This document discusses general principles in the assessment and treatment of nonunions. It begins with definitions of nonunion and delayed union, and classifications of nonunions including hypertrophic, oligotrophic, atrophic, and pseudarthrosis. It then discusses the biomechanics, etiology from host factors, fracture/injury factors, initial treatment factors, and the role of infection in nonunions. Evaluation of the patient includes history, physical exam, imaging, and assessing goals/expectations. Treatment options discussed include nonoperative methods like electrical stimulation and ultrasound, as well as operative treatment.
Assessment of Femoral Tunnel Placement in ACL ReconstructionJeremy Burnham
This study reviews the literature on tunnel placement in anterior cruciate ligament reconstruction, and assess the ability of experienced physicians and surgeons to evaluate the tunnel position using x-rays.
Assessment of Femoral Tunnel Placement in ACL ReconstructionJeremy Burnham
This study reviews the literature on tunnel placement in anterior cruciate ligament reconstruction, and assess the ability of experienced physicians and surgeons to evaluate the tunnel position using x-rays.
Distal femur fractures what makes it complex ,dr mohamed ashraf,hod orthopae...drashraf369
distal femur fractures are notorious for post operative complications due to malreduction and improper fixation.unless plan and execute a sound and stable fixation,this injury will lead to undesirable results.dr mohamed ashraf HOD orthopaedics govt TD medical college is presenting how to avoid complications in surgical management of these fractures..
a simplified version of periprosthetic fractures, easy to learn and understand with lots of images and classification. It includes hip, shaft of femur, knee, shoulder
Can read freely here
https://sethiortho.blogspot.com/
Fracture Healing and
Mechanical stability
Perren`s strain theory
Fracture healing
Indirect Healing
Direct healing
Fixation techniques and stability
Nonunion and Management
Fracture healing
Biological environment
Age
Nutritional status
Blood supply
Metabolic
Mechanical stability
Absolute
Relative
Surgical procedure
Alters biological environment
Selection of fixation
Alters mechanical environment
Mechanical Stability
Parren's strain theory
Strain
Relative deformation of a material when a given force is applied
Relative changes in the fracture gap divided by original fracture gap = L / L
Stability determines the Strain at the fracture site
Stable fixation – less strain
Unstable fixation – high strain
Large gap fracture – less strain
Cross section of the fracture-
Fracture gap strain VS cells response
The degree of inter fragmentary strain appears to govern the cellular response.
Each of these tissues is able to tolerate a different amount of strain:
Perren's strain theory….
When the inter fragmentary strain is <2% bone repair occurs by direct healing
While for intermediate amount of IFS (5–10%) the fracture heals by indirect healing.
Stain theory of healing –Indirect healing
Indirect Healing
Indirect Healing…
Hard callus formation
Indirect Healing
Remodeling Stage
Months to years
Conversion of woven bone into lamellar bone
Formation of Medullary cavity
Return of biomechanical property
Influenced by wolf law – Remodeling based on stress
Stain theory of healing…pseudo arthrosis
Complete instability
Callus is unable to form because the strain is too much for it to tolerate.
The more strain-tolerant fibrous tissue forms
Bone ends are sealed over with cortical bone
Formation of false joint with synovial fluid in the gap
Hypertrophic nonunion
Unstable fracture
Excess callus formation unable to reduce the IFS
Creates a hypertrophic non union
Direct Healing
Anatomically reduced rigid fixed fractures
Formation of cutting cones
>100,000 remodeling units work at time
Direct osteonal remodeling
Without callous
Activation
resorption by osteoclasts
osteoid formation by osteoclasts
Primary osteons
Mineralization
Direct Healing….
Fixation techniques and stability
Relative stability
Intramedullary nailing
Load sharing device
Inter fragmentary micro motion
Fracture gap strain is usually 2-10%
Body responds by forming more soft callus to try and decrease the strain
Fixation of diaphyseal fractures – strength and less duration
Relative stability
Absolute stability
Absolute stability
TBW
Lag screw fixation
Interfragmentary strain,
Nonunion and Management
Nonunion ….
