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