The non-union site is exposed. Fibrous tissue between the bone ends is excised. The bone ends are freshened to bleeding cancellous bone. Autologous bone graft (usually from the iliac crest or via RIA from the femoral canal) is packed around the non-union. The fixation is revised — either replacing or augmenting the existing metalwork — to provide stable compression and/or alignment. For infected non-unions, radical debridement is performed and antibiotic treatment precedes or accompanies reconstruction. The operation takes one and a half to four hours depending on complexity.
Surgery is recommended when a fracture shows no healing progress by six to nine months, with pain at the fracture site and motion at the non-union. Risk factors for non-union include smoking, diabetes, NSAID use, infection, inadequate fixation, poor blood supply, bone loss, and soft tissue interposition.
Bone stimulators (electromagnetic, low-intensity pulsed ultrasound — limited evidence), smoking cessation and metabolic optimisation, and acceptance of the non-union (rarely appropriate for lower limb).
Full-length X-rays and CT to assess the non-union. Blood tests to exclude infection (CRP, ESR, WCC). Assessment of bone quality and defect size. Metabolic screen (vitamin D, calcium, thyroid, PTH) to identify correctable factors. Smoking cessation is mandatory.
Healing rates for non-union surgery with bone grafting and stable fixation are approximately 85–95%. Identification and correction of the underlying cause (infection, mechanical instability, biological impairment) is the key to success.
Prolonged recoveryExpected
Non-unions take longer to heal than primary fractures — three to six months after revision surgery.
Bone graft donor site painCommon
Iliac crest pain is common (10–30%).
Persistent non-unionUncommon
Approximately 5–15% of revised non-unions still fail to heal.
InfectionUncommon
Higher risk than primary fixation, particularly if occult infection is present.
Implant failureUncommon
The revision metalwork may fail if the non-union does not heal.
Nerve or vessel injuryUncommon
From surgery through scar tissue.
Donor site fractureRare
Iliac crest fracture after graft harvest. Very rare.
AmputationRare
For recalcitrant infected non-unions in severe cases. Very rare.
General or regional anaesthesia. Two surgical sites if iliac crest graft is used.
Weight-bearing depends on the fixation and bone quality. Regular X-rays every six to eight weeks to monitor healing. Physiotherapy for joint mobility and muscle strengthening. Full recovery six to twelve months after non-union surgery. Smoking cessation is essential — smokers have five times the failure rate.
X-rays every six to eight weeks until union confirmed. Blood tests if infection was a concern. Metabolic reassessment.
Why did my fracture not heal?
Common causes include smoking (the single biggest modifiable risk factor), inadequate fixation, infection, poor blood supply, fracture gap or bone loss, diabetes, vitamin D deficiency, and NSAID use. Often multiple factors contribute.
What can I do to help it heal?
Stop smoking completely (this is the most important thing), ensure adequate vitamin D and calcium, avoid NSAIDs, optimise diabetes control, maintain good nutrition, and follow weight-bearing guidance. These factors significantly influence healing.