Fracture is fixed rigidly but a gap is present
Direct healing may not be able to bridge the gap
The lack of strain may inhibit callus formation and secondary healing
Predispose to non-union
Management –
Distal femur fractures what makes it complex ,dr mohamed ashraf,hod orthopae...drashraf369
distal femur fractures are notorious for post operative complications due to malreduction and improper fixation.unless plan and execute a sound and stable fixation,this injury will lead to undesirable results.dr mohamed ashraf HOD orthopaedics govt TD medical college is presenting how to avoid complications in surgical management of these fractures..
a simplified version of periprosthetic fractures, easy to learn and understand with lots of images and classification. It includes hip, shaft of femur, knee, shoulder
Can read freely here
https://sethiortho.blogspot.com/
Fracture Healing and
Mechanical stability
Perren`s strain theory
Fracture healing
Indirect Healing
Direct healing
Fixation techniques and stability
Nonunion and Management
Fracture healing
Biological environment
Age
Nutritional status
Blood supply
Metabolic
Mechanical stability
Absolute
Relative
Surgical procedure
Alters biological environment
Selection of fixation
Alters mechanical environment
Mechanical Stability
Parren's strain theory
Strain
Relative deformation of a material when a given force is applied
Relative changes in the fracture gap divided by original fracture gap = L / L
Stability determines the Strain at the fracture site
Stable fixation – less strain
Unstable fixation – high strain
Large gap fracture – less strain
Cross section of the fracture-
Fracture gap strain VS cells response
The degree of inter fragmentary strain appears to govern the cellular response.
Each of these tissues is able to tolerate a different amount of strain:
Perren's strain theory….
When the inter fragmentary strain is <2% bone repair occurs by direct healing
While for intermediate amount of IFS (5–10%) the fracture heals by indirect healing.
Stain theory of healing –Indirect healing
Indirect Healing
Indirect Healing…
Hard callus formation
Indirect Healing
Remodeling Stage
Months to years
Conversion of woven bone into lamellar bone
Formation of Medullary cavity
Return of biomechanical property
Influenced by wolf law – Remodeling based on stress
Stain theory of healing…pseudo arthrosis
Complete instability
Callus is unable to form because the strain is too much for it to tolerate.
The more strain-tolerant fibrous tissue forms
Bone ends are sealed over with cortical bone
Formation of false joint with synovial fluid in the gap
Hypertrophic nonunion
Unstable fracture
Excess callus formation unable to reduce the IFS
Creates a hypertrophic non union
Direct Healing
Anatomically reduced rigid fixed fractures
Formation of cutting cones
>100,000 remodeling units work at time
Direct osteonal remodeling
Without callous
Activation
resorption by osteoclasts
osteoid formation by osteoclasts
Primary osteons
Mineralization
Direct Healing….
Fixation techniques and stability
Relative stability
Intramedullary nailing
Load sharing device
Inter fragmentary micro motion
Fracture gap strain is usually 2-10%
Body responds by forming more soft callus to try and decrease the strain
Fixation of diaphyseal fractures – strength and less duration
Relative stability
Absolute stability
Absolute stability
TBW
Lag screw fixation
Interfragmentary strain,
Nonunion and Management
Nonunion ….
Fracture is fixed rigidly but a gap is present
Direct healing may not be able to bridge the gap
The lack of strain may inhibit callus formation and secondary healing
Predispose to non-union
Management –
Fracture nonunion is a debilitating complication of fracture healing.
Effective management requires adequate understanding of its pathogenesis and risk factors.
Options of management could be operative or non operative.
