Non Union
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Non Union

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This presentation was prepared for a AOSEC course in Chittagong, Bangladesh. This course was organized by AO Foundation.

This presentation was prepared for a AOSEC course in Chittagong, Bangladesh. This course was organized by AO Foundation.

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Non Union Non Union Presentation Transcript

  • AO SEC Trauma May, 15-17, Chittagong. Welcome
  • Prof. Muhammad Shahiduzzaman Head, Department of Orthopaedics and Traumatology Dhaka Medical College Hospital
    • Definition
    • Etiology
    • Evaluation
    • Classification
    • Treatment principles
      • Stabilization
      • Biology
    • Prevention
    • Non Union
    • 9 months elapsed time with no healing progress for 3 months.
    • Union is delayed and a fracture has ceased to show any evidence of healing
    • Practically,
    • A fracture that has no potential to heal without further intervention
    • Delayed union
    • Failure to consolidate within the normally expected time for fracture types and location
    • Pseudoarthrosis
    • Formation of a false joint where a fibro-cartilaginous cavity is lined with synovial membrane
    • What does nature do with a broken bone?
    Indirect Healing It will heal by callus formation
    • Stages of fracture healing
    • Hematoma formation
    • Inflammation and cellular proliferation
    • Callus formation
    • Consolidation
    • Remodeling
    bony bridging
    • Poor Vascularity (biology)
    • Instability
    • Infection
    • Others
  • Traumatic Iatrogenic
  • Inadequate stabilization: Resorption of bone at fracture site. too flexible gap
  • Infection: Infection and loss of soft tissue covering.
    • Local Risk factors
      • Open Fractures
      • High energy fractures with bone devitalization.
      • Severe associated soft tissue injury
      • Bone loss
      • Infection
    • Iatrogenic Factors:
      • Poor reduction
      • Unstable fixation
      • Bone devitalization
    • Systemic Risk Factors
      • Malnutrition
      • Smoking
      • NSAIDs
      • Systemic Medical Conditions like Diabetes, paraplegia.
      • Chronic alcoholism.
    • Patient Factors
      • Non Compliance
    • Site
    • - Diaphyseal
    • - Metaphyseal:
    • - Extraarticular
    • - Intraarticular
    • Callus
    • - Hypertrophic
    • - Oligotropic
    • - Atropic
    • Infection
    • - Aseptic
    • - Infected
  • Hypertrophic Atrophic Necrotic Defect Oligotrophic Vascular/Vital Avital? Avital
    • Persistent Pain
    • Non physiologic motion
    • Progressive deformity
    • No radiographic evidence of healing
    • Failing implants
    • Standard radiographs are often diagnostic
    • 45 degree oblique films can increase diagnostic accuracy
    • Despite additional projections, the potential for false-positive results for fracture healing remains.
    • Serial Radiological Assessment is necessary.
    • Stress radiograph gives the status of stability of the fixation.
    • It also confirm the clinical diagnosis
    Varus stress Valgus stress
    • Computed Tomography: A definitive diagnostic tool
    • Biology: good
    • Stability: lacking
    • Treatment:
    • Provide stability
    • Correct deformity, if present
    • No bone graft required
    Elephant foot Horse hoof
    • Biology: Poor
    • Stability: lacking
    • Treatment:
    • Provide stability
    • Bone graft
    Atrophic
    • Biology: None
    • Stability: lacking?
    • Treatment:
    • Provide stability
    • Bone graft
    • Other reconstruction
    Necrotic Defect
    • Principle of surgical management
    • Cure infection if present
    • Correct Deformity if significant
    • Provide stability through implants
    • Add biologic stimulus when necessary
    • Treatment principle of infected non union
    • Contaminated implants and devitalized implants must be removed
    • Infection treated:
      • Temporary stabilization (external fixation)
      • Culture specific antibiotics
      • +/- local antibiotic delivery (antibiobic beads)
    • Secondary stabilization with augmentation of osteogenesis (cancellous grafting)
    • External Fixation
    • Plate
    • Intramedullary Devices
    • Largest indication is a temporary stabilization following infection debridement
    • Also useful in correction of stiff deformity and lengthening
    • Plates provide a powerful reduction tool
    • Surgical technique should strive for absolute stability
    • Locking plates have improved stability and fixation strength
    • Other relative indications:
      • Absent medullary canal
      • Metaphyseal nonunions
      • When open reduction or removal of prior implants is required
    • Multiple Indications for plate
      • Broken implants require that removal
      • Metaphyseal nonunion
      • Significant deformity
    • Technique
      • Blade properly positioned in the distal fragment
      • Reduction obtained by bringing plate to the shaft
      • Absolute stability with lag screw
      • Nonunion was not exposed
    Broken Plate
  • Broken Plate
    • Ideal case – Femur or tibia with an existing canal and no prior implants
    • Exchange nailing provides a good option for the tibia and femur
    • Special equipment is often necessary to traverse sclerotic canals
  • Broken Plate
    • Often unnecessary in hypertrophic cases with sufficient inherent biologic activity
    • Options
      • Aspirated stem cells (with or without expansion)
      • Demineralized Bone Matrix
      • Autogenous Cancellous Graft
      • Growth Factors
        • Platelet derived
        • Recombinant BMPs
        • Gene Therapy
    • Gold standard for biological and mechanical purposes.
    • Properties of Autograft:
    Osteogenic a source of vital bone cells Osteoinductive recruitment of local mesenchymal cells Osteoconductive scaffold for ingrowth of new bone Bone graft can also be allograft.
    • Aspirated iliac crest stem cells has been shown to enhance the activity of osteoconductive grafts.
    • There are few commercially available Recombinant BMP proved to be effective treating nonunions.
  • Decortication (Judet, 1972) Muscle pedicle bone graft Enhance the healing response creating well-vascularized bed Shingling Cancellous bone graft
  • 8 months after injury 68-year-old, women
  • 68-year-old, women
    • Electromagnetic
      • Direct Current
      • Inductive coupling (PEMF, CMF)
      • Capacitive coupling
    • Ultrasound
      • mechanical energy in the form of low frequency acoustic waves 30 mW/cm 2
  • Biological fixation: Preservation of blood supply to bone and soft tissue
    • The commonest cause of nonunion is the failure to diagnose and treat delayed union
    • - Careful evaluation of abnormal findings clinically and radiologically
    • - Adequate regimen of aftertreatment
    • Definition of delayed unions/nonunions and natural course of fracture healing
    • Causes of disturbed bone healing such as vascularity, instability, and infection
    • Principles of treatment applied based on types of nonunion:
    • - stabilization
    • - enhancement of biology
    • - eradication of infection if any
    • How to prevent delayed unions/nonunions:
    • - biological fixation in original operation
    • - early recognition of delayed union
  • Thank You all