Introduction of a new management algorithm for tibial non-union in developing countries

Objectives: We aimed to describe the epidemiological profile of tibial non-unions in our context and to evaluate outcomes achieved using a standardized algorithm adapted to limited-resource settings. Methods: We conducted a prospective, multicenter study from January 2017 to December 2021 that included all patients ≥16 years of age treated for tibial non-union and followed for at least 12 months. Septic non-unions and defects >10 cm were excluded. Management was based on a predefined algorithm that integrated the Weber-Cech classification and the Catagni bone-loss classification, accounting for septic status, biological vitality, and defect size. Aseptic non-unions were treated by Judet periosteal decortication, with or without bone grafting. Septic or bone-loss cases underwent staged treatment with radical debridement, targeted antibiotics, and reconstruction by bone grafting, induced membrane technique, or intertibio-fibular grafting. Results: Among 517 tibial fractures treated, 115 non-unions were identified (18.5%); 104 were analyzed. The mean age was 35.5 years. Forty-nine cases (47.1%) were aseptic, and 55 (52.9%) were septic. Vital non-unions accounted for 66.6%. After a mean follow-up of 16.8 months, union was achieved in 101 patients (97.1%). Persistent infection occurred in three immunocompromised HIV-positive patients. According to the Association for the Study and Application of the Ilizarov method, bone consolidation was excellent or good in 91.3% of cases, and functional results were excellent or good in 81.7% of cases. No amputations were required. Conclusion: Even in low-resource environments, strict adherence to a codified algorithm is associated with high union rates and favorable functional outcomes.