An effective treatment protocol must ensure careful rehabilitation of the patient
Non union of fractures dr mohamed ashraf,HOD orthopaedics,govt TD medical col...drashraf369
presentation about pathophysiology and pathmechanics of delayed and non union of fractures.it shows how to manage different types of bone non union. presentation is by Dr Mohamed ashraf professor and head of orthopaedics,govt TD medical college, alleppey,kerala,india
Stress fracture: diagnosis, management and return to sportsVaibhav Bagaria
Stress fracture is a common orthopedic condition often seen in athletes and sportsperson. A customised approach is necessary to ensure a rapid return to activity and sports.
little bone mineral density brought on by changed bone microstructure is known as osteoporosis, which ultimately predisposes individuals to fragility fractures with little force. The quality of life is significantly reduced as a result of osteoporotic fractures, which also increase morbidity, mortality, and disability.
Soon, a presentation on the management of osteoporosis with physical therapy will be made available.
Potts spine is the classical destruction of disc space and the adjacent bodies , destruction of other spinal elements,severe progressive kyphosis subsequently
Also know as spinal tuberculosis
Similar to G17-General-Principles-Nonunion-Feb-2017.ppt (20)
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
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1. General Principles in the Assessment
and Treatment of Nonunions
Jaimo Ahn, MD, PhD & Matthew Sullivan, MD
Revised February 2017
Previous Authors:
Peter Cole, MD; March 2004
Matthew J. Weresh, MD; Revised August 2006
Hobie Summers, MD & Daniel S. Chan MD; Revised April 2011
2. Definitions
• Nonunion: (reasonably arbitrary)
– A fracture that is not currently healed and is
not going to
• Delayed union:
– A fracture that requires more time than usual to
heal
– Shows healing progress over time
3. Definitions
• Nonunion: A fracture that is a minimum of 9
months post occurrence and is not healed and has
not shown radiographic progression for 3 months
(FDA 1986)
• Not pragmatic
– Prolonged morbidity
– Narcotic abuse
– Professional and/or emotional impairment
4. Definitions (pragmatic)
• Nonunion: A fracture that has
no potential to heal without
further intervention
All images unless indicated: Rockwood and Green's Fractures in Adults, 8th Edition 2015
6. Hypertrophic
• Vascularized
• Callus formation present on x-ray
• “Elephant’s foot” - abundant callus
• “Horse’s hoof” - less abundant callus
Biology is more than sufficient but can’t consolidate
likely need mechanically favorable solution
7. Oligotrophic
• Some/minimal callus on x-ray
– Not an aggressive healing response, but
not completely void of biologic activity
• Vascularity is present on bone scan
Is there sufficient biology / mechanics
for healing?
8. Atrophic
• No evidence of callous formation on x-ray
• Ischemic or cold on bone scan
Not enough biology likely need
biologically favorable solution
9. Pseudarthrosis
• Typically has adequate vascularity
• Excessive motion/instability
• False joint forms over significant time
Sufficient biology but so much mechanical
instability that the body is “tricked” into
thinking there should be a joint there
likely need to reset the whole system
11. Biomechanics of Nonunions
• Important factors for consideration
• Biologic and Mechanical environment
– Presence or absence of infection
• Septic vs Aseptic
– Vascularity of fracture site
– Stability – mechanical environment
– Deformity
– Bone involved and surrounding soft tissues
13. Etiology of Nonunion – Host
• Smoking
• Hormones and related
– Diabetes melitus, Thyroid/ parathyroid disorders,
testosterone/estrogen deficiency, Vit D deficiency, Ca and/or Phos
abnormality
• Malnutrition
• Medications
– Steroids, Chemotherapy (& XRT), Antivirals,
Anticonvulsants, Immunosuppressives
• Bone quality, vascular status
• Balance, compliance with weight bearing restrictions
– Psychiatric conditions, dementia
14. Smoking
• Decreases peripheral oxygen tension
• Dampens peripheral blood flow
• Well documented difficulties in wound
healing in patients who smoke
Schmitz, M.A. e.t. al. Corr 1999
Jensen J.A. e.t. al. Arch Surg 1991
15. Systematic Literature Review
• Medline, Pubmed, Cochrane databases for
Level I-III studies
• Search headings:
– smoking, tobacco, nicotine WITH fracture,
nonunion, delayed union, and healing
J Bone Joint Surg Am. 2014 Apr 16;96(8):674-81. doi: 10.2106/JBJS.M.00081.
