Fracture Nonunion (Pseudoarthrosis) Treatment in Germany

Fracture nonunion (pseudoarthrosis, false joint, Pseudoarthrose) is a condition in which the bone fails to heal within the expected timeframe and the consolidation process ceases. Fibrous or cartilaginous tissue forms at the fracture site instead of bone, creating a "false joint" with pathological mobility. Nonunion develops in 5–10% of all fractures and is one of the most challenging problems in traumatology. German clinics employ modern methods of bone healing stimulation: autologous bone grafting, BMP, Ilizarov apparatus, and innovative regenerative therapy with autologous stem cells.

What is Fracture Nonunion

Normally, a fracture heals in 3 stages: inflammation (1–2 weeks), callus formation (4–12 weeks), remodeling (months–years). If 6–9 months after fracture no radiographic progression of healing is observed, nonunion is diagnosed. Delayed union is diagnosed when healing has not occurred within the usual timeframe, but the process continues.

Pseudoarthrosis forms when the fragment ends become covered with fibrous tissue or cartilage, and a gap resembling a joint space develops between them. With prolonged existence, a synovial membrane and capsule form — a "true" false joint.

Types of Pseudoarthrosis

Causes

1. Insufficient fixation — unstable osteosynthesis, poor reduction, early hardware removal. Movement at the fracture site → fibrosis instead of bone.
2. Disrupted blood supply — femoral neck, scaphoid, and talus fractures — areas with poor blood supply. Extensive soft tissue trauma.
3. Bone defect — loss of a bone fragment in an open fracture or surgery. Gap > 1 cm.
4. Infection — postoperative infection destroys regenerating bone tissue. Osteomyelitis.
5. Systemic factors — osteoporosis, diabetes mellitus, smoking (reduces blood flow by 25%), NSAID and corticosteroid use, vitamin D deficiency, poor nutrition.
6. High-energy trauma — open fractures, multiple fractures, gunshot fractures.

Symptoms

• Weight-bearing pain — persistent or recurrent pain at the fracture site 3–6 months after injury.
• Pathological mobility — sensation of movement at the fracture site under load or palpation.
• Functional impairment — inability to bear full weight, limping, restricted motion in adjacent joints.
• Limb deformity — angular or rotational deviation, shortening.
• Swelling — persistent soft tissue swelling at the fracture site.
• In infected pseudoarthrosis: fistulae with purulent discharge, skin redness, general malaise.

Diagnostics

1. X-ray — lack of callus progression on serial images at 6–8 week intervals. Edge sclerosis, gap, "elephant foot" or end atrophy.
2. CT — gold standard for consolidation assessment. 3D reconstruction for surgical planning, bone defect evaluation.
3. MRI — visualization of fibrous tissue in the fracture gap, bone end viability assessment, ruling out infection.
4. Scintigraphy — metabolic activity assessment at the fracture site (hypertrophic vs atrophic).
5. Laboratory tests — ESR, CRP, leukocytes (ruling out infection); calcium, vitamin D, PTH, TSH (metabolic causes); bone turnover markers.
6. Bacteriological study — if infected pseudoarthrosis is suspected: aspiration, culture, sensitivity testing.

Conservative Treatment

• Extracorporeal shock wave therapy (ESWT) — osteogenesis stimulation with extracorporeal waves. 60–80% efficacy in hypertrophic pseudoarthrosis.
• Ultrasound stimulation (LIPUS) — low-intensity pulsed ultrasound. Exogen device: 20 minutes/day, 3–6 months.
• Electrical stimulation — electromagnetic fields stimulate osteoblasts. Used for superficial pseudoarthrosis.
• Systemic factor correction — smoking cessation (!), vitamin D and calcium normalization, diabetes control, NSAID discontinuation.
• Brace stabilization — for stable hypertrophic pseudoarthrosis combined with ESWT/LIPUS.

Surgical Treatment

1. Re-osteosynthesis with autologous bone grafting — removal of non-viable tissue, stable fixation with plate or nail + autograft from the iliac crest. Gold standard for atrophic pseudoarthrosis.
2. Judet decortication — removal of the cortical plate around the fracture zone to stimulate blood supply. For hypertrophic type + stable fixation.
3. Compression osteosynthesis (Ilizarov apparatus) — external fixator with gradual compression of the fracture zone. Indicated for infected pseudoarthrosis, bone defects. Maslov–Ilizarov method: bone segment transport to close the defect.
4. BMP (bone morphogenetic protein) — BMP-2 (InFuse), BMP-7 (OP-1). Powerful osteogenesis stimulation. Used for severe atrophic pseudoarthrosis.
5. Vascularized bone graft — transplantation of a bone segment with a vascular pedicle (fibula). For large defects and disrupted blood supply.
6. Masquelet technique (induced membrane) — two-stage: (1) cement spacer placement → induced membrane formation; (2) after 6–8 weeks — cement removal + bone grafting inside the membrane. For defects > 4 cm.

Treatment Cost

All treatment prices in Germany.

Clinics