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FIGURE 46.13
(A) Anteroposterior femoral radiograph of a 16-year-old skeletally mature patient with a proximal femoral shaft non-union.
The patient has a modified Bailey-Dubow rod in place, which is bent into varus (along with the femur itself) near the fracture site. In addition,
there is a varus deformity in the distal shaft. (B) Lateral femoral radiograph showing the apex anterior deformity at the non-union site as well
as of the femoral intramedullary fixation. In addition, there is an apex anterior deformity in the distal shaft. (C) Anteroposterior femoral radio-
graph of the same patient 3 months after revision rodding with removal of the existing Bailey-Dubow device, closed reduction of the proximal
deformity at the femoral fracture site, and distal femoral shaft osteotomy to correct the apex lateral and anterior deformity. In this case, closed
reduction of the fracture straightened the proximal male portion of the fixation, allowing it to be removed through an incision near the greater
trochanter. The distal male and entire female portions of the fixation were removed through knee arthrotomy and distal osteotomy sites, respec-
tively. Because the patient is skeletally mature, non-elongating intramedullary fixation is used. (D) Lateral femoral radiograph showing the cor-
rection of the apex anterior deformity.
treated their patient with a staged resection of the non-
union, gradual correction of the deformity with an exter-
nal fixator, intramedullary rodding and bone graft.
Atrophic and “gap” non-unions are more difficult to
treat, particularly if there is segmental bone absence due,
in part, to the lack of a sufficient source of structural auto-
graph bone. Gamble et al.
74
described one patient with
an atrophic non-union which failed to unite after surgery,
and eventually underwent amputation. Agarwal et al.
116
described five humeral “gap” non-unions resulting from
fractures that were not adequately immobilized. All had
atrophic non-unions with significant bone loss at the frac-
ture site. Most occurred at the junction of the middle and
distal thirds of the humeral shaft. Three of the non-unions
were treated surgically, with structural bone homografts
from relatives to span the segmental bone absence. All of
the surgically treated atrophic non-unions failed to unite
in their series. One patient with bilateral painless humeral
non-unions was treated in a thermoplastic splint to lessen
the instability and improve function of the extremity.
Raut et al.
118
described the case of a gap non-union
involving the distal third of the humerus, and an atro-
phic non-union of the femur in the same patient.
Treatment included resection of the non-union with
shortening and intramedullary rodding of the femur, fol-
lowed by staged humeral resection, structural autograft
from the previously resected femur and intramedullary
rodding. At short-term follow-up, neither site had
healed. Devalia et al.
119
reported a case of a humeral
“gap” non-union treated with maternal fibular homo-
graft with success. They advocated maternal fibula
homograft over autograft, because of poor autogenous
bone stock, and over allograft to lessen the risk of infec-
tion and non-union.
In summary, it is important to provide sufficient
immobilization following any long bone fracture in a
child with OI, even those fractures that seem trivial.
This approach would be especially warranted in those
children who have the type III form of the disorder. For
hypertrophic or atrophic non-unions without significant
segmental bone loss, intramedullary fixation with autog-
enous bone graft, combined with concomitant realign-
ment if necessary, is the treatment of choice (
Figure 46.10
).
Similarly, for small gap non-unions, shortening with
autogenous cancellous graft and intramedullary fixation
is suggested. For the more difficult “gap” non-unions
with segmental bone loss, no treatment consensus exists.
For larger gap non-unions, structural allograft or homo-
graft with intramedullary fixation is preferred due to a
lack of sufficient structural autograft in this patient popu-
lation. Asymptomatic non-unions in the upper extremity
(or in any extremity in non-ambulatory patients) that are
atrophic may be better treated in a functional brace rather
than with surgery.