Cigarette smoking increases complications following fracture: a systematic review.
Scolaro JA, Schenker ML, Yannascoli S, Baldwin K, Mehta S, Ahn J.
16. Summary
• Increased risk of NONUNION
– Overall 15% higher, OR 2.31
– Tibia fractures ONLY 15% higher, OR 2.42
– Open fractures ONLY 12% higher, OR 2.06
• Prolonged fracture healing times?
– Overall 24wks vs. 30wks
– Tibia fractures ONLY 25wks vs. 32wks
• Increased wound healing complications?
– Deep OR 1.42
– Superficial OR 1.38
17. Diabetes
(Neuropathic Fractures)
• Best studied in ankle and pilon fractures:
• Complicated diabetics – those with end organ disease –
neuropathy, PVD, renal dysfunction
– Increased rates of infection and soft tissue complications
– Increased rates of nonunion, time to union significantly longer
– Prolonged NWB required
• Inability to control response to trauma can result in
hyperemia, osteopenia, and osteoclastic bone resorption
– Charcot arthropathy
Kline et al, Foot Ankle Int. 2009
Wukick et al, JBJS, 2008
18. Malnutrition
• Adequate protein and energy is required for
wound healing
• Majority of organic phase of bone is protein
• Screening test:
– serum albumin
– total lymphocyte count
• Albumin less than 3.5 and lymphocytes less
than 1,500 cells/ml is significant
Seltzer et.al. JPEN 1981
19. Etiology of Nonunion –
Fracture/Injury Factors
• High energy injury
– Fracture mechanism
– – MVC vs fall from standing
• Open or closed fracture
• Bone loss
• Soft tissue injury
• Bone involved and anatomic location
Open tibial shaft fx with bone loss vs closed nondisplaced
proximal humerus fx
Think about the personality of the fracture!! Sullivan M, unpublished
20. Fracture Pattern
• Fracture patterns in higher energy injuries
(i.e.: comminution, bone loss, or segmental
patterns) have a higher degree of soft tissue
and bone ischemia
• Acute compartment syndrome associated
with tibial plateau and tibial shaft nonunion
– surrogate for soft tissue injury
Blair, et al. JOT 2016
21. Traumatic Soft Tissue Disruption
• Risk of nonunion is increased with open fractures
• More severe open fracture (e.g. Gustilo III B vs
Type I) have higher risk
Gustilo et al. JOT 1984
Widenfalk et al. Injury 1979
Edwards et al. Ortho Trans 1979
Velazco et al. JBJS 1983
Westgeest et al. JOT 2016
22. Tscherne Soft Tissue Classification
• Not all high energy fractures are open
fractures. This classification emphasizes
the importance of viability of the soft tissue
envelope at the zone of injury.
Tscherne & Oestern, Unfallheilkunde 1982
23. Tscherne Classification:
closed fractures
Grade 0: Soft tissue damage is absent or negligible
Grade I: Superficial abrasion or contusion caused by
fragment pressure from within
Grade II: Deep, contaminated abrasion associated with
localized skin or muscle contusion from direct trauma
Grade III: Skin extensively contused or crushed, muscle
damage may be severe. Subcutaneous avulsion,
possible artery injury, compartment syndrome
24. Revascularization of ischemic bone fragments in
fractures is derived from the soft tissue. If the soft
tissue (skin, muscle, adipose) is ischemic, it must
first recover prior to revascularizing the bone.
Holden CE, JBJS 1972
25. Etiology: Surgeon
• Excessive soft tissue
stripping
• Improper or unstable
fixation
– Absolute stability
• Gap due to distraction or poor
reduction
– Relative stability
• Excessive motion
Wu CC, JOT 1996
26. Etiology of Nonunion – Initial
Treatment Factors
• Nonunion may occur after completely appropriate
treatment of a fracture, or after less than
appropriate treatment
• Was appropriate management performed initially?
