Trauma: Non-Union: New Trends

Fracture healing is a complex physiological process caused by the interaction of cellular elements that are activated and controlled by an array of cytokines and signalling proteins [11]. This process is both temporal and spatial in nature and usually results in the formation of new bone, which is structurally and mechanically similar to the pre-fracture state [10]. For al lot of reasons this process can fail and result in non-union of bone in 10% of all fractures and in up in 50% of open fractures of the tibia. These patients develop a nonunion, which leads to long-lasting inability to work, loss of employment and high social costs. These cost are estimated in a paper of Sprague 2002 to be at approximately $80,000 in case of 18 weeks delay of fracture healing [28]. The overall costs of delayed fracture healing are estimated to be at $14.6 million in United States alone [6]. Many attempts have been made to reduce the rate of disturbed fracture healing but despite the correct osteosynthesis, which is mandatory, and new improved interlocking plates, biologic osteosynthesis and improved surgical techniques like subcutaneous plating, the overall rate has not been reduced. The standard procedure to induce or enhance bone healing in a delayed status is autologous bone grafting. This procedure provides osteogenic, osteoinductive and osteoconductive properties and has a success rate of 50–80% [7, 9, 29, 33]. But the success of this “gold standard” depends on the quality of the harvested bone and is naturally limited by the amount available from the donor. Nowadays it could be stated, that correct technical debridement and knowledge about “correct osteosynthesis” is the basic treatment and the rules of stability have to be implemented. But there are some new possibilities which can help as an adjunct to increase the healing rate of fractures and/or non-unions. New trends are: