Non Union

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

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Non Union

  1. 1. AO SEC Trauma May, 15-17, Chittagong. Welcome
  2. 2. Prof. Muhammad Shahiduzzaman Head, Department of Orthopaedics and Traumatology Dhaka Medical College Hospital
  3. 3. <ul><li>Definition </li></ul><ul><li>Etiology </li></ul><ul><li>Evaluation </li></ul><ul><li>Classification </li></ul><ul><li>Treatment principles </li></ul><ul><ul><li>Stabilization </li></ul></ul><ul><ul><li>Biology </li></ul></ul><ul><li>Prevention </li></ul>
  4. 4. <ul><li>Non Union </li></ul><ul><li>9 months elapsed time with no healing progress for 3 months. </li></ul><ul><li>Union is delayed and a fracture has ceased to show any evidence of healing </li></ul><ul><li>Practically, </li></ul><ul><li>A fracture that has no potential to heal without further intervention </li></ul>
  5. 5. <ul><li>Delayed union </li></ul><ul><li>Failure to consolidate within the normally expected time for fracture types and location </li></ul><ul><li>Pseudoarthrosis </li></ul><ul><li>Formation of a false joint where a fibro-cartilaginous cavity is lined with synovial membrane </li></ul>
  6. 6. <ul><li>What does nature do with a broken bone? </li></ul>Indirect Healing It will heal by callus formation
  7. 7. <ul><li>Stages of fracture healing </li></ul><ul><li>Hematoma formation </li></ul><ul><li>Inflammation and cellular proliferation </li></ul><ul><li>Callus formation </li></ul><ul><li>Consolidation </li></ul><ul><li>Remodeling </li></ul>bony bridging
  8. 8. <ul><li>Poor Vascularity (biology) </li></ul><ul><li>Instability </li></ul><ul><li>Infection </li></ul><ul><li>Others </li></ul>
  9. 9. Traumatic Iatrogenic
  10. 10. Inadequate stabilization: Resorption of bone at fracture site. too flexible gap
  11. 11. Infection: Infection and loss of soft tissue covering.
  12. 12. <ul><li>Local Risk factors </li></ul><ul><ul><li>Open Fractures </li></ul></ul><ul><ul><li>High energy fractures with bone devitalization. </li></ul></ul><ul><ul><li>Severe associated soft tissue injury </li></ul></ul><ul><ul><li>Bone loss </li></ul></ul><ul><ul><li>Infection </li></ul></ul>
  13. 13. <ul><li>Iatrogenic Factors: </li></ul><ul><ul><li>Poor reduction </li></ul></ul><ul><ul><li>Unstable fixation </li></ul></ul><ul><ul><li>Bone devitalization </li></ul></ul>
  14. 14. <ul><li>Systemic Risk Factors </li></ul><ul><ul><li>Malnutrition </li></ul></ul><ul><ul><li>Smoking </li></ul></ul><ul><ul><li>NSAIDs </li></ul></ul><ul><ul><li>Systemic Medical Conditions like Diabetes, paraplegia. </li></ul></ul><ul><ul><li>Chronic alcoholism. </li></ul></ul><ul><li>Patient Factors </li></ul><ul><ul><li>Non Compliance </li></ul></ul>
  15. 15. <ul><li>Site </li></ul><ul><li>- Diaphyseal </li></ul><ul><li>- Metaphyseal: </li></ul><ul><li>- Extraarticular </li></ul><ul><li>- Intraarticular </li></ul><ul><li>Callus </li></ul><ul><li>- Hypertrophic </li></ul><ul><li>- Oligotropic </li></ul><ul><li>- Atropic </li></ul><ul><li>Infection </li></ul><ul><li>- Aseptic </li></ul><ul><li>- Infected </li></ul>
  16. 16. Hypertrophic Atrophic Necrotic Defect Oligotrophic Vascular/Vital Avital? Avital
  17. 17. <ul><li>Persistent Pain </li></ul><ul><li>Non physiologic motion </li></ul><ul><li>Progressive deformity </li></ul><ul><li>No radiographic evidence of healing </li></ul><ul><li>Failing implants </li></ul>
  18. 18. <ul><li>Standard radiographs are often diagnostic </li></ul><ul><li>45 degree oblique films can increase diagnostic accuracy </li></ul><ul><li>Despite additional projections, the potential for false-positive results for fracture healing remains. </li></ul><ul><li>Serial Radiological Assessment is necessary. </li></ul>
  19. 19. <ul><li>Stress radiograph gives the status of stability of the fixation. </li></ul><ul><li>It also confirm the clinical diagnosis </li></ul>Varus stress Valgus stress
  20. 20. <ul><li>Computed Tomography: A definitive diagnostic tool </li></ul>
  21. 21. <ul><li>Biology: good </li></ul><ul><li>Stability: lacking </li></ul><ul><li>Treatment: </li></ul><ul><li>Provide stability </li></ul><ul><li>Correct deformity, if present </li></ul><ul><li>No bone graft required </li></ul>Elephant foot Horse hoof
  22. 22. <ul><li>Biology: Poor </li></ul><ul><li>Stability: lacking </li></ul><ul><li>Treatment: </li></ul><ul><li>Provide stability </li></ul><ul><li>Bone graft </li></ul>Atrophic
  23. 23. <ul><li>Biology: None </li></ul><ul><li>Stability: lacking? </li></ul><ul><li>Treatment: </li></ul><ul><li>Provide stability </li></ul><ul><li>Bone graft </li></ul><ul><li>Other reconstruction </li></ul>Necrotic Defect
