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Delayed Union and non union fractures
 

Delayed Union and non union fractures

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Dr Samir Bhirud

Dr Samir Bhirud
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    Delayed Union and non union fractures Delayed Union and non union fractures Presentation Transcript

    • Delayed Union and Nonunion of Fractures
      Dr Samir D Bhirud,
      Dept of Orthopedics
      ESIPGIMSR MGM HOSPITAL
    • Approximately 5% of all long bone fractures will result in non-unions and even more in delayed unions
    • 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
    • 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
    • Factors contributing :
      Systemic
      Local
      Delayed/Nonunion
    • 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
    • Fracture characteristics-
      Open
      Infected
      segmental
      Comminuted by severe trauma
      Anatomic Location of Fractures
      Local factors
    • Soft tissue injury
      Traumatic
      Iatrogenic
      Treatment related
      Insecure fixation
      Insufficient immobilization
      Fixation in distraction
      Irradiated bone
    • Based on viability of the bone ends
      Hypervascular non-unions
      Avascular nonunion
      Classification
    • Hypervascular or Hypertrophic:
      Elephant foot (hypertrophic, rich in callus)
      Horse foot (mildly hypertrophic, poor in callus)
      Oligotrophic (not hypertrophic, no callus)
    • Avascular or Atrophic
      Torsion wedge (intermediate fragment)
      Comminuted (necrotic intermediate fragment)
      Defect (loss of fragment)
      Atrophic (scar tissue with no osteogenic potential)
    • 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
    • Electrical
      Electro-magnetic
      Ultrasound
      Surgical
      Treatment
      PREVENTION IS ALWAYS BETTER THAN CURE
    • 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
    • Autogenouscancellous boneremains the “gold standard” in grafting material
      Other options
      allograft bone
      synthetic bone substitute
      Vascularised bone grafting
      BoneGrafting
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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.
    • 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
    • Adequate stabilization obtained by -
      Plates and screws.
      Intra-medullary nails.
      External fixation.
      Provide sufficient stability – without excessive rigidity.
      Stabilizationoffragments.
    • 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.
    • 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
    • Infection,
      Poor Soft-tissue Quality,
      Short Peri-articular Fragments,
      Significant Deformity.
      FactorsComplicatingNonunion
    • 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
    • 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.
    • Deformity, Shortening, and Segmental Bone Loss
      Ilizarov Method
      According to Ilizarov, to eliminate infection and obtain union, vascularity must be increased.
    • Monofocal
         Compression   Sequential distraction-compression   Distraction   Sequential compression-distraction
      Bifocal
          Compression-distraction lengthening  Distraction-compression transport (bone transport)
      Trifocal
         Various combinations
    • Good reduction
      Bone grafting
      Firm stabilization
      biomechanical stability and
      biological vitality of the bone.
      Surgicalguidelines
    • THANKYOU