Judet decortication and compression plate fixation of long bone non-union:
Is bone graft necessary?
D.N. Ramoutar*, J. Rodrigues, C. Quah, C. Boulton, C.G. Moran
Department of Trauma and Orthopaedics, Queen’s Medical Centre, Nottingham, UK
Fracture non-union can occur in up to 5–10% of all fractures.7A
variety of mechanical and biological factors cause healing to stop
whilst the fracture is still present and the fracture will not unite
without surgical intervention. It is usually established between 6
and 8 months post fracture but if there is an absence of progressive
repair radiologically between 3 and 6 months, progression to non-
union can be assumed.8Classification of non-unions is often
difficult but broadly speaking is divided into aseptic and infected
cases. Aseptic non-unions are subdivided into hypertrophic
(usually a mechanical cause) and atrophic (usually a biological
cause) cases.12Fracture non-union has significant impact on the
affected limb with subsequent osteopenia, disuse muscle atrophy
and related joint stiffness causing substantial loss of function7and
a very poor quality of life.
A variety of methods can be used to treat non-unions. Fixation
may be external or internal and must provide stability.14Many
authors recommend the use of bone graft.11,13,18Harvesting of
autologous bone graft in itself may be associated with significant
complications.19Alternatives to the use of autologous bone graft
include use of osteoinductive molecules such as bone morphogenic
protein (BMP) but these are yet to be firmly established in the
primary treatment of non-unions.
The aim of our study was to evaluate the results of compression
plate fixation for long bone fracture non-union and assess the
impact of bone grafting on union rates.
All patients undergoing compression plate fixation of a long
bone non-union under the care of a single surgeon were identified
Injury, Int. J. Care Injured 42 (2011) 1430–1434
A R T I C L E
I N F O
Accepted 21 March 2011
A B S T R A C T
Non-union occurs in 5–10% of all fractures and is caused by a variety of mechanical and biological factors.
Stable fixation is essential and many authors recommend the addition of bone graft. Our aim was to
evaluate the results of internal fixation using Judet decortication and compression plating for long bone
fractures and assess the impact of bone grafting on union rates. Our study group comprised all the
patients undergoing compression plate fixation under a single surgeon over a fourteen year period
(n = 96). AO principles were used and the standard technique involved Judet decortication, compression
plating and lag screws. Autologous bone graft was harvested from the iliac crest. The mean age was 45
years and 62% were male. The fracture site was the clavicle (n = 20); humerus (n = 23); radius and ulna
(n = 5); femur (n = 31) and tibia (n = 17). The primary fracture treatment was non-operative (n = 41); IM
nail (n = 22); plate fixation (n = 28) and external fixation (n = 5). Deep infection was present in 6 cases.
Bone graft was used in 40 cases. 91/96 non-unions treated with compression plating healed (95%). Bone
grafting was used in all cases for the initial part of the series but its use declined as the surgeon became
more confident that the non-unions would heal without the use of bone graft. The case mix and
complexity remained constant throughout the study period and the union rate also remained constant.
The mean time to radiological union was 6.4 months. In those treated with a compression plate without
bone graft the union rate was 94.6% whilst the addition of bone graft resulted in a union rate of 95%
(p = 0.67). From our study we concluded that the routine use of autologous bone graft may not be
necessary and, based upon the union rates observed in this study, a prospective randomised study to
evaluate the use of bone graft in non-union surgery would need a sample size of 194,000 to detect a
significant increase in union with 80% power. In terms of Numbers Needed Treat (NNT), we would need
to give 1179 patients a bone graft to prevent one additional failure of healing.
? 2011 Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: +44 7900184173.
E-mail address: email@example.com (D.N. Ramoutar).
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