Download - 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