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

1. PATHOGENESIS OF NON-UNION
Case scenario: MANAGEMENT OF FEMORAL
SHAFT NON-UNION IN A 45YR OLD MAN
DR. ALUMONA CHRISTIAN
Senior Registrar
National Orthopaedic Hospital, Lagos
Nigeria

2. OUTLINE
• Introduction
• Epidemiology
• Burden of Disease
• Definition
• Pathophysiology
• Normal Bone healing
• Aetiology & Risk factors
• Classification
• Management
• Background
• Aims

3. Outline cont
• Clinical evaluation
• History
• Physical evaluation
• Imaging
• Plain radiograph
• CT
• Nuclear imaging
• Laboratory investigation

4. Outline Cont
• Treatment
• General principles
• Non-operative
• Operative
• Adjuncts to operative repair
• Long term outcomes and risk factors for non union repair failure
• Rehabilitation and Follow up
• Conclusion
• References

5. Introduction
• Bone healing: A complex biological phenomenon.
• Interruptions may delay or impede the process.
• Factors relating to the patient, primary injury or treatment received
• Associated functional impairment, protracted treatment, lost wages
and chronic pain.
• Significant psycho-social impairment, and economic burden to both
the patient and the health system.

6. Epidemiology
• Overall rate on non-union: 4.9%1,2
• US: 4-9%3
• UK: 5-10%3
• Nigeria: ?
• TBS treated fractures: 25%4 ends up as nonunion
• Open fractures: 2.7%5 results in delayed/non union
• Prevalence expected to be higher in sub-Saharan Africa
• High TBS patronage >80%4
• Late presentation of open fractures

7. Definition:
• Based on clinical and radiologic findings
• Delayed union: clinical and radiological features of union lags
behind expected time table but healing is still possible
• Nonunion: Failure of a fracture to heal within the expected time
and is not likely to heal without new intervention.
• 6-8months7 or 9months post op8.
• Fracture healing is variable: age, bone, region of bone, type of
fracture, energy of injury, soft tissue state, method of treatment.
• On a cellular level
• Cessation of reparative process antecedent to bony union7

8. Disease Burden
• Debilitating chronic medical condition.
• Substantial negative effects on health
• Health related quality of life worse than Type 1 DM, stroke and AIDS6

9. Pathophysiology

10. Normal bone healing
• Cells: osteocytes, osteoblast,
osteoclasts
• Intercellular matrix
• Organic: collagen (mostly type 1)
• Inorganic: hydroxyapatite (Ca, ph),
Mg, K etc
• Blood supply: epiphyseal, periosteal
and nutrient vessels
• Regions: epiphyses, physis, metaphysis,
dialysis
• Hormones: PTH, Vit D, calcitonin etc

11. Normal bone healing cont
• Hematoma
• Inflammatory
• Soft callous
• Hard callous
• Remodeling

12. • Primary healing
• Secondary healing

13. Perren Strain theory
• Fractures heal by elastic
dynamization
• Interfragmentory strain
• >10: non-union
• 10-2: Secondary bone
healing
• <2: Primary bone
healing

14. Etiology & risk factors for nonunion
Host related factors Fracture specific factors Treatment Factors
Systemic factors
Diabetes
Smoking
NSAIDS9, opiods & Cox 2
inhibitors10
Hypovitaminosis D
Malnutrition,
immunosuppression, steroid
use, malignancy
Age, sex (clavicular nonunion)11
Bone and region of involved
bone
(metaphyseal vs diaphyseal),
base of 5th metartasal, talar
neck, neck of femur, scaphoid
waist
Insufficient immobilization:
poor fitting IM nail, loose
casts
Rigid internal fixation without
compression
Energy of injury
(degree of communition, soft
tissue injury & perisoteal
striping, bone loss)
Poor technique: soft tissue
injury, periosteal stripping,
loss of fragments
Local factors
Infection
Malignancy
local irradiation Closed vs Open

15. Classification of Nonunion
• Septic vs Aseptic
• Atrophic vs oligotrophic vs hypertrophic
• Pseudoarthrosis
• Bone defects

16. Atrophic Nonunion
• Avascular/nonviable/avital
nonunion
• absence on bone reaction at
fracture site
• Poor blood supply
• Requires debridement and
biological stimulus
• Cold on bone scan

17. Hypertrophic Nonunion
• Hypervascular/Vital/nonunion
• Biological potential for healing
present
• Unfavourable mechanical factors at
fracture site
• Callus formation present on x-ray
with intervening unmineralized
fibrocartilage
• Elephant’s foot - abundant callus
• Horse’s hoof - less abundant callus
• Bone grafting not necessary

18. Oligotrophic Nonunion
• Minimal radiographic healing
potential (Callous)
• Increased uptake on bone scan
• Usually due to lack of
approximation of fracture ends
• Requires compression and bone
grafting

19. Pseudoarthrosis
• False joint with synovial lined
pseudo-capsule
• Contains joint fluid
• sealed medullary cavity
• Usually due to excessive and
chronic motion
• Cold on bone scan
• Requires debridement, re-
canalization, stabilization and
bone grafting

20. Bone defect/loss
• May result from initial injury or
from treatment
• Abnitio requires intervention to
achieve union
• Bone grafting or transport
procedure in addition to
stabilization

21. Management
• Background
• 45yr old man
• Femoral shaft nonunion
• Aims
• Appropriately diagnose and classify the pathology
• Identify possible etiology and risk factors in the patient
• Optimize comorbidities
• Accurately describe any associated bone or joint deformity that may require
correction
• Understand impact of disease and selected treatment option to achieve union
• Rehabilitate and reintegrate the patient