– Operative vs non-operative?
• Was the stability achieved initially appropriate?
• Consider:
– Bone and anatomic location (shaft vs metaphysis)
– Patient – host status, compliance with care
27. Etiology of Nonunion – Initial
Treatment Factors
• After operative treatment…..
• Was the appropriate implant and technique
employed? (Fixation strategy)
– Relative vs absolute stability?
– Direct vs indirect reduction?
– Implant size/length, number of screws, locking vs
conventional
– Location of incisions. Signs of poor dissection?
• Iatrogenic soft tissue disruption, devascularization of bone
28. Etiology of Nonunion – Initial
Treatment Factors
• Is the current construct too flexible or too stiff?
• Implant too short?
• Bridge plating of a simple pattern with lack of
compression?
• Why did the current treatment fail?
• Understanding the mode of failure for the initial
procedure helps with planning the nonunion
surgery
29. Anatomic Location of Fractures
• Some areas of skeleton are at risk for nonunion
due to anatomic vascular considerations i.e.:
– Proximal 5th metatarsal, femoral neck, carpal
scaphoid
• Open diaphyseal tibia fractures are the classic
example with high rates of nonunion
throughout the literature
30. Infection
“Of all prognostic factors in tibia
fracture care, that implying the
worst prognosis was infection”
Nicoll EA, CORR 1974
31. Infection
• May be obvious
– Open draining wounds, erythema, inadequate
soft tissue coverage
• Subclinical is more difficult
– High index of suspicion
– ESR, CRP may indicate infection and provide
baseline values to follow after debridement and
antibiotic therapy
32. Infection
• Nonunion should be considered infected until
proven otherwise
• Dramatic association between deep infection and
nonunion
• Debridement, debridement, debridement
• Multiple cultures. Identify the bacteria
• Infectious disease consult is helpful
• Infected bone requires stability to resolve infection
• May achieve union in the presence of infection
with appropriate treatment
Westgeest et al. JOT 2016
33. Patient Evaluation
• History of injury and prior treatment
• Medical history and co-morbidities
• Physical examination
– Including deformity!
• Imaging modalities
• Patient needs, goals, expectations
34. Patient Evaluation – History of
Injury
• Date and nature of original injury (high or low energy)
• Open or closed injury?
• Number of prior surgical procedures
• History of drainage or wound healing difficulties?
• Prior infection? Identify antibiotics used and bacteria cultured (if
possible)
• Written timeline in complex cases
• Current symptoms – pain, deformity, motion problems, chronic
drainage
• Ability to work and perform ADL’s
35. Patient Evaluation – Medical
History
• Diabetes, endocrinopathies, vit D, etc
• Physiologic age – co-morbidities
– Heart disease, COPD, kidney/liver disease
• Nutrition
• Smoking
• Medications
• Ambulatory/functional status now and prior to
original injury
36. Patient Evaluation – Physical
Exam
• Appearance of limb
– Color, skin quality, prior incisions, skin grafts
– Erythema or drainage
• Range of motion of all joints
• Pain – location and contributing factors
• Strength, ability to bear weight
• Vascular status and sensation
• Deformity
– Clinically = Length, alignment, AND rotation
37. Patient Evaluation - Imaging
• Any injury-related imaging available – plain film and CT
• Serial plain radiographs from injury to present are
extremely helpful (hard to get)
• Most current imaging – orthogonal x-rays, typically
diagnostic for nonunion
– Healing of 3 out of 4 cortices without pain is typically considered
union.
