treatment aseptic non union
DESCRIPTION
TREATMENT ASEPTIC NON UNION. Dr. T . K . Jeejesh kumar. Aim. To discuss various treatment options Merits and demerits of the each options To arrive a conclusion in the aseptic nonunion treatment. Non union. Classification Hypertrophic – large volume of callus - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/1.jpg)
TREATMENT ASEPTIC NON UNION
Dr. T . K . Jeejesh kumar
![Page 2: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/2.jpg)
To discuss various treatment options
Merits and demerits of the each options
To arrive a conclusion in the aseptic nonunion treatment
Aim
![Page 3: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/3.jpg)
Classification
Hypertrophic – large volume of callus
Atrophic – little or no callusFibrous union – fibrous or fibro
cartilage fill the gap Pseudo arthrosis -Cartilage over the
fracture ends with cavity containing clear fluid
Non union
![Page 4: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/4.jpg)
According to vascularity of fracture ends Studied with radiology and strontium 85
uptake study Hypervascular
2 types Avascular
JUDET MULLER WEBER & CECH
![Page 5: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/5.jpg)
Rich blood supply at fracture ends - 3 types
Elephant foot
Horse hoof
Oligo trophic
1.Hyper vascular
![Page 6: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/6.jpg)
Elephant foot
Hypertrophic ends
Rich callus
Rich vascularity
Causes
Increase mobility
Premature weight bearing
![Page 7: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/7.jpg)
Horse hoof
Mildly hypertrophic ends
Poor callus
Little sclerosis
Causes
Moderately unstable fixation with plate
![Page 8: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/8.jpg)
Oligo trophic
Non hypertrophic ends
Vascular
Absent callus
Causes
Major displacement and distraction
Internal fixation without apposition
![Page 9: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/9.jpg)
Deficient vascularity
Incapable of biologic reaction
4 types Torsion wedge
Communated non union
Defect non union
Atrophic non union
2.Avascular
![Page 10: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/10.jpg)
Torsion wedge
Intermediate fragment with decreased blood supply
![Page 11: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/11.jpg)
Communated non union
1 or more intermediate fragment necrotic
![Page 12: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/12.jpg)
Defect non union
Ends are viable with defect in between
![Page 13: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/13.jpg)
Atrophic non union
Fibrous tissue fills defects of bone loss
Ends are osteoporotic and atrophic
![Page 14: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/14.jpg)
Tibial non union based on clinical and
radiological features
2 types
Type A
Type B
Paley et al
![Page 15: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/15.jpg)
Type A – Bone loss < 1cmA1- Mobile deformity
A2 – 1 Without deformity
A2 – Fixed non union A2 – 2 with
deformity
![Page 16: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/16.jpg)
![Page 17: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/17.jpg)
Type B – Bone loss > 1 cm
B1 – No shortening Bone defect
B2 – Shortening no Bone defect
B3 – Both bone defects and
shortening
Modified with presence of infection
![Page 18: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/18.jpg)
General Optimize metabolic and nutritional status
Discontinue tobacco and alcohol
Consider
Soft tissue
Neurovascular status of limb
Status of boneComplicating factors
Infection, deformity, bone loss
Treatment
![Page 19: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/19.jpg)
Nonoperative Operative
Treatment
![Page 20: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/20.jpg)
Electrical stimulation Ultrasound Extracorporeal shock wave therapy
Nonoperative
![Page 21: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/21.jpg)
Debridement and hardware removal
Plate osteosynthesis Intramedullary
nailing External fixation
Autogenous bone graft Bone marrow aspirate Allograft bone Demineralized bone matrix BMP’s Platelet concentrates
Operative Treatment
![Page 22: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/22.jpg)
Best Indication -Minimal deformity-Atrophic nonunion with open bone grafting
- No LLD
1.Acute correction
Treatment Options
![Page 23: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/23.jpg)
![Page 24: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/24.jpg)
Best Indication -Large deformity-Stiff nonunion with deformity-Associated LLD-Bone defect
2.Gradual correction
Treatment Options
![Page 25: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/25.jpg)
![Page 26: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/26.jpg)
Best Indication -Metaphyseal/periarticular location
- Excellent soft-tissue envelope - No infection
3.Plate and screw fixation
Treatment Options
![Page 27: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/27.jpg)
Best Indication - Intramedullary nail in place- Need for exchange nailing- Diaphyseal location- No infection
4.Intramedullary nailing
Treatment Options
![Page 28: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/28.jpg)
![Page 29: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/29.jpg)
