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BONE HEALING
Dr BASSEY, A E
ORTHOPAEDICS & TRAUMA
UATH, ABUJA
OUTLINE
• Introduction
• Types of bone healing
• Stages of bone healing
• Regulation of bone healing
• Factors affecting bone healing
• Assessment
• Complications
• Current trends
• Conclusion
Introduction
• Bone healing refers to complex and sequential
events that occur to restore injured bone to pre-
injury state
• Bone injury remains a constant counterpart to
human existence, we are able to cope with this
due to bone healing. The surgeon must therefore
have adequate understanding of its processes,
influencing factors and complications in order to
achieve optimum outcome
Types of bone healing
• Healing by callus formation (indirect,
secondary)
• Healing by direct union (primary)
Stages of bone healing
• Healing by callus formation
– Haematoma formation
• Occurs immediately
– Inflammation and cellular proliferation
• 8hrs to 1-2weeks
• Migration of inflammatory cells (macrophages,
neutrophils, platelets)
• Elaboration of cytokines, growth factors, other
mediators
• Proliferation and differentiation of mesenchymal stem
cells, migration of fibroblasts and osteoclasts
• neovascularization
Stages of bone healing
• Healing by callus formation
– Callus formation
• 2-3wks to 4-8wks
• Osteoclasts mop up dead bone
• Collagen matrix formation
• Osteoid deposition and mineralisation
• Formation of woven bone
– Consolidation
• Weeks to 2-3mnths
• Lamellar bone formation
• Remaining gaps filled by lamellar bone
Stages of bone healing
• Healing by callus formation
– Remodelling
• 2mnths to years
• Guided by stress exposure
• Osteoclasts are responsible
• Healing by direct union
– Occurs in fractures where ends are compressed,
with intervening space <500microns
– No callus formation
– Gap healing – occurs if space is 200-500microns
– Contact healing – occurs if space is <200microns
HAEMATOMA INFLAMMATION CALLUS CONSOLIDATION REMODELLING
Regulation of fracture healing
• Local factors
– TGF-B
– PDGF
– FGF
– IGF
– VEGF
– BMP
– Cytokines
• Systemic factors
– Hormones
Regulation of fracture healing
• TGF-B
– Promotes proliferatn & diff of stem cells
– Stimulates collagen synthesis
• PDGF
– Stimulates T1 collagen synth by osteoblast
– Stimulates osteoclast resorption
• FGF
– Stimulates fibroblast proliferation
– Stimulates angiogenesis
• VEGF
– Stimulates angiogenesis
Regulation of fracture healing
• IGF
– Stimulates bone collagen & matrix synthesis
– Inhibits bone collagen degradation
• BMP
– Osteoinductive
– Stimulates diff of osteoprogenitors to osteoblasts
• Cytokines
– IL-1,6 stimulate bone resorption
– Chemotaxis and regulation of inflammatory cells
Regulation of fracture healing
• Systemic factors
– Growth hormone – acts via IGF
– Thyroid hormones – increase bone resorption
– Oestrogen – minimises bone resorption
Factors influencing bone healing
• Local
– Type of bone
– # pattern
– # site
– Soft tissue devitalisation
– Soft tissue interposition
– Blood supply
– Infection
– Irradiation
Factors influencing bone healing
• Systemic
– Malnutrition
– DM
– Drugs – NSAIDs, steroids, cytotoxics
– Tobacco use
– Thyroid disorders
– Vitamin deficiency
– CNS trauma
– HIV
Assessment of fracture healing
• Clinical
• Radiological
Complications
• Malunion
• Delayed union
• Non-union
• Infection
• Post-traumatic arthritis
• Growth abnormalities
Current trends
• rBMP
– Delivered locally at 10-1000x natural expression
– Enhance # healing
– Decrease infection in GA IIIa & b #s
– Useful in recalcitrant non-unions
• Pulsed electromagnetic field (PEMF)
– Used in treatment of nonunions
• Low-intensity pulsed ultrasound (LIPUS)
– Increases gene expression, enhances blood flow,
enhances remodelling
– Reverses anti-angiogenic effect of nicotine
Conclusion
• Despite major advancement in understanding
of bone healing, problems/complications still
continue to arise.
