Fracture Nonunion, Malunion & Revision Surgery of the Foot and Ankle
- sarangndesai
- Aug 16
- 13 min read
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By Sarang Desai, DO — Fellowship-Trained Orthopedic Foot and Ankle Surgeon
Sports Medicine | McKinney and Flower Mound, Texas
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A lot of patients come to me frustrated and worried, having been told some version of: "Your fracture didn't heal," or "It healed, but crooked." Let me reassure you right away — both of these problems are fixable. When a bone fails to heal it's called a nonunion; when it heals in the wrong position it's called a malunion. Both cause pain and dysfunction, and both are among the most common reasons patients seek a second opinion or revision surgery. Nonunion happens in roughly 5% to 10% of all fractures, and the surgery to correct these problems — done well — has healing rates commonly reported between 80% and 100%.[1][2][3]
This is exactly the kind of complex, "the first surgery didn't go as planned" problem that fellowship-trained foot and ankle surgeons are trained to solve. Let me walk you through what's happening and what can be done.
For related reading: The Complete Guide to Ankle Fractures · Jones Fracture Surgery: The Complete Guide
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FIRST, THE VOCABULARY: NONUNION VS. MALUNION VS. DELAYED UNION
These terms get thrown around, so let me define them clearly:
- Delayed union — the fracture is still healing, just slower than expected. It's showing signs of progress, but hasn't crossed the finish line in the anticipated timeframe.[2]
- Nonunion — the healing process has essentially stopped, and the bone will not heal on its own without intervention. This is generally recognized when a fracture hasn't healed by about 6 months, or shows no healing progress over three consecutive months.[4]
- Malunion — the bone healed, but in a bad position — too short, rotated, angled, or with a joint surface that's no longer smooth. The bone is solid; it's just in the wrong shape.[5]
The distinction matters because the treatment is different: a nonunion needs help healing, while a malunion needs realignment.
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TWO TYPES OF NONUNION — AND WHY IT MATTERS
Not all nonunions are the same, and identifying the type drives the treatment. Surgeons use the classic Weber-Cech classification:[6]
- Hypertrophic nonunion ("vital") — the bone is biologically alive and trying hard to heal, forming abundant callus, but it can't bridge the gap because there's too much motion at the fracture. This is a mechanical problem. The fix is usually better stability (a stronger plate or compression), and the bone often heals without needing a graft.[6]
- Atrophic nonunion ("avital") — the bone shows little to no callus and isn't healing because the biology has failed — poor blood supply, poor healing capacity. This needs biological help: bone grafting, and often growth factors, in addition to stable fixation.[6]
Think of it this way: hypertrophic means the bone "wants" to heal but can't hold still; atrophic means the bone "can't" heal and needs a biological jump-start. Many surgeons use the "diamond concept" — the idea that successful healing requires all the key ingredients together: mechanical stability, osteogenic cells, growth factors, and a scaffold.[6]
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WHY DO FRACTURES FAIL TO HEAL? (THE RISK FACTORS)
Understanding why the first fracture didn't heal is the whole ballgame — because if we don't fix the underlying reason, revision surgery can fail too. In the largest study of its kind (over 309,000 fractures), the strongest risk factors for nonunion were identified. They fall into a few buckets:[1]
Things about the injury itself:
- Open fractures (bone broke through skin) — higher energy, more soft-tissue and blood-supply damage[1][7]
- Multiple fractures and high-energy injuries[1]
- A gap between the bone ends or significant displacement[7]
- Infection — one of the most powerful causes of failed healing[7]
- Fracture location — the tibia and certain "watershed" areas with poor blood supply (like the base of the 5th metatarsal in a Jones fracture) are notoriously prone to nonunion[1][7]
Things about you (many of which we can modify):
- Smoking / nicotine — nicotine constricts blood vessels and poisons bone healing. This is the single most important modifiable factor.[1][8]
- Diabetes[1]
- Certain medications — long-term NSAIDs (anti-inflammatories), opioids, steroids, and anticoagulants[1][2]
- Osteoporosis and vitamin D deficiency[1]
Here's why I emphasize this: many of these are within your control. Stopping smoking, optimizing vitamin D and nutrition, controlling diabetes, and avoiding certain medications genuinely improve your odds — both for preventing nonunion and for making revision surgery succeed.[1][8]
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HOW WE DIAGNOSE A NONUNION OR MALUNION
A careful workup is essential before any revision, because the plan depends entirely on what we find:
- X-rays — the starting point, often compared with your other side. They show whether the bone has bridged and how it's aligned.[9]
- CT scan — the workhorse for these problems. It's far better than X-ray at confirming whether a fracture has truly healed and at mapping a malunion in three dimensions for surgical planning. For complex malunions, some surgeons even use 3D-printed models.[9][10]
- MRI — helpful for assessing blood supply and soft tissues.
