non union

AO SEC TraumaAO SEC TraumaMay, 15-17, May, 15-17, Chittagong.Chittagong.

WelcomeWelcome

Prof. Muhammad ShahiduzzamanProf. Muhammad Shahiduzzaman

Head, Department of Orthopaedics and TraumatologyDhaka Medical College Hospital

•Definition•Etiology•Evaluation•Classification•Treatment principles

• Stabilization• Biology

•Prevention

Non Union

•9 months elapsed time with no healing progress for 3 months.

•Union is delayed and a fracture has ceased to show any evidence of healing

Practically,A fracture that has no potential to heal without further intervention

Delayed unionFailure to consolidate within the normally expected time for fracture types and location

PseudoarthrosisFormation of a false joint where a fibro-cartilaginous cavity is lined with synovial membrane

What does nature do with a broken bone?

Indirect Healing

It will heal by callus formation

bony bridging

Stages of fracture healing

• Hematoma formation

•Inflammation and cellular proliferation

•Callus formation

•Consolidation

•Remodeling

• Poor Vascularity (biology)

• Instability

• Infection

• Others

Traumatic Iatrogenic

too flexible gap

Inadequate stabilization:Resorption of bone at fracture site.

Infection:Infection and loss of soft tissue covering.

• Local Risk factors

– Open Fractures

– High energy fractures with bone devitalization.

– Severe associated soft tissue injury

– Bone loss

– Infection

• Iatrogenic Factors:– Poor reduction

– Unstable fixation

– Bone devitalization

• Systemic Risk Factors– Malnutrition

– Smoking

– NSAIDs

– Systemic Medical Conditions like Diabetes, paraplegia.

– Chronic alcoholism.

• Patient Factors– Non Compliance

Site- Diaphyseal- Metaphyseal:

- Extraarticular- Intraarticular

Callus- Hypertrophic- Oligotropic- Atropic

Infection- Aseptic- Infected

Hypertrophic Atrophic Necrotic DefectOligotrophic

Vascular/Vital Avital? Avital

• Persistent Pain• Non physiologic motion• Progressive deformity• No radiographic evidence of

healing• Failing implants

•Standard radiographs are often diagnostic

•45 degree oblique films can increase diagnostic accuracy

•Despite additional projections, the potential for false-positive results for fracture healing remains.

•Serial Radiological Assessment is necessary.

•Stress radiograph gives the status of stability of the fixation.

•It also confirm the clinical diagnosis

Varus stress Valgus stress

•Computed Tomography: A definitive diagnostic tool

Biology: good Stability: lacking

Treatment:•Provide stability•Correct deformity, if present •No bone graft required

Elephant foot Horse hoof

Biology: PoorStability: lacking

Treatment:•Provide stability•Bone graft

Atrophic

Biology: NoneStability: lacking?

Treatment:•Provide stability•Bone graft•Other reconstruction

Necrotic Defect

Principle of surgical management

• Cure infection if present• Correct Deformity if significant• Provide stability through

implants• Add biologic stimulus when

necessary

•Treatment principle of infected non union

•Contaminated implants and devitalized implants must be removed

• Infection treated:• Temporary stabilization (external fixation)• Culture specific antibiotics• +/- local antibiotic delivery (antibiobic beads)

•Secondary stabilization with augmentation of osteogenesis (cancellous grafting)

• External Fixation• Plate• Intramedullary Devices

• Largest indication is a temporary stabilization following infection debridement

• Also useful in correction of stiff deformity and lengthening

• Plates provide a powerful reduction tool• Surgical technique should strive for absolute stability• Locking plates have improved stability and fixation strength• Other relative indications:

– Absent medullary canal– Metaphyseal nonunions– When open reduction or removal of prior implants is

required

• Multiple Indications for plate– Broken implants require that

removal– Metaphyseal nonunion– Significant deformity

• Technique– Blade properly positioned in the

distal fragment– Reduction obtained by bringing

plate to the shaft– Absolute stability with lag screw– Nonunion was not exposed

Broken Plate

Broken Plate

• Ideal case – Femur or tibia with an existing canal and no prior implants

• Exchange nailing provides a good option for the tibia and femur

• Special equipment is often necessary to traverse sclerotic canals

Broken Plate

• Often unnecessary in hypertrophic cases with sufficient inherent biologic activity

• Options– Aspirated stem cells (with or without expansion)– Demineralized Bone Matrix– Autogenous Cancellous Graft– Growth Factors

• Platelet derived• Recombinant BMPs• Gene Therapy

Gold standard for biological and mechanical purposes.

Properties of Autograft:

Osteogenic a source of vital bone cells

Osteoinductive recruitment of local mesenchymal cells

Osteoconductive scaffold for ingrowth of new bone

Bone graft can also be allograft.

• Aspirated iliac crest stem cells has been shown to enhance the activity of osteoconductive grafts.

• There are few commercially available Recombinant BMP proved to be effective treating nonunions.

Decortication (Judet, 1972)

Shingling Cancellous bone graft

Muscle pedicle bone graftEnhance the healing responsecreating well-vascularized bed

8 months

after injury

68-year-old, women

68-year-old, women

•Electromagnetic– Direct Current– Inductive coupling (PEMF, CMF)– Capacitive coupling

•Ultrasound– mechanical energy in the form of low frequency acoustic

waves 30 mW/cm2

Biological fixation: Preservation of blood supply to bone and soft tissue

The commonest cause of nonunion is the failure to diagnose and treat delayed union

- Careful evaluation of abnormal findings clinically and radiologically

- Adequate regimen of aftertreatment

• Definition of delayed unions/nonunions and natural course of fracture healing

• Causes of disturbed bone healing such as vascularity, instability, and infection

• Principles of treatment applied based on types of nonunion:- stabilization- enhancement of biology - eradication of infection if any

• How to prevent delayed unions/nonunions:- biological fixation in original operation- early recognition of delayed union