bone healing ppt

1. Bone healing and replacement surgeries
VENBA.E
M.Sc., NURSING II YEAR,
COLLEGE OF NURSING,
MMC,CHENNAI -03.

2. INTRODUCTION
• Fracture is a break in the structural continuity of bone or periosteum.
• The healing of fracture is in many ways similar to the healing in soft
tissue wounds except that the end result is mineralized mesenchymal
tissue i.e. Bone.
• Fracture healing starts as soon as bone breaks and continues
modelling for many years.
• The essential event in fracture healing is the creation of a bony bridge
between the two fragments which can be readily be built upon and
modified to suit the particular functional demands

3. FRACTURE HEALING TYPES
Fracture healing is divided according to bone--
1. Cortical bone of the shaft.
2. Cancellous bone of the metaphyseal region of the long
bones and the small bones.

4. STAGES OF FRACTURE HEALING
 Tissue destruction and hematoma formation
 Inflammation and cellular proliferation
 Stage of callus formation
 Stage of consolidation
 Stage of remodeling

5. Tissue destruction and Hematoma
formation
• Torn blood vessels hemorrhage
• A mass of clotted blood
(hematoma) forms at the
fracture site
• Site becomes swollen, painful,
and inflamed

6. INFLAMMATION AND CELLULAR
PROLIFERATION
• Within 8 hours inflammatory
reaction starts.
• Proliferation and differentiation of
mesenchymal stem cells.
• Secretion of tgf-b , pdgf and various
bmp factors.

7. Callus Formation
• Fibrocartilaginous callus forms
• Granulation tissue (soft callus) forms a few days
after the fracture
• Capillaries grow into the tissue and phagocytic
cells begin cleaning debris

8. CALLUS FORMATION THEORY
Osteoprogenitor cell present in all endosteal and subperiosteal
surface give rise to callus.
Callus arises from non-specialized connective tissue cells in the
region of fracture which are induced into conversion to osteoblasts.

9. STAGE OF CONSOLIDATION
• New bone trabeculae appear in the
fibrocartilaginous callus
• Fibrocartilaginous callus converts into a bony
(hard) callus
• Bone callus begins 3-4 weeks after injury, and
continues until firm union is formed 2-3
months later

10. STAGE OF REMODELLING
Excess material on the bone shaft exterior
and in the medullary canal is removed
Compact bone is laid down to reconstruct
shaft walls

11. FACTORS INFLUENCING BONE HEALING
Local factors
 Edema
 Ischemia necrosis
 Foreign bodies
Systemic factors
 Inadequate perfusion
 Inflammation
 Nutrient deficiency
 Metabolic diseases
 Immune suppression

12. Additional factors
 Smoking
 Alcoholism
 Poor nutrition
 Diabetes
 Steroids
 Overweight

13. COMPLICATIONS OF FRACTURE HEALING
• MALUNION
• DELAYED UNION
• NONUNION

14. MAL UNION
A malunited fracture is one that has healed with the fragments in a
non anatomical position.
CAUSES
1 inaccurate reduction
2 ineffective immobilization
Malunion can Impair function by
Abnormal joint surface
ROTATION or ANGULATION
Overriding
Movement of neighboring joint may be blocked

15. DELAYED UNION
• 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 mths).
• Treatment usually is by an efficient cast that allows as much function
as possible can be continued for 4 to 12 additional weeks

16. Cont…
• If still non united a decision should be made to treat the fracture as
nonunion.
• External ultrasound or electrical stimulation may be considered.
• Surgical treatment should be carried out to remove interposed soft
tissues and to oppose widely separated fragments.

17. NONUNION
• 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 (ie long bone shaft fracture 6
months, femoral neck fracture 3 months)

18. DELAYED/NONUNION .
Systemic factors:
• Metabolic
• Nutritional status
• General health
• Activity level
• Tobacco and alcohol use

19. DELAYED/NONUNION
Local factors
• Open
• Infected
• Segmental (impaired blood supply)
• Comminuted
• Insecurely fixed
• Immobilized for an insufficient time
• Treated by ill-advised open reduction
• Distracted by (traction/plate and screws)
• Irradiated bone
• Delayed weight-bearing > 6 weeks
• Soft tissue injury > method of initial treatment

20. INTRODUCTION
• Total joint replacement is one of the most
commonly performed and successful
operations in orthopedics as defined by
clinical outcomes and implant
survivorship.
• Most joint replacement consist of metal
(cobalt-chromium), titanium and high
density polyethylene components.
• Total Joint replacement also called as
‘ARTHROPLASTY’.