• More research is needed in this all-important
area if these problems are to be satisfactorily
prevented or overcome
Thank
you
References
• Apley’s system of orthopaedics and fractures,
9th
Ed, pp689 – 692
• http://www.slideshare.net/hardikpawar1/fracture
• http://www.orthobullets.com/basic-science/9009/
• http://www.hughston.com/hha/a.fracture.ht
m

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Bone healing

  • 1. BONE HEALING Dr BASSEY, A E ORTHOPAEDICS & TRAUMA UATH, ABUJA
  • 2. OUTLINE • Introduction • Types of bone healing • Stages of bone healing • Regulation of bone healing • Factors affecting bone healing • Assessment • Complications • Current trends • Conclusion
  • 3. Introduction • Bone healing refers to complex and sequential events that occur to restore injured bone to pre- injury state • Bone injury remains a constant counterpart to human existence, we are able to cope with this due to bone healing. The surgeon must therefore have adequate understanding of its processes, influencing factors and complications in order to achieve optimum outcome
  • 4. Types of bone healing • Healing by callus formation (indirect, secondary) • Healing by direct union (primary)
  • 5. Stages of bone healing • Healing by callus formation – Haematoma formation • Occurs immediately – Inflammation and cellular proliferation • 8hrs to 1-2weeks • Migration of inflammatory cells (macrophages, neutrophils, platelets) • Elaboration of cytokines, growth factors, other mediators • Proliferation and differentiation of mesenchymal stem cells, migration of fibroblasts and osteoclasts • neovascularization
  • 6. Stages of bone healing • Healing by callus formation – Callus formation • 2-3wks to 4-8wks • Osteoclasts mop up dead bone • Collagen matrix formation • Osteoid deposition and mineralisation • Formation of woven bone – Consolidation • Weeks to 2-3mnths • Lamellar bone formation • Remaining gaps filled by lamellar bone
  • 7. Stages of bone healing • Healing by callus formation – Remodelling • 2mnths to years • Guided by stress exposure • Osteoclasts are responsible • Healing by direct union – Occurs in fractures where ends are compressed, with intervening space <500microns – No callus formation – Gap healing – occurs if space is 200-500microns – Contact healing – occurs if space is <200microns
  • 8. HAEMATOMA INFLAMMATION CALLUS CONSOLIDATION REMODELLING
  • 9.
  • 10. Regulation of fracture healing • Local factors – TGF-B – PDGF – FGF – IGF – VEGF – BMP – Cytokines • Systemic factors – Hormones
  • 11. Regulation of fracture healing • TGF-B – Promotes proliferatn & diff of stem cells – Stimulates collagen synthesis • PDGF – Stimulates T1 collagen synth by osteoblast – Stimulates osteoclast resorption • FGF – Stimulates fibroblast proliferation – Stimulates angiogenesis • VEGF – Stimulates angiogenesis
  • 12. Regulation of fracture healing • IGF – Stimulates bone collagen & matrix synthesis – Inhibits bone collagen degradation • BMP – Osteoinductive – Stimulates diff of osteoprogenitors to osteoblasts • Cytokines – IL-1,6 stimulate bone resorption – Chemotaxis and regulation of inflammatory cells
  • 13. Regulation of fracture healing • Systemic factors – Growth hormone – acts via IGF – Thyroid hormones – increase bone resorption – Oestrogen – minimises bone resorption
  • 14. Factors influencing bone healing • Local – Type of bone – # pattern – # site – Soft tissue devitalisation – Soft tissue interposition – Blood supply – Infection – Irradiation
  • 15. Factors influencing bone healing • Systemic – Malnutrition – DM – Drugs – NSAIDs, steroids, cytotoxics – Tobacco use – Thyroid disorders – Vitamin deficiency – CNS trauma – HIV
  • 16. Assessment of fracture healing • Clinical • Radiological
  • 17. Complications • Malunion • Delayed union • Non-union • Infection • Post-traumatic arthritis • Growth abnormalities
  • 18. Current trends • rBMP – Delivered locally at 10-1000x natural expression – Enhance # healing – Decrease infection in GA IIIa & b #s – Useful in recalcitrant non-unions • Pulsed electromagnetic field (PEMF) – Used in treatment of nonunions • Low-intensity pulsed ultrasound (LIPUS) – Increases gene expression, enhances blood flow, enhances remodelling – Reverses anti-angiogenic effect of nicotine
  • 19. Conclusion • Despite major advancement in understanding of bone healing, problems/complications still continue to arise. • More research is needed in this all-important area if these problems are to be satisfactorily prevented or overcome
  • 21. References • Apley’s system of orthopaedics and fractures, 9th Ed, pp689 – 692 • http://www.slideshare.net/hardikpawar1/fracture • http://www.orthobullets.com/basic-science/9009/ • http://www.hughston.com/hha/a.fracture.ht m