• Obliques may be helpful for radiographic diagnosis of
nonunion
• CT can be helpful but metal artifact can make it difficult
• Radiographic Union Scale for Tibia (RUST) seems reliable
– Litrenta J et al, JOT 2015
38. Patient Evaluation – Imaging
Tomography
• CT and MRI have replace linear
tomography
• Consider Digital Tomography if available
Anari et al. JOT 2016
39. University of Texas Medical Branch
Classification of Adult Osteomyelitis
Cierny-Mader Classification
Anatomic Type
• Medullary
• Superficial
• Localized
• Diffuse
Physiologic Class
• A-Host
Healthy Immune System
• B-Host
Local compromise (BL)
Systemic compromise (BS)
• C-Host
Treatment is worse than disease
Anatomic Type + Physiologic Class = Clinical Stage
40. Radionuclide Scanning – Infected
Nonunion?
• Technetium - 99 diphosphonate
– Detects repairable process in bone ( not specific)
• Gallium - 67 citrate
– Accumulates at site of inflammation (not specific)
• Sequential technetium or gallium scintigraphy
– Only 50-60% accuracy in subclinical ostoemyelitis
Esterhai et al. J Ortho Res. 1985
Smith MA et al. JBJS Br 1987
41. Labeled Leukocyte Scan – Infected
Nonunion?
• Good with acute osteomyelitis, but less
effective in diagnosing chronic or subacute
bone infections
• Sensitivity 83-86%, specificity 84-86%
• Technique is superior to technetium and
gallium to identify infection
Nepola JV e.t. al. JBJS 1993
Merkel KD e.t. al. JBJS 1985
42. MRI – Infected Nonunion?
• Abnormal marrow with increased signal on
T2 and low signal on T1
• Can identify and follow sinus tacts and
sequestrum
• Mason study- diagnostic sensitivity of
100%, specificity 63%, accuracy 93%
Modic MT et al. Rad Clin Nur Am 1986
Mason MD et al. Rad 1989
43. Patient Evaluation – Goals &
Expectations
• What are the patient’s goals and needs?
– Household ambulation vs marathon runner
• Pain relief expectations
• Range of motion expectations
– Long standing nonunions may have stiff
adjacent joints
• Risks to neurovascular structures (radial
nerve in humerus nonunion)
46. Electrical Stimulation
• Applied mechanical stress on bone generates
electrical potentials
– Compression = electronegative potentials = bone
formation
– Tension = electropositive potentials = bone resorption
• Basic science suggests e-stim upregulates TGF-β
and BMP’s suggesting osteoinduction
47. Three Modalities of Electric bone
Growth Stimulators
• 1. Direct current - implantation of cathode in
bone and anode on skin
• 2. Inductive coupling – pulsed electromagnetic
field with device on skin
• 3. Capacitive coupling - electrodes placed on
skin, alternating current
• SR/MA suggests improvement in pain and
healing but not function Mollon et al, JBJS 2008
Aleem IS et al, Sci Rep 2016 (SR)
48. Contraindication to Electric
Stimulation
• Synovial pseudoarthrosis
• Electric stimulation does not address
associated problems of angulation,
malrotation and shortening – deformity!!
49. Evidence for use of Electrical Stimulation
• Pain
– Statistically significant improvement in pain scores with
e.stim
• Function
– no improvement with e.stim.
• Preventing and treating non union –
– Significantly greater union with e.stim. Number needed
to treat = 7.
• Irrespective of e.stim modality
Pooled meta-analysis data from Aleem, et al, 2016
50. Ultrasound
• Piezoelectric transducer generates an
acoustic pressure wave
• Some evidence to show faster healing in
fresh fractures
• Evidence is moderate to poor in quality with
conflicting results
• SR/MA suggests there may be improvement
in healing but not function
Busse et al, BMJ 2009
Rutten S et al, JBJS Rev 2016 (SR)
51. LIPUS (Low Intensity Pulsed UltraSound)
• TRUST Data
– Multicenter, double blinded, randomized controlled
clinical trial LIPUS vs Sham unit
– Open and closed tibial shaft fractures treated with IM nail
– No difference between groups in:
• Union rate
• SF-36 score
• Time to full weight bearing
• Return to pre-injury status
– Study stopped early due to lack of efficacy of LIPUS
TRUST (Trial to re-evaluate ultrasound in the treatment of tibial fractures) Busse et al, 2016
52. Extracorporeal Shock Wave
Therapy
• Single impulse acoustic wave with a high
amplitude and short wavelength.
