Long Bone Non-Unions and Malunions: Risk Factors and Treatment Outcomes in Calabar, Southern Nigeria

Ikpeme A. Ikpeme, Nkese E. Mkpanam, Innocent E. Abang, Ngim E. Ngim, Anthony M. Udosen

Department of Community Medicine, University of Calabar, Calabar, Nigeria.
Department of Orthopaedics & Traumatology, University of Calabar, Calabar, Nigeria.
Department of Orthopaedics & Traumatology, University of Calabar, Calabar, Nigeria;.

DOI: 10.4236/ojo.2013.36047                

Abstract

Background: Diaphyseal non-unions and malunions constitute significant morbidities in fracture care. Fracture treatment modalities seek to restore anatomic orientation and functional rehabilitation as soon as possible after a fracture incident. Malunions and non unions present a treatment challenge with the need for prolonged hospitalization, multiple surgical interventions and economic burden. In the developing world, traditional bonesetting practices are popular and these often result in a host of preventable complications. The added socioeconomic costs of treating these complications present a considerable strain on the resources of these already fragile economies and households. Aim: To document the risk factors, treatment options and outcomes for diaphyseal non-unions and malunions in our environment. Patients and Methods: Fifty-two consecutive patients comprising 37 non-unions and 15 malunions who presented in the orthopaedic unit of a tertiary hospital in Southern Nigeria were evaluated. Information sought included biodata, location of pathology, type of incident fracture, local risk factors including traditional bonesetting; treatment options and final outcomes. Information obtained was analyzed using SPSS version 20 (IBM, New York). Results are presented in simple frequency tables. Results: There were 34 males and 18 females (M:F = 1.9:1) with a mean age of 38.76 ± 14.55 years. There were 37 non-unions and 15 malunions. The femur was the commonest site of pathology in 21 (40.4%) cases, and among the non-unions, the atrophic variety was the commonest type (n = 26; 70.3%). The mean fracture-to-surgery interval was 11.35 ± 7.95 months and traditional bonesetting was the commonest risk factor (n = 36; 69.2%). Plate and screw Osteosynthesis with bonegraft augmentation was the commonest treatment modality and the overall union rate was 94%. Conclusion: Traditional bonesetting plays a major role in the health seeking behaviour of many African societies. The complications are varied and add to the overall socioeconomic burden of fracture care in these developing economies. Identification of traditional bonesetting practices as an important risk factor should translate into a focus on these practices in preventive public health decisions in fracture care. Continuing public health education backed by political will and can potentially drive a paradigm shift in health seeking attitudes in the developing word.

