Dr Samir Bhirud Registrar

1. Delayed Union and Nonunion of Fractures Dr Samir D Bhirud, Dept of Orthopedics ESIPGIMSR MGM HOSPITAL

2. Approximately 5% of all long bone fractures will result in non-unions and even more in delayed unions

3. The exact time when a given fracture should be united cannot be defined Union is delayed when healing has not advanced at the average rate for the location and type of fracture (Between 3-6 months) Delayed Union

4. FDA defined nonunion as “established when a minimum of 9 months has elapsed since fracture with no visible progressive signs of healing for 3 months” Every fracture has its own timetable (long bone shaft fracture 6 months, femoral neck fracture 3 months) Nonunion

5. Factors contributing : Systemic Local Delayed/Nonunion

6. Systemicfactors Nutritional status- Malnutrition Metabolic - Diabetes (neurovascular) Smoking Tobacco and alcohol use General health Activity level Use of NSAIDs (have been found to decrease fracture healing in multiple animal studies) THE LITERATURE IS STILL CONFLICTING CONCERNING THE INFLUENCE OF NSAIDS ON FRACTURE HEALING

7. Fracture characteristics- Open Infected segmental Comminuted by severe trauma Anatomic Location of Fractures Local factors

8. Soft tissue injury Traumatic Iatrogenic Treatment related Insecure fixation Insufficient immobilization Fixation in distraction Irradiated bone

9. Based on viability of the bone ends Hypervascular non-unions Avascular nonunion Classification

10. Hypervascular or Hypertrophic: Elephant foot (hypertrophic, rich in callus) Horse foot (mildly hypertrophic, poor in callus) Oligotrophic (not hypertrophic, no callus)

11. Avascular or Atrophic Torsion wedge (intermediate fragment) Comminuted (necrotic intermediate fragment) Defect (loss of fragment) Atrophic (scar tissue with no osteogenic potential)

12. Classification (Paley et al) Type A<2cm of bone loss A1 (Mobile deformity) A2 (fixed deformity) A2-1 stiff w/o deformity A2-2 stiff w/ fixed deformity Type B>2cm of bone loss B1 w/ bony defect B2 loss of bone length B3 both

14. Electrical Electro-magnetic Ultrasound Surgical Treatment PREVENTION IS ALWAYS BETTER THAN CURE

15. General Treatment principals Vast number of surgical and nonsurgical methods available but…. Rarely - one method successful . Simplest, most easily tolerated. Should allow potential use of other methods

16. Autogenouscancellous boneremains the “gold standard” in grafting material Other options allograft bone synthetic bone substitute Vascularised bone grafting BoneGrafting

17. Theories stimulates the genes involved in inflammation and bone regeneration. increases blood flow through dilation of capillaries and enhancement of angiogenesis, increasing the flow of nutrients to the fracture site. chondrocyte stimulation is enhanced, which leads to an increase in enchondral bone formation. PROTOCOL IS TO USE THE ULTRASOUND EQUIPMENT FOR 20 MINUTES ONCE A DAY Low intensty ultrasound

18. Bone growth stimulators - used in conjunction. External electrical stimulation -advantageous in infected nonunion. Electrical and electromagnetic stimulation. EXTERNAL ELECTRICAL STIMULATION IS ESPECIALLY ADVANTAGEOUS IN INFECTED NONUNION MANAGEMENT OR WHEN SURGICAL INTERVENTION IS CONTRAINDICATED

19. Systemic and local fracture management must be considered in the treatment of non-unions. Metabolic and nutritional factors should be optimized. Patients should be encouraged to discontinue tobacco use. Activity levels of patients may require alteration before treatment for non-unions. Considerations before Surgery

20. Status of Soft Tissues and Neurovascular Structures – Unyielding scar tissues, Deep scarring may prevent bone transport or grafting. Soft-tissue contractures must be considered Considerations before Surgery

21. Hypertrophic (hypervascular) non-unions stable fixation. Atrophic (avascular) non-unions decortication and bone grafting StatusofBones Consideration to the factors responsible for non or delayed union is desired before proceeding to further treatment

22. According to the classification of Paley et al Type A non-unions can be treated with restoration of alignment, followed by compression. Type B non-unions may require additional cortical osteotomy and either internal bone transport or overall lengthening to obtain the original bone length.

23. The fragments are mobilized, preserving their normal soft-tissue attachments as much as possible. Extensive dissection is avoided, resecting only the scar tissue and the rounded ends of the bones so that contact is maximal Medullary canals are cleared of fibrous tissue to aid in medullaryosteogenesis and they are apposed ReductionofFragments

24. Adequate stabilization obtained by - Plates and screws. Intra-medullary nails. External fixation. Provide sufficient stability – without excessive rigidity. Stabilizationoffragments.

25. Choice of internal fixation depends on- Type of nonunion. Condition of the soft tissues and bone Size and position of the bone fragments Size of the bony defect.

26. Advantage– relatively noninvasive and does not disturb soft tissues surrounding the nonunion. ability to correct deformity and provide stable fixation. The Ilizarov external fixatoris very effective, tool in the treatment of non-unions. ExternalFixation

27. Infection, Poor Soft-tissue Quality, Short Peri-articular Fragments, Significant Deformity. FactorsComplicatingNonunion

28. Conventional Treatment – The objectives of the conventional method are to convert an infected and draining nonunion into one that has not drained for several months and to promote healing of the nonunion by bone grafting. This method of treatment often requires 1 or more years to complete and usually results in stiffness of adjacent joints. Infection

29. Active Treatment – The objective of the active method is to obtain bony union early and shorten the period of convalescence and preserve motion in the adjacent joints. PolymethylMethacrylate Antibiotic Beads- Heat-stable antibiotics, such as tobramycin and gentamicin, can be mixed with PMMA and used locally to achieve 200 times the antibiotic concentration achieved with intravenous administration.

30. Deformity, Shortening, and Segmental Bone Loss Ilizarov Method According to Ilizarov, to eliminate infection and obtain union, vascularity must be increased.

32. Monofocal Compression Sequential distraction-compression Distraction Sequential compression-distraction Bifocal Compression-distraction lengthening Distraction-compression transport (bone transport) Trifocal Various combinations

33. Good reduction Bone grafting Firm stabilization biomechanical stability and biological vitality of the bone. Surgicalguidelines

34. THANKYOU