More Related Content
NONUNION.pptx
- 1. NON-UNION DR. SHAHZAIB RIAZBALOCH SENIOR RESIDENT ORTHOPEDICS DEPARTMENT DR. ZIAUDDIN HOSPITAL KARACHI
- 2. A nonunion isan arrest in the fracture repair process Definition: A minimum of 9 months has elapsed since injury and the fracture shows no visible progressive signs of healing for 3 months (FDA) A fracture that, in the opinion of the treating physician, has no possibility of healing without further intervention (Brinker Et Al)
- 3. BIOLOGIC ETIOLOGIES OF NONUNION LOCAL Excessive soft-tissue stripping (from injury or surgeon) Bone loss Vascular injury Radiation Infection SYSTEMIC Age Chronic diseases Diabetes mellitus Chronic anemia Metabolic or endocrine abnormalities (vitamin D deficiency) Malnutrition Medications (steroids, NSAIDs, antiepileptics) Smoking
- 4. MECHANICAL ETIOLOGIES OF NONUNION MALREDUCTION Malposition Malalignment Distraction INAPPROPRIATE STABILIZATION Too little or insufficient fixation Too much or too rigid fixation Inappropriate implant choice Inappropriate implant position Technical error(s)
- 5. Delayed unionoccurs when periosteal callus formation ceases prior to complete union, leaving the stability of the fracture dependent on the late endosteal healing. In such a case the bending stiffness of 7 N-m per degree will not be reached by 20 weeks after the fracture. Non-union occurs when both the endosteal and periosteal callus formation fails. Sclerosis of the medullary canal Fracture either remains open or becomes filled by scar tissue, usually fibrous in nature
- 7. STATUS OF BONES Depends on the type and duration of the fracture and the method of any previous treatment. CLASSIFICATION IS BASED ON 1. LOCATION Epiphyseal, Metaphyseal, Or Diaphyseal 2. PRESENCE OR ABSENCE OF INFECTION Septic Or Aseptic 3. TYPE Hypertrophic, Oligotrophic, Atrophic, Pseudarthrosis
- 8. Septic nonunion Caused by infection CRP test as the most accurate predictor of infection Hypertrophic nonunion (Vascularized) Inadequate stability with adequate blood supply and biology Abundant callous formation without bridging bone Typically heal once mechanical stability is improved 1. Elephant foot: Inadequte stabilization or immobilization. Premature weight bearing 1. Horse hoof Mildly hypertrophic & poor I callus Moderate unstable fixation
- 9. Pseudoarthrosis anabnormal union formed by fibrous tissue between parts of a bone Atrophic nonunion Inadequate immobilization and inadequate blood supply Oligotrophic nonunion Produced by inadequate reduction with fracture fragment
- 10. AVASCULAR Torsion wedge: Intermediatefragment with decreased or absent supply. Healed to one fragment Comminuted : Presence of one or more necrotic fragments. No callus. Defect nonunion: Loss of bone fragment End viable but no union. Atrophic nonunion: consequence of segmental defect. Scar tissue that lacks osteogenic potential.
- 11. Paley’s Nonunion Classification Paley et al. Described a classification of nonunions of the tibia that can be applied to nonunions of other bones. Nonunions with bone loss of less than 1 cm (type A) Those with more bone loss (type B).
- 12. STIFF The formershows no evidence of clinical movement, and callus formation is usually of the hypertrophic type with a large area of bony contact. LAX A lax-non union has little inherent mechanical stability, and is defined as moving more than seven degrees in any plane
- 13. INVESTIGATIONS Radiographs plainradiographs are the cornerstone for evaluation of fracture healing full length weight bearing films should obtained if a limb length discrepancy is present CT Scan if the status of union is in question, a CT scan should be obtained; hardware artifact may limit utility of the CT scan
- 14. Triple Phase BoneScan Technetium - 99 diphosphonate Detects repairable process in bone ( not specific) Gallium - 67 citrate Accumulate at site of inflammation (not specific) Sequential technetium or gallium scintigraphy Only 50-60% accuracy in subclinical ostoemyelitis
- 15. Indium III -Labeled Leukocyte Scan Good with acute osteomyelitis, but less effective in diagnosing chronic or subacute bone infections Sensitivity 83-86%, specificity 84-86% Technique is superior to technetium and gallium to identify infection Nepola JV e.t. al. JBJS 1993 Merkel KD e.t. al. JBJS 1985
- 17. Indian J NuclMed. 2018 Oct-Dec; 32(4): 326–329. doi: 10.4103/ijnm.IJNM_50_17
- 18. MRI Abnormal marrowwith increased signal on T2 and low signal on T1 Can identify and follow sinus tacts and sequestrum Mason study- diagnostic sensitivity of 100%, specificity 63%. Berquist TH et.al. Magn Res Img Modic MT et.al. Rad. Clin Nur Am 1986 Mason MD et.al. Rad. 1989
- 19. TREATMENT NONOPERATIVE Fracturebrace immobilization Bone stimulators Contraindications include synovial pseudoarthroses, nonunions that move and greater than 1 cm between fracture ends
- 20. LOW-INTENSITY ULTRASOUND low-intensity ultrasound(30 mW/cm2) to heal nonunions increases blood flow through dilation of capillaries and enhancement of angiogenesis, increasing the flow of nutrients to the fracture site. 70% to 93% for nonunions and delayed unions. EXTRACORPOREAL SHOCK WAVE THERAPY Efficacy in treatment of nonunions has been reported to be above 75%.
