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Nonunion definition, causes, classification and management
- 1. Nonunion:definition,causes,classification and outline ofmanagement. Dr. Bipul Borthakur Professor, SMCH,Assam
- 2. Non Union •9 monthselapsed since injury & the fracture show 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
- 3. • Poor Vascularity(biology) • Instability • Infection • Others
- 4.
- 5. too flexible gap Inadequatestabilization: Resorption of bone at fracture site.
- 6. Infection: Infection and lossof soft tissue covering.
- 7. • Local Riskfactors – Open Fractures – High energy fractures wit h bone devitalization. – Severe associated soft tis sue injury – Bone loss – Infection
- 8. • Iatrogenic Factors: –Poor reduction – Unstable fixation – Bone devitalization
- 9. • Systemic RiskFactors – Malnutrition – Smoking – NSAIDs – Systemic Medical Conditions li ke Diabetes, paraplegia. – Chronic alcoholism. • Patient Factors – Non Compliance
- 10. Judet and Judet,Müller, Weber and Cech, and others classified nonunions into two types according to the viability of the ends of the fragments. hypervascular (hypertrophic) or viable and is capable of biological reaction. avascular (atrophic) or inert and are not capable of uniting without intervention.
- 11. Classification Hypervascular nonunions aresubdivided as follo ws: • “Elephant foot” nonunions • “Horse hoof” nonunions • Oligotrophic nonunions.
- 12. “Elephant foot” “Horsehoof” Oligotrophic
- 13. Classification… Avascular nonunions aresubdivided as follows: • Torsion wedge nonunions • Comminuted nonunions • Defect nonunions • Atrophic nonunions.
- 14. Torsion wedge ComminutedDefect Atrophic
- 15. Classification… Paley et atdivided nonunions, clinically and radi ographically, into two major types : • Type A: nonunions with bone loss of less than 1 cm • Type B: those with more bone loss
- 16. Type A nonunionsare subdivided into: • Type A1: nonunions with a mobile deformity • TypeA2: those with a fixed deformity • Type A2 is subdivided further into: • Type A2-1: a stiff nonunion without deformity , • Type A2-2, a stiff nonunion with a fixed defor mity
- 17. Type B nonunionsare subdivided into: • Type B1: nonunions with a bony defect • Type B2: loss of bone length • Type B3: both.
- 18. Classification of nonunionsas described by Paley et al
- 19. Classification… Rosen et alin the AO manual have divided infect ed nonunion in two broad categories: • Infected non draining nonunion further divided into: a)quiescent(dry non draining for at least three months) b)active (non draining but with abscess and fever) • Infected draining nonunion:
- 20. • Persistent Pain •Non physiologic motion • Progressive deformity • No radiographic evidence of hea ling • Failing implants
- 21. •Standard radiographs areoften diagn ostic •45 degree oblique films can increase diagnostic accuracy •Despite additional projections, the po tential for false-positive results for frac ture healing remains. •Serial Radiological Assessment is nece ssary.
- 22. •Stress radiograph giv esthe status of stabili ty of the fixation. •It also confirm the cli nical diagnosis Varus stress Valgus stress
- 23. •Computed Tomography: Adefinitive diagnostic tool
- 24. Biology: good Stability: lacking Treatment: •Providestability •Correct deformity, if present. •No bone graft required Elephant foot Horse hoof
- 25. Biology: Poor Stability: lacking Treatment: •Providestability •Bone graft Atrophic
- 26. Biology: None Stability: lacking? Treatment: •Providestability •Bone graft •Other reconstruction Necrotic Defect
- 27. Principle of surgicalmanagement • Cure infection if present • Correct Deformity if significant • Provide stability through implan ts • Add biologic stimulus when nec essary
- 28. •Treatment principle ofinfected non union •Contaminated implants and devitalized implants must be rem oved • Infection treated: • Temporary stabilization (external fixation) • Culture specific antibiotics • +/- local antibiotic delivery (antibiotic beads) •Secondary stabilization with augmentation of osteogenesis (c ancellous grafting)
- 29. • External Fixation •Plate • Intramedullary Devices
- 30. • Largest indicationis a tempora ry stabilization following infect ion debridement • Also useful in correction of stiff deformity and lengthening
- 31. • Plates providea 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 requi red
- 32. • Multiple Indicationsfor plate – Broken implants that require rem oval – Metaphyseal nonunion – Significant deformity • Technique – Blade properly positioned in the dis tal fragment – Reduction obtained by bringing plat e to the shaft – Absolute stability with lag screw – Nonunion was not exposed Broken P late
- 33. • Primary nailing •Exchange nailing— • new large dimeter nail • reamed nails -provides local bone graft,no bone loss shoul ed be their • correction of angular alignment • asso. Fibular osteotomy • Dyanamization--- removal of static screw, dynamic screw, all screws
- 34. Accordion Manoeuvre • “Bloodlessstimulation” of bone healing • Alternate compression & distraction at the fracture sit e • Compression brings the fragments into contact & crush es the scar tissue between them. • Distraction creates columnar fibro-vascular tissues • Repeated distraction stimulates the production of oste oblast and helps the collagen bundles consolidate withi n a bony matrix
- 35. Broken P late • Oftenunnecessary 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
- 36. Gold standard forbiological 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.
- 37. Bone graft Onlay bonegraft Dual onlay graft Cancellous insert graft Massive sliding graft Whole fibular transplants
- 38. Nonunion oftibial shaft treated by dual onlay grafts.
- 39. Gill massivesliding graft
- 40.
- 41. • Aspirated iliaccrest stem cells h as been shown to enhance the a ctivity of osteoconductive grafts . • There are few commercially avai lable Recombinant BMP proved to be effective treating nonunio ns.
- 42. •Electromagnetic – Direct Current –Inductive coupling – Capacitive coupling •Ultrasound – mechanical energy in the form of low frequency acoustic w aves
- 43. REFERENCES Cambell’s operativeorthopaedics 11th edition Textbook of orthopaedics and trauma by GS Kulkarni
- 44.