- Blood work and infection workup — this is critical and often overlooked. Any nonunion could be an infected nonunion, and missing that leads to failed surgery. Labs and sometimes intraoperative cultures help rule this out before proceeding.[11]
- Metabolic evaluation — checking vitamin D, thyroid, and other factors that impair healing, especially in patients with unexplained or multiple nonunions.[1]
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TREATING NONUNION: FIXING BOTH THE MECHANICS AND THE BIOLOGY
The principle is simple even if the surgery isn't: give the bone what it's missing. Revision surgery for nonunion typically addresses stability, biology, or both.[6]
Non-surgical options (for select cases):
- Bone growth stimulators — devices using electromagnetic fields or ultrasound (LIPUS). The evidence is mixed and mostly helpful for early delayed unions rather than established nonunions, but they're a reasonable, low-risk option to try before surgery in the right patient.[3][12]
Surgical options — improving stability:
- Revision fixation — removing the old hardware and re-stabilizing with a stronger construct, usually a compression plate that squeezes the bone ends together. For hypertrophic (mechanically unstable) nonunions, this alone often does the trick because the biology is already willing.[6][11]
- Exchange nailing or augmentation plating for certain long-bone patterns.[6]
Surgical options — improving biology:
- Bone grafting — the cornerstone for atrophic nonunions. Your own bone (autograft, often from the pelvis or heel) is the gold standard because it brings living cells, scaffold, and growth factors all at once.[11]
- Bone marrow aspirate (BMA) — concentrated healing cells injected or grafted. Recent network meta-analysis found BMA combined with autologous cancellous bone had among the highest healing rates and the lowest complication risk of available biologics.[12]
- Bone morphogenetic protein (BMP) — a potent growth factor. In a prospective series of nonunions (including infected cases), rhBMP-2 combined with autologous bone achieved 100% union at one year.[13]
- Platelet-rich plasma (PRP) — as a biologic adjunct in nonunion surgery (a very different use than for arthritis), PRP-enhanced grafting has shown improved healing rates and shorter healing times in revision settings.[14]
For infected nonunions — a staged approach is standard: first surgery to remove hardware, debride the infection, and place antibiotic spacers/beads with an external fixator; then, once infection is cleared (typically 6–8 weeks and guided by an infectious disease specialist), definitive fixation and grafting.[11]
Across the board, well-selected revision surgery achieves union in roughly 80–100% of cases for common procedures like plating with bone graft.[3]
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TREATING MALUNION: PUTTING THE BONE BACK WHERE IT BELONGS
A malunion is a solid bone in the wrong position — and in the foot and ankle, even small malalignments cause big problems because these are precision weight-bearing joints. The most common and important example is a malunited ankle fracture with a shortened fibula.