21. DEFINITION
• Total joint replacement is a surgical procedure in
which parts of an arthritic or damaged joint are
removed and replaced with a metal, plastic or ceramic
device called a prosthesis. The prosthesis is designed to
replicate the movement of a normal, healthy joint.

22. TJA: INDICATIONS
Debilitating joint pain.
Slow loss of cartilage in affected joints which related to loss of motion and
movement.
Rheumatoid Arthritis.
Osteoarthritis.
Synovitis.
Connective tissue disease.
Paget’s disease.
Congenital deformity.
Trauma-RTA, Sports injury, Crush injury.
Tumours.
Sepsis.
Failed prior procedure.

23. • Arthritis is the second most common chronic condition in the US.
• Most common among elderly
• 20-30% of people over age 70 suffer from osteoarthritis (OA) of the
hip
• Arthritis affects over 32 million people in the US

24. GOALS OF JOINT REPLACEMENT SURGERY
Relieve pain.
Improving joint motion.
Restore function, mobility.
Correcting deformity and mal-alignment.
Removing intra-articular causes of erosion.

25. COMMON REPLACEMENT SURGERIES OF JOINTS
Total Hip Replacement.
Total Knee Replacement.
Finger Joint Arthroplasty.
Elbow and Shoulder Arthroplasty.
Ankle Arthroplasty.

26. IMPLANT MATERIAL
1. Metal: Metal used in implants are screws, plates,
prosthesis. Those commonly used are stainless steel,
cobalt chromium alloys and titanium alloys.
2. Silicon compound: there is a wide variety of silicon
polymers of which silicon rubber is particularly used.
3. Ceramic compound: these are being used either alone
or bonded to metal for joint replacement prosthesis.
4. Carbon compound: is used to replace ligaments. This
are the substitute for natural ligament.
5. Acrylic cement: in joint replacements the prostheses are
often fixed to the bone with acrylic cement
( polymethyl methacrylate ).
6. Hydroxyapatite:- this material has been used to
reproduce the osteoinductive and osteoconductive
properties of bone grafts.

27. TOTAL HIP REPLACEMENT
Total Hip Replacement is a surgical procedure in
which the hip joint is replaced by a prosthetic implant, that
is, a hip prosthesis. Hip replacement surgery can be
performed as a total replacement or a hemi replacement.
Indications
• Arthritis
• Fracture
• Osteonecrosis

28. THA IMPLANTS

29. IMPLANT CHOICE
Cemented
•Elderly (>65)
•Low demand
•Better early fixation
•late loosening

30. IMPLANT CHOICE
Cementless:
•Younger
•More active
•Protected weight-
bearing first 6 weeks
•Better long-term
fixation

31. TECHNIQUE: TOTAL HIP REPLACEMENT
• Femoral neck resection

32. TECHNIQUE: TOTAL HIP REPLACEMENT
• Acetabular reaming  Insertion of acetabular
component

33. TECHNIQUE: TOTAL HIP REPLACEMENT
• Reaming/broaching of
femoral component
 Insertion of femoral
component

34. TECHNIQUE: TOTAL HIP REPLACEMENT
• Femoral head impaction  Final implant

35. TOTAL KNEE REPLACEMENT
• Total knee replacement surgery is considered for patients who
have severe pain and functional disabilities related to destruction
of joint surfaces by osteoarthritis and rheumatoid arthritis.
• Metal and acrylic prosthesis designed to provide the patient with
a functional, painless , stable joint may be used.

36. KNEE REPLACEMENT
There are two types of knee replacement surgery:-
• Partial knee replacement
• Total knee replacement

38. FINGER JOINT ARTHOPLASTY
• A silicon rubber arthroplastic device is used to help restore
function in the fingers of the patient with rheumatoid arthritis.
• Before surgery the patient is instructed to do hand exercises
including flexion, extension, abduction, adduction.
• Post-operatively the hand is kept elevated with a bulky dressing in
place and neuro-vascular assessment is conducted to assess for
signs of infection.
• Once the dressing is removed a guided splinting is initiated and
patient will be instructed to use splint while sleeping and hand
exercises to be performed.

