Despite this all-too-common complication, no universally accepted definition of nonunion exists in the orthopedic literature. While the precise definition of fracture nonunion is controversial, the concept of failed union after an adequate period of healing is well recognized to the orthopaedist. This review will discuss these autologous, allogenic and synthetic substrates with an emphasis on their contribution to modern fracture care and bone loss. The field of orthopaedic surgery has experienced unprecedented advancements over the last 20 years, with bone graft and orthobiologics playing a significant role. Depending on their properties, preparation and application, bone grafts augment natural healing via osteoinductive, osteoconductive and/or osteogenic mechanisms. Modern bone grafts, bone substitutes and bioactive factors attempt to facilitate and enhance the healing process when suboptimal conditions exist. Yet even with the efficacy of modern internal fixation techniques, infection, poor vascularity, malnutrition and substantial bone or soft tissue loss can impede effective osteosynthesis. For thousands of years, man has recognized the importance of immobilization for fracture healing. Unfortunately, conditions for spontaneous bone healing are not always ideal. At its core, orthopaedic fracture care is an attempt to harness this amazing regenerative capacity and let the body do its work. This unique restorative capacity, shared perhaps with only the adult human liver, allows bones to heal at shapes, sizes and strengths essentially equal to their pre-injured forms. The human skeleton has a remarkable ability to regenerate itself after injury.
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