Why a malunited fibula matters: If the fibula heals short or rotated, the talus no longer sits perfectly centered in its socket. That uneven loading is a direct path to chronic pain and post-traumatic arthritis. The fix is a fibular lengthening osteotomy — the surgeon re-cuts the fibula, restores its correct length and rotation, and re-stabilizes it, often with revision of the syndesmosis.[5][15]
The results are genuinely rewarding when done for the right patient. In one prospective series of ankle fracture malunions treated with fibular re-balancing, AOFAS scores improved substantially and osteotomies healed in good correction.[5] In another series of malunions corrected with malleolar osteotomies, AOFAS scores climbed from an average of 45 to 87, with most patients rating their function excellent or good at 5 years.[16]
The key concept — "joint-preserving vs. salvage":
- If the cartilage is still healthy (no significant arthritis yet), a corrective osteotomy to realign the bone can preserve your own joint, relieve pain, and delay or avoid fusion. Timing matters — correcting a malunion before arthritis sets in gives the best results.[17][16]
- If the joint is already badly arthritic, realignment alone won't relieve the pain, and the better option is a salvage procedure — a corrective fusion (arthrodesis) or, in select cases, ankle replacement. This is especially true for hindfoot malunions after talus and calcaneus fractures, where corrective osteotomy combined with fusion of the affected joint gives high satisfaction and pain relief.[17]
Getting a good realignment also has a hidden benefit: even if you eventually need a fusion or replacement later, that surgery is far easier and more successful when the bones are properly aligned first.[16]
Problem | What It Means | Main Fix | References |
Delayed union | Healing slowly, still progressing | Optimize biology, consider bone stimulator; watch | |
Hypertrophic nonunion | Bone alive but too much motion | Better stability (compression plate) | |
Atrophic nonunion | Biology failed, poor blood supply | Bone graft ± BMA/BMP ± stable fixation | |
Infected nonunion | Failed healing + infection | Staged: debride + antibiotics, then fix/graft | |
Malunion, healthy cartilage | Healed crooked, joint still good | Corrective osteotomy (realignment) | |
Malunion + arthritis | Healed crooked, joint worn out | Corrective fusion or replacement |
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RECOVERY AFTER REVISION SURGERY
I'll be honest with patients: revision recovery is often longer and more protected than the original surgery, because we're asking a bone that already struggled to heal to do it right this time. General expectations:
- Protected weight-bearing for a longer period than a routine fracture — often several weeks to a few months, individualized to your specific surgery, bone quality, and whether grafting was done.[16]
- If bone was taken from your pelvis or heel (autograft), there's a second surgical site that needs its own recovery, and donor-site discomfort can linger.[26]
- Physical therapy to restore motion, strength, and gait once healing allows. Physical Therapy After Ankle Fracture Surgery
- Full recovery commonly takes several months to a year, with the payoff being a healed, well-aligned bone and meaningful pain relief.[5][16]
The single most important thing you can do to help revision surgery succeed: don't smoke, optimize your nutrition and vitamin D, and control your diabetes. These directly determine whether the bone heals this time.[1][14]
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COMMON MISCONCEPTIONS
- "If it didn't heal once, it never will." Not true — with the right diagnosis and surgery, healing rates are commonly 80–100%.[3]
- "A crooked-but-healed bone is fine if it doesn't hurt now." A malunion, especially a short fibula, often leads to arthritis over time. Correcting it early can prevent that.[5][15]
- "Nonunion just means I need another surgery like the first." Often the fix is different — more stability for a hypertrophic nonunion, or biology (graft) for an atrophic one, and always ruling out infection first.[6][11]
- "Smoking a little won't matter for healing." It matters enormously — nicotine is one of the strongest, most controllable causes of failed bone healing.[1][8]
- "Bone stimulators and PRP are miracle cures." They're useful adjuncts in specific situations, but they don't replace fixing the mechanical and biological problem.[3][14]
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FREQUENTLY ASKED QUESTIONS
1. What's the difference between a nonunion and a malunion?
A nonunion means the bone didn't heal at all; a malunion means it healed but in the wrong position. Nonunion needs help healing; malunion needs realignment.[6][5]
2. How common is nonunion?
About 5–10% of all fractures fail to heal, though it varies widely by bone and by risk factors.[1][2]
