BONE HEALING PROBLEMS

By

Mohammad Hassan
MBBCh, MCh(Orth), DrCh(Orth),


Lecturer, Department of Orthopaedic
Surgery & Traumatology,
Faculty of Medicine, University of
Alexandria
 Definitions
Nonunion
• Is arrest of the process of union and the
fracture has no possibility of healing without
further intervention.

• F D A definition: a fracture that is, at least, 9

months old and has not shown any signs of
progression to healing for 3 consecutive
months.
 Incidence
Between 5% and 10% of long bone fractures
Predisposing Factors

▪ Instability
▪ Inadequate Vascularity
▪ Poor Bone Contact
▪ Other factors
 Predisposing Factors
Mechanical Instability
Factors producing mechanical instability
• Inadequate fixation
• Distraction at the fracture site
• Bone loss
• Poor bone quality (i.e., poor purchase)
 Predisposing Factors
Mechanical Instability

Excessive motion at the fracture site with

adequate vascularity >>> abundant callus
formation that fails to bridge the gap at the
fracture site >>>> Hypertrophic Nonunion
 Predisposing Factors
Inadequate Vascularity

Open fractures & Surgical dissection

Excessive stripping and damage to the

periosteum & periosteal blood supply.
 Predisposing Factors
Inadequate Vascularity

Inadequate vascularity >>>> necrotic bone

at the ends of the fracture fragments
>>>> Atrophic Nonunion
 Predisposing Factors
Poor Bone Contact
May result from
▪ Soft tissue interposition
▪ Bone loss
▪ Distraction of the fracture fragments.
 Predisposing Factors
Poor Bone Contact

Creates a gap that the fracture healing process must

bridge.

As these gap increase in size, the probability of

fracture union decreases >>>>>>>> Oligotrophic
Nonunion
 Predisposing Factors
Other Contributing Factors
Infection
▪ Implants loosening >>>>> instability

▪ Sequestrated bone is avascular

▪ Poor bony contact dt osteolysis at the

fracture site & ingrowth of infected
granulation tissue.
 Predisposing Factors
Other Contributing Factors
Smoking

! local vascularity and cellular

function at the fracture site

" osteoporosis and

mechanical instability due to poor
bone quality for purchase
 Predisposing Factors
Other Contributing Factors
Certain medications
• NSAIDs
• Phenytoin
• Ciprofloxacin
• Steroids
• Anticoagulants
 Predisposing Factors
Other Contributing Factors
▪Advanced age
▪Systemic diseases
▪Poor functional level
▪Venous stasis
▪Obesity
▪ Alcohol abuse
▪ Metabolic bone disease
▪ Malnutrition
▪ Vitamin deficiencies
 Clinical Evaluation
History
▪ The date of injury
▪ The mechanism of injury
▪ Preexisting medical problems
(e.g., diabetes, malnutrition)
▪ Prior wound infections.
▪ Cigarette smoking
▪ NSAID.
 Clinical Evaluation
Physical Examination
• The general health
• The overlying skin
• Non physiologic motion.
• If a bone grafting is
contemplated, the anterior and
posterior iliac crests should be
examined
 Classification
Hypertrophic Nonunion

▪ Viable (adequate blood supply)

▪ Lack mechanical stability
▪ Do not display gross motion
▪ XR : Abundant callus, radiolucent line
▪ Technetium bone scan >>> Increased
uptake at the nonunion site
 Classification
Hypertrophic Nonunion
▪ The treatment is to add mechanical stability.
▪ No bone grafting,
▪ The nonunion site need not be resected
 Classification
Oligotrophic Nonunions

• Viable with adequate blood

supply

• Little or no callus formation.

• Inadequate reduction >>>> poor

contact at the bony surfaces.
 Classification
Oligotrophic Nonunions

Treatment methods include

1. Better reduction & fixation of the bony

fragments
2. Or bone grafting,
3. Or combination of both.
 Classification
Atrophic Nonunions

• Nonviable.
• Poor blood supply
• Incapable of biologic activity.
 Classification
Atrophic Nonunions

▪ Treatment needs biologic and mechanical

techniques.

▪ Necrotic fragments are excised, and the

defect is bridged with bone graft.