Best Indication 5.Circular external fixation
-Large deformity-Stiff nonunion with deformity-Associated LLD-Poor soft-tissue envelope-Concern about infection-Bone defect-Metaphyseal/periarticular location -Diaphyseal location
![Page 30: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/30.jpg)
Hypertrophic nonunion Atrophic nonunion Nonunion with deformity Diaphyseal nonunion Metaphyseal nonunion Articular nonunion
Clinical management
![Page 31: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/31.jpg)
pitfalls Failure to provide
adequate fixation
1.Hypertrophic nonunion
Goal
Provide stabilitySurgical Tactic
Plate, nail, external fixationPearls
Does not require grafting, do not disturb biology
Classification Group
![Page 32: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/32.jpg)
2.Atrophic nonunion Goal
Provide biological simulation and stability
Surgical Tactic
Bone graft or substitute, provide stability
pearls
Thorough debridement of bone ends is a must
pitfalls
Failure to provide biological stimulation
Classification group
![Page 33: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/33.jpg)
3.Nonunion with deformity
Goal Correct deformity and nonunion
Surgical Tactic
Osteotomy or osteoplasty, provide biology and stability
pearls
Fully analyze deformity including length
pitfalls
Failure to correct deformity
Classification group
![Page 34: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/34.jpg)
4. Diaphyseal nonunion
Goal Maintain axial alignment and length
Surgical Tactic
Nail, external fixation, plate
pearls
Exchange nailing is primary technique
pitfalls
Maintain length, rotation, and axial alignment
Classification group
![Page 35: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/35.jpg)
5.Metaphyseal nonunion
Goal Maintain axial alignment and length
Surgical Tactic
Plate, external fixation
pearls
Carefully plan periarticular fixation
pitfalls
Maintain angular alignment
Classification group
![Page 36: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/36.jpg)
6. Articular nonunion
GoalPreservation of the reconstructed joint
Surgical Tactic
Rigid internal fixation, arthroplasty
Pearls
Comminuted nonunions require arthroplasty
Pitfalls
Prognosis of the joint is poor
Classification group
![Page 37: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/37.jpg)
Bone graftingGraft Ost
egenic
Ost inductive Ost conduction
Autogenic
Cancellous
Cortical
Bone marrow
+
+
+
+
+
+
+
+
+
Allograft
DBM
-
-
+/-
+
+
+
Collagen - + +
Ceramics - - +
BMP - ++ -
![Page 38: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/38.jpg)
Inlay graft by Albee
Bed in cut across non union
Graft from normal side put
in the bed
Sliding inlay
Graft from one
segment slide
across the non
union
![Page 39: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/39.jpg)
Onlay graft
Described by Campbell
Modification of
Henderson
Bed prepared over the
non union, cortical graft
put and fixed with screws
Dual onlay – Boyd
Congenital
pseudoarthrosis
Short osteoporotic non
union near joint
Elderly ostioporotic
Cortical bone either side
and cancellous chips in
between the fragments
held by screws
![Page 40: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/40.jpg)
![Page 41: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/41.jpg)
Cancellous insert graft - Nicoll
Bridging gap of fracture < 2.5cm
Filled with solid cancellous bone
Fixed with plates
![Page 42: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/42.jpg)
Massive slide graft – Gill
Sliding the graft from ½ circumference of bone
Disadvantage later grafting difficult
![Page 43: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/43.jpg)
Phemister onlay graft 1931- Modified by Feber
Sub perostial grafting across the non union
Forbes modified with cancellous graft of 2mm
thickness >3cm both ends
Along with internal fixation and external
immobilization
![Page 44: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/44.jpg)
Whole fibular transplant
Bone loss in radius, ulna and SOH
Small size
Closure easy
![Page 45: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/45.jpg)
Free vascularised fibular graft
AVN head of femur
Non onion after radiation
Intramedullary
Fibular allograft
Humoral non
union
Along with DCP
![Page 46: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/46.jpg)
Ostioblaste and progenator cells
Rich in cytokines
Degradable matrix of fibrin
Easily available less morbid
Autogenous bone marrow injection
![Page 47: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/47.jpg)
Demineralized bone matrix Long bone # with defect ↓morbidity Available in many forms Demineralization increases available proteins Sterilization by radiation Frozen or freeze dried Undifferentiated cell proliferate endochondral
ossification
Bone graft substitute
![Page 48: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/48.jpg)
Collagen
Type I collagen of
bovine skin
Graft substitute
Ceramics
Hydroxy apetite
Tricalcium phosphate
Ca sulphate
In combination
Act as scaffold for bone
generation
![Page 49: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/49.jpg)
Ostio induction
Increased production of matrix
Stem cell migration and maturation
Bone growth factor TGF Beta
BMP’S
BMP subclass 1 – 10
Inhibin etc.
