Challenges in Healing Open Fractures: A Case Study of Tibia and Fibula

Incomplete healing after open reduction and internal fixation of a right distal tibiofibular fracture?

Hello Doctor, I had an open fracture of the distal fibula on the right side due to a car accident in January this year, and I underwent surgery with self-funded internal fixation using steel nails.
I started to put down the crutches around April.
During the follow-up visits, I noticed that the anterior tibial bone growth was very slow.
On the advice of my doctor, I received a PRP injection at the open wound site in late July.
During my follow-up in September, there was noticeable progress, but in October, I found that the bone healing seemed to have plateaued.
An X-ray showed a gap of about 0.2 cm.
The doctor suggested extracorporeal shock wave therapy or autologous bone grafting, but when I visited the orthopedic clinic today for an ultrasound examination, the doctor found that the gap was about 1 cm.
He thought that the angle might have affected the X-ray results, which did not capture the full picture.
Given the size of the gap and that it has been nearly 9 months, he suggested that the effectiveness of extracorporeal shock wave therapy would be limited and recommended that I go to a major hospital to see if surgical intervention for bone grafting is necessary.
1.
It has been nearly 9 months since the injury.
Considering the location of the injury (near the ankle), my age (41), and the fact that I do not smoke or drink, is there still a chance for healing if I continue with simple rehabilitation activities, take calcium and vitamin D3 supplements, and increase my protein intake?
2.
If I opt for autologous bone grafting to fill the gap, would that mean starting over, and would I need to have new steel nails for fixation again? Shouldn't the recovery time be faster than the initial injury? (Time to stop using crutches)

Yu, 40~49 year old female. Ask Date: 2022/10/06

Dr. Shi Guozheng reply Orthopedics

1.
If there is a defect in the bone, healing can be very slow, and sometimes it may not heal at all.
In such cases, surgical bone grafting may be necessary to promote healing.
Usually, if a fracture has not healed after one year, surgery can be considered.

2.
If the fracture site is currently stable, then it may only require bone augmentation.
However, if there is still movement at the fracture site, then it will be necessary to reinsert bone screws and plates.

Reply Date: 2022/10/06

More Info

Open fractures, particularly those involving the tibia and fibula, present significant challenges in orthopedic treatment and healing. Your case highlights several critical aspects of managing such injuries, including the complexities of bone healing, the potential for complications, and the various treatment options available.

Firstly, open fractures are characterized by a break in the bone that communicates with the external environment, which increases the risk of infection and complicates the healing process. The severity of the injury, the extent of soft tissue damage, and the presence of any contamination can significantly affect the healing trajectory. In your case, the slow healing of the tibia, particularly at the site of the open wound, is concerning and not uncommon. Factors such as age, nutritional status, and overall health can influence bone healing. At 41 years old, and without smoking or alcohol use, you have a favorable profile for healing, but other factors may still play a role.

Regarding your specific questions:
1. Continued Healing Potential: While simple rehabilitation, calcium, vitamin D3, and protein supplementation are beneficial for bone health, they may not be sufficient alone to promote healing in a case of delayed union or non-union, especially after nine months. The gap of approximately 1 cm at the fracture site indicates that the bone may not be healing adequately. In such cases, more aggressive interventions are often necessary. The use of therapies like PRP (Platelet-Rich Plasma) can aid in healing, but their effectiveness can vary. If the bone continues to show signs of non-union, surgical intervention may be warranted.

2. Autologous Bone Grafting: If your doctor recommends autologous bone grafting to fill the gap, this procedure involves taking bone from another site in your body (often the iliac crest) and transplanting it to the fracture site. This method can indeed be seen as "starting over" in terms of the healing process. It may require the reinstallation of hardware (like plates or screws) to stabilize the bone during the healing phase. The recovery time can vary; however, with proper surgical intervention and rehabilitation, the healing process may be expedited compared to the initial injury, especially if the graft is successful in promoting bone growth.

In summary, the management of open fractures, particularly in the tibia and fibula, requires careful monitoring and sometimes aggressive treatment strategies. Given the complexity of your situation, it is crucial to maintain open communication with your orthopedic surgeon about the best course of action. They can provide tailored recommendations based on your specific healing progress and overall health status. If surgery is deemed necessary, ensure that you understand the procedure, the expected recovery timeline, and the rehabilitation process that will follow. With appropriate intervention and diligent rehabilitation, there is a good chance for improved healing outcomes.

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