3. When is a fracture officially called a nonunion?
Generally when it hasn't healed by around 6 months, or shows no healing progress over three consecutive months.[4]
4. Why didn't my fracture heal?
Common reasons include smoking, diabetes, infection, poor blood supply at the fracture site, too much motion, a gap between bone ends, and certain medications. Identifying the cause is essential before revision.[1][7]
5. Can a nonunion heal without surgery?
Sometimes — early delayed unions may respond to bone growth stimulators and optimizing your health. But established nonunions usually need surgery.[3]
6. What does revision surgery involve?
It depends on the cause: better stability (compression plate) for a mechanically unstable nonunion, bone grafting and biologics for a biologically failed one, and a staged approach if infection is present.[6][11]
7. What is a corrective osteotomy?
A surgery that re-cuts the healed-but-crooked bone to restore proper alignment — for example, a fibular lengthening osteotomy for a malunited ankle fracture.[15]
8. Will I definitely need bone from my hip?
Not always. Hypertrophic nonunions often heal with better fixation alone. When grafting is needed, options include your own bone, bone marrow aspirate, or growth factors.[6][12]
9. Does a malunion always cause arthritis?
Not always, but malalignment — especially a short fibula — significantly raises the risk of post-traumatic arthritis, which is why timely correction matters.[5][15]
10. What are the success rates?
Union rates for common revision procedures are commonly reported at 80–100%, and malunion corrections often produce large improvements in function and pain when done before arthritis develops.[3][16]
11. How long is recovery?
Usually longer than the original surgery — often several months to a year — with a period of protected weight-bearing and physical therapy.[16]
12. Why see a fellowship-trained foot and ankle surgeon for this?
Revision surgery is complex — it requires correctly diagnosing why the first surgery failed, ruling out infection, and choosing the right combination of stability, biology, and realignment. Experience matters enormously here.[6][17]
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THE BOTTOM LINE
A fracture that didn't heal (nonunion) or healed crooked (malunion) is a solvable problem. The key is a careful diagnosis — identifying whether the issue is mechanical, biological, or both; ruling out infection; and correcting the underlying reason the bone failed the first time.[1][6][11] With the right revision strategy — better fixation, bone grafting and biologics, or a corrective osteotomy — healing and realignment succeed in the large majority of patients, often with dramatic improvements in pain and function.[3][16] And much of your success is in your hands: stopping smoking and optimizing your health genuinely change the outcome.[1][14]
If you've been told your foot or ankle fracture didn't heal, or that it healed in a bad position, don't lose hope — and don't wait too long, since correcting a malunion before arthritis develops gives the best results. Bring your imaging and come in for a focused evaluation.
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RELATED READING
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ABOUT THE AUTHOR
Dr. Sarang Desai is a fellowship-trained orthopedic foot and ankle surgeon with particular expertise in sports medicine and complex revision surgery. With over 15 years of experience, Dr. Desai serves as a professional sports team physician and treats the full spectrum of foot and ankle conditions — including fracture nonunions and malunions, revision surgery, ankle fracture-dislocations, pilon, talus, and calcaneus fractures, syndesmosis injuries, cartilage injuries, chronic ankle instability, peroneal tendon disorders, Achilles tendon injuries, Jones fractures, Lisfranc injuries, bunions, foot and ankle arthritis, and total ankle replacement.
He is a published researcher, an orthopedic implant inventor, a national lecturer, and a former University of Texas All-American athlete.
Offices in McKinney and Flower Mound, Texas, serving patients throughout Plano, Frisco, Denton, Lewisville, Southlake, Dallas, Fort Worth, Arlington, and the greater Dallas–Fort Worth metroplex and beyond.
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📞 (972) 547-0047
📍 McKinney, TX | Flower Mound, TX
If you've been told your fracture didn't heal or healed in a bad position, a focused revision evaluation can give you a clear path forward. Bring your X-rays, CT scans, and prior operative reports — the more information, the better the plan.
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This article is for educational purposes only and does not constitute personal medical advice. Always consult a qualified physician about your individual situation.
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