• Microtrauma induced in bone thought to
stimulate neovascularization and cell
differentiation
• Clinical studies are of a poor level and no
strong evidence for use in nonunions is
available Biedermann et al, J Trauma 2003
Petrisor B et al, Indian J Orthop 2009 (SR)
53. Operative Treatment
• Debridement and
hardware removal
• Plate osteosynthesis
• Intramedullary nailing
• External fixation
• Autogenous bone graft
– ICBG, RIA
• Bone marrow aspirate
• Allograft bone
• Demineralized bone
matrix
• BMP’s
• Platelet concentrates
54. Autogenous Bone Marrow
Aspirate
• Transplant osteoprogenitor and mesenchymal
stem cells to nonunion site
• Osteoinductive, not osteoconductive
• Level III and IV studies available
• Positive correlation between number of
progenitor cells in aspirate and amount of callous
• Animal data positive but no high level clinical
Hernigou et al, JBJS 2005
Gianakos A et al, JOT 2016 (SR)
55. BMP’s
• rhBMP-2 and rhBMP-7 have been shown to
be equivalent to autologous iliac crest for
delayed reconstruction of tibial bone defects
• May be a reasonable alternative to ICBG for
the management of nonunion
• Very expensive!!
Jones et al, JBJS 2006
Friedlaender et al, JBJS 2001
Dai J et al, PLoS One 2015 (SR)
56. Autogenous Bone Grafting
• Considered the “gold standard”
• Osteoinductive - contain proteins and other
factors promoting vascular ingrowth and
healing
• Osteogenic – contains viable osteoblasts,
progenitor cells, mesenchymal stem cells
• Osteoconductive - contains a scaffolding for
which new bone growth can occur
• ICBG versus more recent RIA from femur?
57. Reamer-Irrigator-Aspirator Bone
Graft Harvest
(Synthes, West Chester, PA, USA)
• Compared to posterior or anterior ICBG
– Greater Volume
– Less operative time
– No difference in union rates
– Less expensive for larger defects
– ??Less donor site morbidity
– ??More significant complications
Dawson J, et al, JOT 2014
59. Surgical/Fixation Strategy
• Define nonunion type
– Hyper-, oligo-, atrophic, or pseudarthrosis
• Fracture location – diaphysis vs metaphysis
• Infected vs Aseptic
• Deformity?
• Patient/host factors
• Goals and expectations
60. Plate Osteosynthesis
• Correction of malalignment
– Osteotomy may be required, planning always required
• Compression in hypertrophic cases
• Immediate mobilization, likely NWB
• Requires adequate soft tissue coverage
– More dissection required for plating and osteotomy in
deformity correction
• Bone graft as needed
61. Plate Osteosynthesis
• Soft tissue and bony dissection are
extremely important!
• Preserve periosteum and muscular
attachment to bone
– Concept of “working window”
– Only expose the necessary amount of
bone to do the case, maintain
vascularity
62. Plate Osteosynthesis:
Osteoperiosteal Decortication
• Management of the bone…
– Do not simply elevate the periosteum off the bone!!
