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Successful Reconstruction for Complex Malunions and Nonunions of the Tibia and Femur
Geert A. Buijze, MD1; Shawn Richardson, BA1; Jesse B. Jupiter, MD1
1 Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Yawkey Center, Suite 2100, 55 Fruit Street, Boston, MA 02114. E-mail address for G.A. Buijze: gbuijze@partners.org
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Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the Netherlands Organisation for Scientific Research (NWO). Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Investigation performed at the Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Mar 02;93(5):485-492. doi: 10.2106/JBJS.J.00342
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Information regarding the long-term outcomes of the treatment of lower-extremity fracture malunion and nonunion is lacking.


Twenty-nine secondarily referred patients with complex malunion or nonunion of the tibia or femur, treated by a single surgeon, were followed for a median of twenty years (range, twelve to thirty-five years) after injury. The patients were referred at a median of twenty months (range, 1.5 to 360 months) postinjury and had undergone a median of three prior surgical procedures (range, zero to twenty-eight). At the time of final follow-up, patient-based outcomes, patient satisfaction, and pain were evaluated.


All twenty-nine patients had healing following treatment of the complex malunion or nonunion of the tibia or femur and were able to bear full weight and walk one block or more. The Lower Extremity Functional Scale (LEFS) outcome tool revealed that twenty patients (69%) experienced moderate-to-severe difficulties in carrying out activities because of their lower-limb disability. The median Short Form-36 (SF-36) score was 67, with a median physical component score of 61 and a median mental component score of 71, indicating substantial impact on physical health status when compared with the norm.


Reconstruction can be a worthwhile endeavor and should be considered for all patients with complex malunion or nonunion of the tibia or femur.

Level of Evidence: 

Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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    Ahmed Shoaib
    Posted on April 22, 2011
    Response to Successful Reconstruction for Complex Malunions and Nonunions of the Tibia and Femur
    Fellow, Limb Reconstrcution, King's College Hospital, London, United Kingdom

    To the Editor:

    We find the conclusions in this article by Buijze et al. very interesting. They have attempted to provide evidence on a very difficult subject. Most patients with these challenging nonunions and malunions have significant morbidity and it is not uncommon for the patients to ask questions about the final outcome during clinical assessments. We find the statistical comparison between in-sample and out-sample quite an appropriate attempt to identify a representative sample. We also agree with the author that in case of lower limb nonunions and malunions, it is very difficult to do prospective randomized or non-randomized studies. We would like to highlight a few points in this study.

    Authors in this study have included femur, tibia, infected, non infected, nonunions and malunions. These entirely different clinical scenarios require different management strategies. For example, management of a mid-shaft femoral nonunion is completely different from a subtrochanteric femoral nonunion. It is difficult to form conclusions from such a small study sample and a diverse group of patients. Patients included in this study were managed from 1982 to 1996. We agree that the purpose of this study was to find out long-term outcome but the operative options in limb reconstruction surgery have evolved tremendously in the last decade. New implants, such as 3-dimensional deformity correction external fixators, have rapidly changed operative practices in the last few years. In the inclusion criteria for the study patients, there is no reference as to how the 1 cm gap in case of nonunion and similar inclusion criteria were established. All patients included in the study were referred to the tertiary referral center. Due to the prolonged natural course of lower limb nonunions and malunions, there is a high impact of initial treatment on the final outcome. We found limited information regarding the initial treatment in this study.

    Patients with better outcome are more likely to attend functional outcome assessments when compared patients with longstanding pain after reconstruction surgery. We understand that this is a frequent problem with studies assessing the functional outcome and we appreciate the author’s attempt to minimize this important confounder.

    Geert A. Buijze, PhD
    Posted on April 22, 2011
    Drs. Buijze and Jupiter respond to Mr. Shoaib and Mr. Rashid
    Research Fellow, Massachusetts General Hospital, Boston, Massachusetts

    To the Editor:

    We thank Dr. Shoaib for his interesting comments regarding our manuscript. We agree that this case series includes a variety of clinicalscenarios requiring different management strategies. The primary aim of this study was not to report on these management strategies but to find the common factor in them and report the long-term outcome using validated outcome scores. It has been our goal to minimize confounders in this study and we are glad to address their comments.

    It is indeed difficult to draw conclusions upon a small diverse group of patients and this limited us to taking conclusions merely on the long-term outcome of successful reconstructions. No conclusions should be drawn from our study regarding the success rate of the elected management. The initial management varied as much (if not more) than the index surgical procedure (with previous surgeries per patient ranging up to twenty-eight) and this makes its summary very difficult. The essence has been reported in the manuscript and in our opinion requires no further focus in this study. With regard to the elected management, no advanced computerized techniques or imaging modalities were used. An Ilizarov device was used in most cases to correct for either deformity or segmental defects (measured on bilateral radiographs). With current advancements in techniques high success rates for reconstructions can be achieved more consistently.

    We are not aware of consistent evidence that patients with better outcome are more likely to attend functional outcome assessments when compared to patients with longstanding pain after reconstruction surgery. In our series, this did not seem to be the case. Of the ten patients that declined participation, most of whom were contacted did not express pain or unsatisfactory outcomes. In fact some patients chose to return for assessment (at no cost) to inquire about further options to manage their disability or pain levels.

    In summary, we think that all of the their concerns can be addressed by narrowing the interpretation of the present study and focusing primarily on outcome instead of management. It presents valuable data for the long-term outcome in patients who have had successful reconstructions of the lower limb. The principle message of the authors is that reconstructions can be worthwhile in all patients, no matter how severe their complication, if expectations are managed adequately. Moderate to severe disability should be expected in some cases, but in the author’s long-term experience, patients express relatively high satisfaction for salvaging their limb.

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