▪ Mechanical stability can be achieved using

internal or external fixation.
 Classification

The classification system can be further

modified by the presence or absence of
infection.
 Classification
Infected Nonunions
Characterized by two of the most difficult
orthopaedic entities to treat: bone
infection and nonunited fracture.

Eradicate the infection >>>>>>>> radical

debridements & the nonunion may be
treated using the Ilizarov method
Radiologic Evaluation
Plain X ray
Radiologic Evaluation
CT
Radiologic Evaluation
Fluoroscopy
 Treatment

Objectives
1. Heal the bone.
2. Eradicate infection.
3. Correct deformities.
 Treatment Modifiers
Anatomic Location
A) Epiphyseal nonunions

Treated with inter fragmentary

compression using lag screw
technique.
 Treatment Modifiers
Anatomic Location
B) Metaphyseal nonunions
▪ Unite rapidly when stimulated biologically by
cancellous bone grafting + internal fixation.
 Treatment Modifiers
Anatomic Location
C) Diaphyseal nonunions
▪ Traverse cortical bone
▪ More resistant to union

▪ Central location >>>>>

more friendly to the widest
array of fixation methods.
Treatment Modifiers
Bone Defects

▪ High-energy open fractures

▪ Debridement of devitalized infected
bone
▪ Excision of necrotic bone associated
with an atrophic nonunion
Treatment Modifiers
Bone Defects

Treated by
• Static methods
• Acute compression methods
• Gradual compression methods
 Treatment Modifiers
Bone Defects
Static Methods.

• To fill the defect between the bone ends.

• The ends of the nonunion do not move, (remain
statically fixed)
 Treatment Modifiers
Bone Defects
Static Methods.
Include the use of
• Autogenous bone graft
• vascularized autograft,
• strut cortical allograft,
 Treatment Modifiers
Bone Defects
Acute Compression Methods.

Immediate bone-to-bone contact

• Dynamic compression plates

• Interlocking nail after over reaming
• Ilizarov
 Treatment Modifiers
Bone Defects
Gradual Compression Methods.

▪ Include simple gradual compression

(i.e., shortening) or bone transport.
Both methods accomplished through
Ilizarov device.
 Treatment Modifiers
Surface Characteristics

▪ Transversely oriented nonunions respond well

to compression.

▪ Oblique oriented nonunions >>>> shear with

axial compression.

▪ Shear moments can be minimized using inter

fragmentary screws or steerage pins when
using external fixation
 Treatment Methods
A) Mechanical Methods
Promote bony union by providing stability
B) Biologic Methods
Promote bony union by stimulating the local biology
C) Combined Methods
improve both the mechanical and biologic status
 Treatment Methods
A) Mechanical Methods
1: Weight Bearing & External Supportive Devices

Used for nonunions of the lower extremity, the tibia.

Used in conjunction with an external support ( casts,
braces, cast braces), dynamization.
 Treatment Methods
A) Mechanical Methods
2: Dynamization
• Allows axial loading (compression) of bone
fragments
• Used in nonunions of the lower extremity
being treated with intramedullary nail fixation
or external fixation
 Treatment Methods
A) Mechanical Methods
2: Dynamization

• The interlocking screws at the

greatest distance from the nonunion
site are removed

• Dynamization of an external fixator

involves removal or loosening of the
external struts that span the
nonunion
 Treatment Methods
A) Mechanical Methods
3: Bone excision
• Excision of bone is performed on the intact bone to allow compression across the
ununited bone.
 Treatment Methods
A) Mechanical Methods
4: Osteotomy
Reorientation of the inclination of the nonunion from a vertical to a more
horizontal position to promote compressive forces across the nonunion
site.
 Treatment Methods
B) Biologic Methods

Ι: Nonstructural Bone Grafts

II: Decortication

III: Electromagnetic, Ultrasound, and

Shockwave
Treatment Methods
B) Biologic Methods
Ι: Nonstructural Bone Grafts


1: Cancellous Graft.
2: Bone Marrow.
3: Bone Graft Substitutes
4: Bone Morphogenetic Proteins and Other
Growth Factors
 Treatment Methods
B) Biologic Methods
Ι: Nonstructural Bone Grafts

1: Autogenous Cancellous Graft

• It is osteoconductive, and osteoinductive.