FGF Acidic
Base
PDGF
IGF I & II
![Page 50: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/50.jpg)
BMP LMW Polypeptide Produced by chondrocyte ostio blasts >24 types BPM2, BMP4, BMP7
BMP - initiates endochondral ossification Recruits and stimulates local proginator cells Induce collagen Act through cell membrane receptors
BMP
![Page 51: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/51.jpg)
No single substrate provides all properties
Composit graft combination of substitutes
LANE et al – rhBMP – 2+ Synthetic matrix +
autogenous BM
Composit graft
![Page 52: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/52.jpg)
New Horizon in treatment Used delayed union and spinal fusion DNA of BMP2 osteogenic on IM injection Bondio et al Frankar berg et al Research PTH1-34 DNA in fracture healing
6.Gene Therapy
![Page 53: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/53.jpg)
7.ELECTRICAL AND ELECTROMAGNETIC FIELD Types –Direct current
Square wave generation
Unusual wave form
Methods
Semi invasive
Percutaneous multiple cathods at # site
Invasive
Electrical leads and generator inside the skin
![Page 54: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/54.jpg)
8.Low Intensity Ultra sound
Mechanism Gene stimulation
Angiogenesis
Temperature
Cellular activity
Enzyme modulation
SAFHS Sonic Accelerated # healing system by Exogen CO
![Page 55: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/55.jpg)
Septic or Aseptic nonunion Atrophic or Hypertrophic variety Stiff or Mobile nonunion LLD is present or not Bone Gap is present or not Whether Adjacent Joints normal ?
Decision making
![Page 56: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/56.jpg)
Available Options
• Freshening of Bone ends
• Acute docking
• Corticotomy & Lengthening
• Compression at NU Site
• Distraction at NU Site
• Bone Grafting
• Freshening of Bone ends
• Acute docking
• Corticotomy & Lengthening
• Compression at NU Site
• Distraction at NU Site
• Bone Grafting
![Page 57: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/57.jpg)
– medullary cavity, early bone to bone contact-“Biological”
- reshaping for stability to axial compression- “Mechanical”
More bone area in contact
Freshening of Bone ends
![Page 58: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/58.jpg)
Corticotomy - site remote from nonunion Restores length Improves vascularity of limb segment Practical only if LLD
Corticotomy & Lengthening
![Page 59: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/59.jpg)
At the nonunion site Both augment stability Distraction - corrects associated deformity Compression - if no deformity
Compression / Distraction
![Page 60: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/60.jpg)
Increased cross sectional area at union site improve healing Is not against Ilizarov “principles”
Bone Grafting
![Page 61: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/61.jpg)
summary
![Page 62: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/62.jpg)
Freshening of Bone ends ? Acute docking ? Corticotomy & Lengthening Compression at NU Site Distraction at NU Site Bone Grafting ?
1.NU - Aseptic, Atrophic
![Page 63: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/63.jpg)
Freshening of Bone ends Acute docking Corticotomy & Lengthening Compression at NU Site Distraction at NU Site Bone Grafting
2.NU - Aseptic, Hypertrophic Stiff, Deformity +
![Page 64: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/64.jpg)
• Freshening of Bone ends • Acute docking • Corticotomy & Lengthening • Compression at NU Site
–Subsequent Distraction at NU Site (if LLD) ?
• Bone Grafting
3.NU - Aseptic, Hypertrophic Stiff, No Deformity
![Page 65: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/65.jpg)
coclusion
![Page 66: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/66.jpg)
… bone is a plant with its roots in soft tissue and when vascular connections are damaged, it often requires not the technique of cabinet maker but understanding of a gardener …
Girdle Stone
![Page 67: TREATMENT ASEPTIC NON UNION](https://reader035.vdocuments.net/reader035/viewer/2022062519/56814f1c550346895dbcad20/html5/thumbnails/67.jpg)