22. Clinical Evaluation: History
• History of present symptoms
• Pain
• Abnormal motion
• Lack of ability to bear weight
• Discharging sinus
• History of index injury
• Mechanism/energy of injury
• soft tissue component; open vs closed
• prior treatments; type and timing, purpose, response
• biopsy mcs result
• complications & recovery

23. History cont
• Impact of illness
• On social life
• On occupation
• Medical and social History
• DM
• Immunosuppression
• Smoking
• Medications: NSAIDS, Opiods, etc

24. Physical examination
• General appearance
• Msk exam
• Gait: antalgic, short limb
• signs of inflammation
• Scarification, surgical scars
• Gross motion
• LLD
• Knee stiffness

25. Investigation: Imaging
• Plain radiographs
• Viability of segments
• Presence of implants
• Features of infection
• CT scan
• Nuclear scan
• determine viability
• detect infection

26. Laboratory investigation
To rule out infection, comorbidity, determine fitness
• FBC
• ESR, CRP, Serum pro calcitonin
• Serum albumin
• FBS, HBA1c
• wound swab mcs

27. Treatment
• Considerations
• Prior treatments and response
• Current level of disability
• Time constraints for future weight bearing restrictions
• Occupational needs
• General measures
• Correction on endocrine and metabolic disorders (DM, parathyroid disorders), HIV
• Optimization of nutrition
• Smoking cessation
• Stoppage/reduction of certain medications (NSAIDS, Opiods, steroids, Selective Cox
2 inhibitors, bisphophonates)
• Control/eradication of infection
• Soft tissue management

28. Non operative management
• Indication
• Little or no clinical symptom
• Acceptable alignment
• Reasonable potential for success with non operative mgt
• Minimal comorbidity associated with time required for non operative mgt
• PT not fit for surgery
• Relative contraindication
• Chronic pain, functional loss, disability
• Progressive fracture malalignment
• Persistent and excessive movement at fracture site
• Infected nonunion

29. Non-operative mgt: options
• Weight bearing
• Splinting with cast or orthosis
• Electromagnetic stimulation
• DC: invasive
• CC: 24hours/day
• PEMF: 8-12hours/day
• CMF: 30min/day

30. • Ultrasound stimulation:
• LIPU,
• ESWT
• Parathyroid hormone

31. Minimaly invasive options
• Percutaneous Mgt
• Percutaneous injection of concentrated bone marrow12
• Percutaneous platelet rich plasma

32. Operative Mgt
• Indication
• Chronic pain, functional loss, disability
• Progressive fracture malalignment
• Persistent and excessive movement at fracture site
• Infected nonunion
• Preference
• Contraindication
• PT not fit for surgery

33. Operative management
• IM Nailing
• Primary nailing
• Exchange nailing
• Dynamization
• Primary nailing
• A common option of mgt of diaphyseal femur nonunion13
• Indications: following primary nonoperative mgt, and in well aligned
nonunion initialy mgt with plate fixation

34. Operative mgt: IM Nailing cont
• Exchange nailing
• Removing a pre existing nail for a new one
• Indication: to correct deficiencies in the existing nail with a
bigger nail
• bone defect,
• lack of rotational control (absence or broken interlocking
screw)
• Lack of stability (undersized nail)
• Added advantage of reaming
• Deposits small bone graft to the nonunion
• Stimulate inflammatory response sufficient to promote healing

35. Operative mgt: IM Nailing cont
• Recommendations for exchange nailing14
• New nail >2mm
• Different manufacturer’s nail
• Static interlocking
• Correction of any endocrine or metabolic abnormalities
• Secondary nail dynamization

36. Operative mgt: IM Nailing cont
• Dynamization:
• Removal of interlocking screws at one end of a nail
• To achieve axial shortening on weight bearing
• Mechanism: compression and micro-motion at fracture site
• Forms
• Removal of static screw and retention of a dynamic screw
• Maintains rotational control
• Limits amount of shortening that can be achieved
• Removal of all interlocking screw from one end
• Greater compression at the expense of rotational control

37. • What end of the nail should be dynamized
• Screws closest to fracture site should be reatined
• Screws opposite the isthmus relative to the fracture site should be removed
• Complications of dynamization
• Loss of rotational control (when all interlocking screws from one end are
removed)
• Loss of length from excessive shortening
• Nail back out into adjacent joint

38. Operative mgt: Plate osteosynthesis
• Pros
• Can address angular, rotational and translational deformities
• Provide greater compression at fracture site
• Can be used in the case of obliterated medullary cavity associated with some
nonunion
• Cons
• Invasive
• Delayed weight bearing
• Can not address limb shortening from bone loss

39. • External Fixation
• LRS
• Ilizarov
• TSF

40. Adjuncts to Operative mgt
• Autogenous bone graft
• Iliac crest bone graft
• Proximal tibia
• Reamer-Irrigator aspirator
• Bone grafts substitutes
• Recombinant proteins: BMPs
• Demineralized bone matrix
• Bone marrow aspirates

41. Rehabilitation and Follow up
• ROM exercises
• Ambulation training
• Follow up radiographs
• Pin site care

42. Long term outcomes and risk factors for non union
repair failure
• Pain
• Knee stiffness
• LLD
• COM
• Failed repair: Risk factors include;
• Mechanism of injury
• Increased BMI
• Cortical size defect
• Smoking
• Failed previous surgical interventions

43. Conclusion
• Fracture nonunion is a chronic debilitating illness that most often
does not receive commensurate attention.
• A holistic approach to management requires a painstaking search for
risk factors and comorbidities in the patient, optimization of such and
the selection of the most appropriate option of treatment while
ensuring that further morbidity are prevented.

44. • Thanks

45. References
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