39. ELBOW AND SHOULDER ARTHROPLASTY
• This procedure is not as common as other forms of
arthroplasty.
• Shoulder replacement is usually performed in patient with
severe pain because of rheumatoid arthritis, osteoarthritis,
trauma, avascular necrosis.
• If joint replacement is necessary for both elbow and shoulder
than elbow is usually done first because a severely painful
elbow may interfere with shoulder rehabilitation programme.
• Functional improvement have resulted in better hygiene and
increased ability to perform activities of daily living in most
patients.

40. ANKLE ARTHROPLASTY
• Indications of ankle arthroplasty include rheumatoid arthritis,
osteoarthritis, trauma and avascular necrosis.
• Ankle fusion is selected over arthroplasty.
• Post-operatively the patient may not bear weight for 6 weeks and
must elevate the extremity to reduce and prevent oedema, and be
cautious to prevent infection and patient should maintain
immobilization.

41. CAUSES OF TOTAL JOINT REPLACEMENT FAILURE
ASEPTIC/MECHANICAL LOOSENING

42. DISLOCATION/ INSTABILITY

43. INFECTION

44. TEAR OF ARTICULAR BEARING SURFACE

45. OSTEOLYSIS

46. IMPLANT FAILURE

47. BONE GRAFTING:
Bone grafting involves taking bone tissue from one part of
the body (autograft) or using donated bone tissue (allograft) to
repair or replace damaged bone. It's commonly used to promote
bone healing in fractures that have trouble mending, to fill bone
deformities caused by trauma or tumor removal, or to enhance
bone growth during spinal fusion surgeries.

48. TYPES OF BONE GRAFTS
• Allografts are commonly used in hip, knee, or long bone reconstruction.
Long bones include arms and legs. The advantage is there’s no additional
surgery needed to acquire the bone. It also lowers your risk of infection
since additional incisions or surgery aren’t required.
• Allograft bone transplant involves bone that has no living cells so that the
risk of rejection is minimal as opposed to organ transplants, in which living
cells are present. Since the transplanted bone doesn’t contain living marrow,
there is no need to match blood types between the donor and the recipient.

49. LIMBS LENGTHENING:
Limb lengthening procedures are performed to correct limb
length discrepancies caused by congenital conditions, trauma,
or diseases like osteomyelitis.
The procedure involves surgically breaking the bone and
gradually lengthening it over time using an external or internal
fixation device.
 New bone gradually forms in the gap created, resulting in
increased limb length.

50. SPINAL FUSION
Spinal fusion is a surgical procedure to join two or more vertebrae
together permanently.
It's often performed to stabilize the spine, alleviate pain, and correct
deformities such as scoliosis or spinal fractures.
During the procedure, bone graft material is placed between the
vertebrae, promoting the growth of new bone that fuses the vertebrae
together.

51. BONE MARROW TRANSPLANTATION
In this procedure, damaged or diseased bone marrow is
replaced with healthy bone marrow stem cells to treat
conditions such as leukemia, lymphoma, or certain genetic
disorders.
 The healthy bone marrow can be obtained from the patient
(autologous transplant) or a compatible donor (allogeneic
transplant).

52. NURSING PROBLEM PRIORITIES
1.Manage pain and provide adequate pain relief measures.
2.Promote wound healing and prevent infection.
3.Ensure patient safety and prevent falls or complications related
to immobility.
4.Facilitate early mobilization and rehabilitation to regain joint
function and prevent complications.
5.Monitor for signs of complications such as deep vein
thrombosis (DVT) or pulmonary embolism (PE) and implement
preventive measures.
6.Provide patient education on self-care, medications, activity
restrictions, and signs of potential complications.

53. NURSING ASSESSMENT
• Pain and discomfort
• Swelling
• Stiffness
• Limited ROM; decreased muscle strength/control
• Bruising and discoloration
• Muscle weakness
• Numbness and tingling sensation around the surgical area
• Difficulty in performing with ADL.