– Use a sharp chisel or osteotome to elevate an
osteoperiosteal flap
– Sharp chisel and a mallet to take some good,
vascularized bone with the periosteum
– Provides excellent environment for bone graft to
produce callous as the elevated bone remains
vascularized by the periosteum
Binod B et al, Arch Orthop Trauma Surg 2016
63. Intramedullary Nailing
• Mechanically stabilizes long bone nonunions as
a load sharing implant
– May allow for early weight bearing
• Must manage malalignment
– Starting and ending points, entrance and exit angle
of each fragment
• Initially destroys endosteal blood supply (will
recover) but increase periosteal blood supply
64. Intramedullary Nailing
• Can be performed without direct exposure or
dissection of the fracture soft tissue envelope
• Or can be performed in conjunction with an
open exposure of the nonunion site and bone
grafting
• Not applicable in articular nonunions and
malunions
65. IM Nail Dynamization
• Removal of interlocking bolt(s) to allow for axial
compression at nonunion with weight bearing
• Commonly performed technique for nonunion
management when IM nail is in place
• Extremely limited data to support this technique
• 83% success rate in tibial nonunion management
• Litrenta, et al. 2015
66. IM Exchange Nailing
• Replacing IM nail with larger IM nail
increased stability (r4)
• Medullary reaming reactive vascularity
• limited data to support this technique
(stronger than dynamization data)
• 90% success rate in tibial nonunion
management
• Litrenta, et al. 2015
67. External Fixation
• Excellent for gradual malalignment correction
• Useful in the management of infected nonunions
– Allows for repeat debridements with stability
– Soft tissue coverage without contaminated
hardware in wound
• Allows for bone transport for large intercalary
defects
• Can generate large compressive forces at nonunion
• Allows mobilization of joints
– May be bulky and difficult for patients to manage
– Pin infections common
• In complex cases, may be good for limb salvage but
may require a long period of time
Ahn J, unpublished
68. Nonunions
Summary
• Definition- a fracture that has not and is not going to heal
• Types- hypertrophic, oligotrophic, atrophic, pseudarthrosis
– If bone forming but not consolidated improve biomechanics
– If not enough bone increase biology
• Assessment- host, injury/fracture, prior treatment; infected?
• Assessment- exam, radiography, CT/MR, serologic markers
• Treatment- address what is lacking in biology and/or mechanics
• Treatment- systemic/pharmacologic,
electric/ultrasound/BMP/MSCs/graft, plate/nail/fixator
69. References
(in order of appearance)
Rockwood and Green's Fractures in Adults, 8th
Edition 2015
Weber & Cech. Pseudarthosis 1976
Schmitz MA, et al. CORR 1999
Jensen J.A. et al. Arch Surg 1991
Scolaro JA, et al. JBJS 2014
Kline et al, Foot Ankle Int. 2009
Wukick et al, JBJS, 2008
Seltzer et.al. JPEN 1981
Blair, et al. JOT 2016
Gustilo et al. JOT 1984
Widenfalk et al. Injury 1979
Edwards et al. Ortho Trans 1979
Velazco et al. JBJS 1983
Westgeest et al. JOT 2016
Tscherne & Oestern, Unfallheilkunde 1982
Holden CE, JBJS 1972
Wu CC, JOT 1996
Nicoll EA, CORR 1974
Litrenta J et al, JOT 2015
Anari et al. JOT 2016
Esterhai J, et al. J Orthop Res 1985
Smith MA et al. JBJS Br 1987
Nepola J, et al. JBJS 1993
Merkel KD, et al. JBJS 1985
Modic MT et al. Rad Clin Nur Am 1986
Mason MD et al. Rad 1989
Aleem IS et al, Sci Rep 2016
Rutten S et al, JBJS Rev 2016
Petrisor B et al, Indian J Orthop 2009
Gianakos A et al, JOT 2016
Dai J et al, PLoS One 2015
Dawson J, et al, JOT 2014
Giori N, et al, JOT 2010
Donders J, et al, JOT 2016
Binod B et al, Arch Orthop Trauma Surg 2016
LC NOTES: Although the image is great, this is truly a mangled extremity. Do you have a better image for a non-union talk of an open tibia etc? – DONE
LKC: can you describe the Cierney Host Classification – DONE a few slides ahead
LKC: COULD YOU PLEASE ADD A SLIDE OR TWO ON THE SCIENTIFIC EVIDENCE OF ELECTRICAL STIMULATION – DONE
LKC: Could you add another slide describing LIPUS as the topic is hot - DONE
LKC: Can you talk about the concept of dynamization-if it schould be considered and then add in exchange nailing-using a bigger size and considering dynamic screws as the target audience is residents - DONE