Keywords

Non-Union; Malunions; Traditional Bonesetting; Resource-Poor Economy

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	K. J. Pugh and S. R. Rozbruch, “Non-Unions and Malunions,” In: M. R. Baumgaertner and P. Tornetta III, Eds., Orthopaedic Knowledge Update, American Academy of Orthopaedic Surgeons, 2011, pp. 115-130.
[2]	J. O. Angleu, M. T. Archdeacon, L. K. Cannada and D. H. Jr., “Avoiding Complications in the Treatment of Humeral Fractures,” The Journal of Bone and Joint Surgery (American), Vol. 90, No. 7, 2008, pp. 1580-1589.
[3]	P. K. Beredjiklian, R. J. Naranja, R. B. Heppenstall, C. T. Brighton and J. L. Esterhai, “Results of Treatment of 111 Patients with Non-Union of Femoral Shaft Fractures,” The University of Pennsylvania Orthopaedic Journal, Vol. 12, 1999, pp. 52-56.
[4]	D. J. Hak, “Management of Aseptic Tibial Non-Union,” Journal of the American Academy of Orthoapedic Surgeons, Vol. 19, No. 9, 2011, pp. 563-573.
[5]	J. Gilles, S. Wallstabe, A. P. Schulz and U. Gerlach, “Is Non-Union of Tibial Shaft Fractures Due to Nonculturable Bacterial Pathologens? A Clinical Investigation Using PCR and Culture Techniques,” Journal of Orthopaedic Surgery and Research, Vol. 7, No. 20, 2012, p. 20. www.josr-online.com/content/pdf/1749-799x-7-20.pdf http://dx.doi.org/10.1186/1749-799X-7-20
[6]	C.-C. Wu, “Treatment of Long-Bone Fractures, Malunions and Non-Unions: Experience at Chang Gung Memorial Hospital, Taoyuan, Taiwan,” Chang Gung Medical Journal, Vol. 29, No. 4, 2006, pp. 347-357.
[7]	Z. U. Malik, K. M. N. T. Ahmed and A. K. S. T. S. Hussai, “Analysis of Causes and Treatment Modality in NonUnion of Long Bones Diaphyseal Fractures,” Pakistani Armed Forces Medical Journal, Vol. 61, No. 3, 2011, pp. 433-437.
[8]	A. M. Udosen, I. A. Ikpeme and N. E. Ngim, “Traditional Bonesetting in Africa: Counting the Cost,” Proceedings of the 5th SICOT/SIROT Annual International Conference, September 2007, Marrakech, Morocco, p. 203.
[9]	L. S. Phieffer and JA Goulet, “Delayed Unions of the Tibia, Instructional Course Lecture,” Journal of Bone and Joint Surgery (American), Vol. 88, No. 1, 2006, pp. 205-216.
[10]	N. Wu, Y.-C. Lee, D. S. H. Murray, T. Wilcox and L. Boulanger, “Economic Burden of Illness among US Patients Experiencing Fracture Non-Union,” Orthopaedics Research and Reviews, Vol. 2013, No. 5, 2013, pp. 21-33. http://dx.doi.org/10.2147/ORR.S41123
[11]	C. R. Wheeless III, “Malunion of the Tibia,” Wheeless Textbook of Orthopaedics, 2012. www.wheelessonline.com/ortho/malunion_of_the_tibia
[12]	J. A. Goulet and D. J. Hak, “Non-Unions and Malunions of the Tibia,” In: M. W. Chapman, Ed., Chapman’s Orthopaedic Surgery, Lippincott Williams & Wilkins, Philadelphia, 2001, pp. 978-999.
[13]	V. Perumal and C. S. Roberts, “Factors Contributing to Non-Union of Fractures,” Current Orthopaedics, Vol. 21, No. 4, 2007, pp. 258-261. http://dx.doi.org/10.1016/j.cuor.2007.06.004
[14]	J.-J. Yang, L.-C. Lin, K.-H. Chao, S.-Y. Chuang, C.-C. Wu, T.-T. Yeh and Y.-T. Lian, “Risk Factors for Non-Union in Patients with Intracapsular Femoral Neck Fractures Treated with Three Cannulated Screws Placed in Either a Triangle or an Inverted Triangle Configuration,” The Journal of Bone & Joint Surgery, Vol. 95, No. 1, 2013, pp. 61-69. http://dx.doi.org/10.2106/JBJS.K.01081
[15]	M. Lee, “Non-Unions of the Humerus,” Journal of Hand Surgery, Vol. 18, No. 1, 2005, pp. 51-53.
[16]	I. R. Murray, C. J. Foster and A. E. C. M. Robinson, “Risk Factors for Non-Union after Non-Operative Treatment of Displaced Midshaft Fractures of the Clavicle,” The Journal of Bone & Joint Surgery, Vol. 95, No. 13, 2003, pp. 1153-1158.
[17]	L. A. Mills and A. H. R. W. Simpson, “The Relative Incidence of Fracture Non-Union in the Scottish Population (5.17 Million): A 5-Year Epidemiological Study,” British Medical Journal Open, Vol. 3, No. 2, 2013, pp. 1-8. http://bmjopen.bmj.com/content/3/2/e002276.full.pdf+html http://dx.doi.org/10.1136/bmjopen-2012-002276
[18]	D. R. Marsh, S. Shah, J. Elliot and N. Kurdy, “The Illizayov Method in Non-Union, Malunion and Infection of Fractures,” The Journal of Bone & Joint Surgery, Vol. 79-B, No. 2, 1997, pp. 273-279. http://dx.doi.org/10.1302/0301-620X.79B2.6636
[19]	G. V. Russell, M. L. Graves, M. T. Archdeacon, D. P. Barei, G. A. Brien Jr. and S. E. Porter, “The Clamshell Osteotomy: A New Technique to Correct Complex Diaphyseal Malunions,” The Journal of Bone & Joint Surgery (American), Vol. 91, No. 2, 2009, pp. 314-324. http://dx.doi.org/10.2106/JBJS.H.00158
[20]	M. Tall, I. Quedraogo, A. N. Kasse, B. J. D. Tekpa, G. Bankoungou, S. Belem and M. F. Toe, “Femur Malunions Treated with Open Osteotomy and Intramedullary Nailing in Developing Countries,” Orthopaedics & Traumatology: Surgery & Research, Vol. 98, No. 7, 2012, pp. 784-787.
[21]	A. B. Omololu, S. O. Ogunlade and V. K. Gopaldasani, “The Practice of Traditional Bonesetting: Training Algorithm,” Clinical Orthopaedics and Related Research, Vol. 466, No. 10, 2008, pp. 2392-2398. http://dx.doi.org/10.1007/s11999-008-0371-8
[22]	A. A. Dada, W. Yinusa and S. O. Giwa, “Review of the Practice of Traditional Bonesetting in Nigeria,” African Health Sciences, Vol. 11, No. 2, 2011, pp. 262-265.
[23]	A. S. Gavaskar and R. Kumar, “Open Interlocking Nailing and Bonegratfing for Neglected Femoral Shaft Fractures,” Journal of Orthopaedic Surgery, Vol. 18, No. 1, 2010, pp. 45-49.