Common Causes of Aseptic Fracture Fixation Failure

The primary goal of treating fractures is to achieve osseous union. This can be accomplished with operative and nonoperative treatment. When fractures are treated operatively, a race between union and hardware failure occurs. When hardware failure occurs, revision surgery will likely be necessary. However, prior to revision surgery, a root cause analysis of the failure should be done so the next intervention will have the greatest chance of success. Hardware failure with nonunion can be attributed to two main causes, the fracture environment created by the surgeon and the innate biological capacity of the patient. Surgical errors and biological deficiencies must be explored prior to further surgery. To understand potential surgical errors, orthopaedic surgeons must have a basic understanding of primary and secondary bone healing processes and how fixation techniques and orthopaedic implants can influence osseous healing. This should allow the surgeon to determine whether proper technique or hardware was used. Ignorance of this can lead to repeating the same surgical misadventures that previously failed all while expecting a different result to occur. Placing the fracture or nonunion in the optimal mechanical environment will provide the best chance possible for union. Also, orthopaedic surgeons should be able to identify atrophic, oligotrophic, hypertrophic and pseudoarthrosis-type nonunions from their radiographic images. Additionally, surgeons need to understand the unique biological environment each nonunion possesses. Understanding this will help lead to the optimal surgical environment but it still may not overcome severe shortcomings in the healing capacity of the patient. Each patient brings a different biological capacity to heal a fracture. All aspects of the patient’s history must be examined including social habits, medications, previous surgeries and medical conditions. Any negative aspect that can be modified or eliminated should be corrected prior to revision surgery to prevent further surgical misadventures and optimize the chance of achieving osseous union.