. Indications Contraindications Pitfalls & Challenges