Nonunion Fractures: To Operate or Not?

Incomplete fracture healing: to undergo surgery or not?

Hello, Doctor.
On December 29, I asked about an open fracture of the right forearm that underwent surgery with titanium alloy nails and plates.
Eleven months later, X-rays show incomplete healing with dark gaps at the fracture site, and three out of six screws show similar dark shadows on the X-ray.
I have several questions regarding the need for another surgery for bone healing:
1.
There is no significant pain, no neurological abnormalities, and finger function is intact.
However, I often experience weakness and difficulty lifting slightly heavy objects, which feels like muscle tightness and soreness.
Why would a doctor recommend another surgery to replace and reinforce the screws and plates after more than nine months of poor bone healing (although there is some healing, it is slow)?
2.
What are the risks associated with undergoing another surgery?
3.
After the previous surgery, my thumb was immobile for several weeks.
If I choose not to have another surgery, what risks might I face in the future? What impact could this have?
4.
The current titanium screws and plates feel quite foreign in my body, and there is a noticeable size difference between my right and left hands.
Would undergoing another surgery to reinforce the screws and plates make the discomfort even greater?
5.
Regarding the titanium metal versus the steel plates covered by health insurance, is there a need to remove them? If the bone heals completely and bone density is good, what are the risks of choosing to have another surgery to remove them under health insurance coverage? What are the differences between the two materials in the body?
The healthcare system here does not allow for in-depth discussions with doctors due to the high volume of patients, making it difficult to get comprehensive answers.
Patients are often left to decide whether to schedule another surgery without fully understanding the implications.
I am seeking guidance to find the best approach for my situation.
Thank you for your selfless dedication, and I greatly appreciate your response to help me in this challenging time.

e.e, 40~49 year old female. Ask Date: 2018/01/14

Dr. Shi Guozheng reply Orthopedics

1.
If there are no signs of healing nearly a year after fracture surgery, the final management option is to perform another surgery and augment the bone.

2.
The risks associated with the surgery, such as infection and nerve injury, are similar to those of general surgeries.

3.
The sensation of foreign body presence is not significantly different.

4.
It is not necessary to remove the plate; however, removal of the plate may be covered by health insurance.

Reply Date: 2018/01/14

More Info

Understanding nonunion fractures can be quite complex, especially when it comes to deciding whether to undergo another surgical procedure. In your case, it appears that you have experienced an open fracture of the right forearm, which was treated with titanium alloy plates and screws. After 11 months, the X-ray indicates incomplete healing, which raises several important considerations.

1. Why is Surgery Recommended for Nonunion?
Nonunion fractures occur when the bone fails to heal properly after a fracture. In your situation, although there is no significant pain and normal function of the fingers, the presence of gaps in the healing bone suggests that the healing process is not progressing as it should. The recommendation for surgery to replace or reinforce the existing hardware and possibly add bone grafting is based on the need to stabilize the fracture site and promote healing. The body requires a stable environment for bone regeneration, and if the current fixation is inadequate, it can lead to further complications.

2. Risks of Reoperation:
Every surgical procedure carries inherent risks, including infection, bleeding, nerve damage, and complications related to anesthesia. Additionally, reoperation may lead to scar tissue formation, which could affect mobility and function. There is also the possibility that the new hardware may not resolve the issue, leading to further surgeries. It’s essential to weigh these risks against the potential benefits of improved healing and function.

3. Consequences of Not Undergoing Surgery:
If you choose not to have the surgery, you may face several long-term consequences. These can include chronic pain, limited mobility, and the inability to perform certain tasks, particularly those requiring strength. Over time, the lack of proper healing could lead to arthritis in the joint or other complications, which may necessitate more invasive treatments in the future.

4. Discomfort from Existing Hardware:
The discomfort you feel from the titanium hardware is not uncommon. If you undergo another surgery to reinforce the fixation, it is possible that the new hardware may feel different, but it should ideally be more effective in promoting healing. The sensation of foreign objects in the body can vary from person to person, and while some may find the new hardware more comfortable, others may not. Discussing these concerns with your surgeon can help set realistic expectations.

5. Differences Between Titanium and Other Materials:
Titanium is often preferred in orthopedic surgeries due to its strength, lightweight nature, and biocompatibility. However, the choice between titanium and other materials, such as those covered by health insurance, often comes down to cost and specific patient needs. If you are considering hardware removal after complete healing, it is crucial to discuss the implications with your healthcare provider, including the risks associated with removal and the potential for complications.

In conclusion, the decision to undergo another surgery for a nonunion fracture should be made after careful consideration of the risks and benefits. It is essential to have an open dialogue with your orthopedic surgeon about your concerns and the implications of both surgical and non-surgical options. Understanding your body and the healing process is vital, and seeking clarity on these issues is a crucial step in making an informed decision about your health.

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