  24. 24. <ul><li>Principle of surgical management </li></ul><ul><li>Cure infection if present </li></ul><ul><li>Correct Deformity if significant </li></ul><ul><li>Provide stability through implants </li></ul><ul><li>Add biologic stimulus when necessary </li></ul>
  25. 25. <ul><li>Treatment principle of infected non union </li></ul><ul><li>Contaminated implants and devitalized implants must be removed </li></ul><ul><li>Infection treated: </li></ul><ul><ul><li>Temporary stabilization (external fixation) </li></ul></ul><ul><ul><li>Culture specific antibiotics </li></ul></ul><ul><ul><li>+/- local antibiotic delivery (antibiobic beads) </li></ul></ul><ul><li>Secondary stabilization with augmentation of osteogenesis (cancellous grafting) </li></ul>
  26. 26. <ul><li>External Fixation </li></ul><ul><li>Plate </li></ul><ul><li>Intramedullary Devices </li></ul>
  27. 27. <ul><li>Largest indication is a temporary stabilization following infection debridement </li></ul><ul><li>Also useful in correction of stiff deformity and lengthening </li></ul>
  28. 28. <ul><li>Plates provide a powerful reduction tool </li></ul><ul><li>Surgical technique should strive for absolute stability </li></ul><ul><li>Locking plates have improved stability and fixation strength </li></ul><ul><li>Other relative indications: </li></ul><ul><ul><li>Absent medullary canal </li></ul></ul><ul><ul><li>Metaphyseal nonunions </li></ul></ul><ul><ul><li>When open reduction or removal of prior implants is required </li></ul></ul>
  29. 29. <ul><li>Multiple Indications for plate </li></ul><ul><ul><li>Broken implants require that removal </li></ul></ul><ul><ul><li>Metaphyseal nonunion </li></ul></ul><ul><ul><li>Significant deformity </li></ul></ul><ul><li>Technique </li></ul><ul><ul><li>Blade properly positioned in the distal fragment </li></ul></ul><ul><ul><li>Reduction obtained by bringing plate to the shaft </li></ul></ul><ul><ul><li>Absolute stability with lag screw </li></ul></ul><ul><ul><li>Nonunion was not exposed </li></ul></ul>Broken Plate
  30. 30. Broken Plate <ul><li>Ideal case – Femur or tibia with an existing canal and no prior implants </li></ul><ul><li>Exchange nailing provides a good option for the tibia and femur </li></ul><ul><li>Special equipment is often necessary to traverse sclerotic canals </li></ul>
  31. 31. Broken Plate <ul><li>Often unnecessary in hypertrophic cases with sufficient inherent biologic activity </li></ul><ul><li>Options </li></ul><ul><ul><li>Aspirated stem cells (with or without expansion) </li></ul></ul><ul><ul><li>Demineralized Bone Matrix </li></ul></ul><ul><ul><li>Autogenous Cancellous Graft </li></ul></ul><ul><ul><li>Growth Factors </li></ul></ul><ul><ul><ul><li>Platelet derived </li></ul></ul></ul><ul><ul><ul><li>Recombinant BMPs </li></ul></ul></ul><ul><ul><ul><li>Gene Therapy </li></ul></ul></ul>
  32. 32. <ul><li>Gold standard for biological and mechanical purposes. </li></ul><ul><li>Properties of Autograft: </li></ul>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.
  33. 33. <ul><li>Aspirated iliac crest stem cells has been shown to enhance the activity of osteoconductive grafts. </li></ul><ul><li>There are few commercially available Recombinant BMP proved to be effective treating nonunions. </li></ul>
  34. 34. Decortication (Judet, 1972) Muscle pedicle bone graft Enhance the healing response creating well-vascularized bed Shingling Cancellous bone graft
  35. 35. 8 months after injury 68-year-old, women
  36. 36. 68-year-old, women
  37. 37. <ul><li>Electromagnetic </li></ul><ul><ul><li>Direct Current </li></ul></ul><ul><ul><li>Inductive coupling (PEMF, CMF) </li></ul></ul><ul><ul><li>Capacitive coupling </li></ul></ul><ul><li>Ultrasound </li></ul><ul><ul><li>mechanical energy in the form of low frequency acoustic waves 30 mW/cm 2 </li></ul></ul>
  38. 38. Biological fixation: Preservation of blood supply to bone and soft tissue
  39. 39. <ul><li>The commonest cause of nonunion is the failure to diagnose and treat delayed union </li></ul><ul><li>- Careful evaluation of abnormal findings clinically and radiologically </li></ul><ul><li>- Adequate regimen of aftertreatment </li></ul>
  40. 40. <ul><li>Definition of delayed unions/nonunions and natural course of fracture healing </li></ul><ul><li>Causes of disturbed bone healing such as vascularity, instability, and infection </li></ul><ul><li>Principles of treatment applied based on types of nonunion: </li></ul><ul><li>- stabilization </li></ul><ul><li>- enhancement of biology </li></ul><ul><li>- eradication of infection if any </li></ul><ul><li>How to prevent delayed unions/nonunions: </li></ul><ul><li>- biological fixation in original operation </li></ul><ul><li>- early recognition of delayed union </li></ul>
  41. 41. Thank You all

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