• It stimulates the local biology at the nonunion
site in oligotrophic and atrophic nonunion.
 Treatment Methods
B) Biologic Methods
Ι: Nonstructural Bone Grafts

2: Allogenic Cancellous Graft

• An osteoconductive graft,

• Mixing it with cancellous autograft or bone marrow

enhances the graft’s osteoinductive capacity.
 Treatment Methods
B) Biologic Methods
Ι: Nonstructural Bone Grafts

3: Bone Marrow
▪ The osteoprogenitor cells capable of forming bone
▪ Harvested percutaneously from the iliac crest.
▪ Injected percutaneously under fluoroscopic image
▪ Works well with small defects (<5mm) that have
excellent mechanical stability.
 Treatment Methods
B) Biologic Methods
Ι: Nonstructural Bone Grafts

4: Bone Graft Substitutes.
Osteoconductive
Hydroxyapatite
Tricalcium phosphate
Calcium sulfate
Osteoconduction and
osteoinduction
Demineralized bone matrix
 Treatment Methods
B) Biologic Methods
Ι: Nonstructural Bone Grafts

5: Bone Morphogenetic Proteins and Other Growth Factors

Elicit their actions by binding to

transmembrane receptors that are
linked to gene sequences in the
nucleus of various cells by a
cascade of chemical reactions.
 Treatment Methods
B) Biologic Methods
II: Decortication

▪ The raising of osteoperiosteal

fragments from the outer cortex
from both sides of the nonunion
using a sharp osteotome
promotes revascularization of the
cortex.
 Treatment Methods
B) Biologic Methods
III: Electromagnetic, Ultrasound, & Shockwave

▪ All have clinical evidence to

support effectiveness
▪ Best suited for hypertrophic
nonunions with good inherent
stability with no significant
deformity or bone defect.
Treatment Methods
C) Mechanical & Biologic

I: Structural Bone Grafts

II: Exchange Nailing
III: Synostosis techniques
IV: Ilizarov Method



Treatment Methods
C) Mechanical & Biologic
I: Structural Bone Grafts
Cortical Bone Grafts.

• Vascularized Autogenous
• Nonvascularized Autogenous
• Allografts
 Treatment Methods
C) Mechanical & Biologic
I: Structural Bone Grafts
Cortical Bone Grafts.
1) Vascularized Autogenous Cortical Bone Grafts.
• Provide living bone to defects.
• Obtained from the fibula, iliac
crest, or ribs
• Graft hypertrophy with loading
• Can span massive defects
 Treatment Methods
C) Mechanical & Biologic
I: Structural Bone Grafts
Cortical Bone Grafts.
2) Nonvascularized Autogenous Cortical Bone Grafts
1. harvested from the fibula or iliac crest
2. Prolonged nonweight bearing for lower
extremity applications & Prolonged support
for upper extremity applications,
3. Progressive graft weakening during
revascularization (years)
 Treatment Methods
C) Mechanical & Biologic
I: Structural Bone Grafts
Cortical Bone Grafts.
3) Cortical Allografts
• Reconstruction of massive defects
• No associated donor site morbidity;
• Possibility of disease transmission from
donor to recipient
• Possibility of Infection
• Possibility of Nonunion at the host-graft
junction
 Treatment Methods
C) Mechanical & Biologic
II: Exchange Nailing
Mechanically
• placement of a larger-diameter nail
augments stability at the nonunion site &
increase the endosteal contact area of the
nail .
Biologically
• Reaming >>> local bone graft at the nonunion site
• Reaming >>>> decrease in endosteal blood flow
>>>>>> dramatic increase in periosteal flow and
periosteal new bone formation.
 Treatment Methods
C) Mechanical & Biologic
III: Synostosis techniques

▪ The creation of bone continuity between

paired bones above and below the nonunion
site

▪ From a functional standpoint, this becomes

a one-bone extremity.
 Treatment Methods
C) Mechanical & Biologic
IV: Ilizarov Method
• Minimal invasiveness & minimal soft tissue
dissection
• Promotion of bony tissue generation
• Simultaneous bony healing and deformity correction,
• Allow immediate weight bearing,
• The tensioned wires allow for the ‘‘trampoline
effect’’ during weight-bearing activities
THANK YOU