Overview
A fracture normally heals through a predictable biological sequence - initial clot, soft callus, hard callus, then remodelling into mature bone. When this process stalls and the fracture site fails to bridge with bone over the expected healing window (typically six to nine months after injury), the result is a non-union.
Non-unions arise from two overlapping problems: mechanical and biological. Mechanical instability at the fracture site - from inadequate fixation, implant failure, or excessive load - disrupts the healing callus before it can mature. Biological deficiency - from poor bone stock, infection, metabolic disease, or an avascular fragment - means the body cannot generate sufficient healing response even when the mechanics are right. Treating a non-union means addressing both: restoring rigid fixation and supplying the biological substrate the original fracture site was missing.
Symptoms
- Persistent pain at the original fracture site beyond the expected healing window
- Visible or palpable motion at the fracture site
- Failure of bony bridging on follow-up X-rays
- Difficulty bearing weight (lower-limb non-union) or loading (upper-limb non-union)
Who's affected
- Patients with high-energy or comminuted initial fractures
- Patients with metabolic risk factors (diabetes, vitamin D deficiency, smoking)
- Patients on long-term steroids or NSAIDs
- Open fractures, infected fractures, or fractures with severe soft-tissue damage
Diagnosis
Non-union is confirmed on serial imaging when X-rays at six to nine months show no progressive bony bridging across the fracture site. A CT scan is typically requested at that point to characterise the non-union type - hypertrophic (adequate biology, inadequate mechanics), atrophic (inadequate biology), or oligotrophic (intermediate) - because the type determines the surgical approach.
A metabolic workup is standard: vitamin D, calcium, and parathyroid hormone levels, HbA1c in diabetic patients, and infection markers (CRP, ESR) where implant infection is a concern. In complex cases with suspected infection, nuclear medicine imaging or tissue sampling at the time of revision surgery may be required. The full picture - fracture pattern, prior fixation, metabolic status, and CT characterisation - is needed before planning revision surgery.
Treatment options
Revision internal fixation (GESY)
Removal of the failed construct and revision plate-and-screw fixation with Hofer Osteosynthesis anatomical locking plates.
Biological augmentation (GESY)
Filling of the non-union site with SmartBone® engineered synthetic bone graft - see the Bone-graft surgery procedure page.
Combined fixation + augmentation
Most non-union cases use both - revision plate plus structural SmartBone® filling for biological support.
Adjunct biologics (private-pay)
Selected cases benefit from autologous PRGF infiltration, BMAC augmentation, or autologous fibrin sealant (Vivostat®) alongside surgical care.
Devices used
Procedures
When to see a surgeon
If your fracture has not shown progressive union on X-rays by six months, a consultation with an orthopaedic trauma surgeon is warranted. Earlier review is appropriate if you have persistent mechanical pain or movement at the fracture site, if your implant has failed, or if you have known metabolic risk factors - diabetes, vitamin D deficiency, or smoking - that make delayed union more likely. Earlier intervention generally means better outcomes: established atrophic non-unions with significant bone loss are more complex to treat than early delayed unions where biological augmentation alongside revision fixation is still effective.
GESY coverage in Cyprus
Revision internal fixation with Hofer Osteosynthesis is GESY-covered in Cyprus.
SmartBone® synthetic bone graft is also GESY-covered in Cyprus, across the IBI SA product family.
Adjunct autologous biologics (PRGF, BMAC) are private-pay - regenerative medicine sits outside the GESY reimbursable tier.