- 21. ELECTRICAL & ELECTROMAGNETIC STIMULATION In infected nonunion management or when surgical intervention is contraindicated Techniques: Invasive - requiring the implantation of electrodes, or Semiinvasive - requiring the percutaneous application of multiple electrodes Uses: Healing nonunions of long and short bones, Open or closed fractures Long-standing nonunions Infected nonunions Nonunions with fracture gaps up to 1 cm
- 22.
- 23. INFECTED NONUNION Oftenassociated with pseudoarthrosis chance of fracture healing is low if infection isn't eradicated staged approach often important modalities Need to remove all infected/devitalized soft tissue use antibiotic beads, VAC dressings to manage the wound with significant bone loss, bone transport may be an option muscle flaps can be critical in wound management with soft tissue loss
- 24. PSEUDOARTHROSIS May befound in association with infection Joint capsule may be encountered with operative exposure Modalities Removal of atrophic, non-viable bone ends Internal fixation with mechanical stability Maintenance of viable soft tissue envelope
- 25. HYPERTROPHIC NONUNIONS Oftenhave biologically viable bone ends Issue with fixation, not the biology Modalities Internal fixation with application of appropriate mechanical stability
- 26. OLIGOTROPHIC NONUNIONS Oftenhave biologically viable bone ends May require biological stimulation Modalities Internal fixation
- 27. ATROPHIC NONUNIONS Oftenhave dysvascular bone ends Mobile Modalities Need to ensure biologically viable bony ends are apposed Fixation needs to be mechanically stable Bone grafting Autologous iliac crest (osteoinductive) is gold standard BMPs Osteoconductive agents (ie. crushed cancellous chips, DBM) Establishment of healthy soft tissue flap/envelope
- 28. BONE GRAFTING Autogenouscancellous bone grafting remains a mainstay of nonunion treatment. The osteoconductive, osteoinductive and osteogenic properties of autogenous cancellous bone make it ideal for nonstructural grafting Sites for Autogenous Grafting Ilium (anterior or posterior iliac crest) Proximal tibia Distal femur Recent technique involves obtaining autogenous graft from the intramedullary canals of long bones (femur and tibia). The Reamer-irrigator-aspirator (RIA, Synthes, Paoli, PA) has been found to obtain large quantities of graft that qualitatively compares favorably to iliac crest autograft
- 29. Onlay BoneGraft The graft is placed subperiosteally across the fragments without mobilizing the fragments. Advantage is its easy and the blood supply of the fragments and the normal impacting forces of the fracture were not disturbed. Dual Onlay Graft 1941 boyd devised an operation Used to fix a nonunited fracture near a joint firmly with a short, osteoporotic fragment. Nonunions near a joint now often are treated by plating and autogenous cancellous bone grafting or by the application of a circular external fixator
- 31. Cancellous InsertGrafts Nicoll described a technique of bridging gaps in bones with solid blocks of cancellous bone and fixing the fragments with metal plates. Useful in patients with defects less than 2.5 cm long Massive Sliding Graft A sliding graft about one half the circumference of the bone and 10 to 15 cm long Whole fibular transplants Useful for bridging defects in the radius or ulna
- 32. Vascularized FreeFibular Graft Duffy et al. reported success using vascularized free fibular grafting for nonunions of shaft fractures of bones that had been irradiated to treat a malignancy Intramedullary Fibular Allografts Muramatsu et al. used vascular bone grafts successfully to treat 23 nonunions of the humerus. Wright et al., Miller et al., and Crosby et al. reported a high percentage of good results in humeral nonunions
- 33. Stabilization of Fragments Internal Fixation The choice of internal fixation depends on the type of nonunion, the condition of the soft tissues and bone, the size and position of the bone fragments, and the size of the bony defect. Plate and screw fixation without bone grafting usually is adequate for hypertrophic nonunions Intramedullary nailing, especially interlocked nailing, is useful nonunions of long bones, such as the tibia, femur, and humerus.
- 34. A relativecontraindication for intramedullary nailing is current or prior infection. The Ilizarov external fixator is a labor-intensive, but very effective, tool in the treatment of nonunions. Useful in nonunions associated with defects, shortening, and deformities. External fixation can be used for temporary or definitive stabilization. One advantage of external fixation is that it is relatively noninvasive and does not disturb soft tissues surrounding the nonunion. Other advantages are its ability to correct deformity and provide stable fixation.
- 36.
- 37. AUTOLOGOUS CORTICAL GRAFTS Tricortical iliac crest grafts Vascularized and nonvascularized fibular grafts (for large defects) Frozen or freeze-dried cortical allografts Osteogenic properties are limited
- 38.
- 40.
- 41. ALLOGRAFT & FROZENOR FREEZE- DRIED GRAFTS
- 42. ANTIBIOTIC BONE CEMENT Bone cement has proven particularly useful because specific active substances Antibiotics - added to the powder component Various antibiotics have been successfully mixed and used gentamycin, tobramycin, erythromycin, cefuroxime, vancomycin, colistin More than 2 g each 40 g of cement, usually from 6 to 8 g each 40 g, for a prolonged and effective release against pathogens
- 44. Ceramics Hydroxyapatite Calciumphosphate Calcium sulfate, or some combination) They have osteoconductive properties Avoid problems with donor site morbidity Best used as delivery devices (antibiotics) or bone graft extenders Bone Morphogenetic Protein Osteoinductive chemical mediators of bone formation. BMP-2 and BMP-7 (also known as OP1-) Bone marrow injection and implantation increase the concentration of osteogenic cells through tissue engineering
- 45. INFECTION 1. Conventional/ Classicmethod 2. Active method Status of bone involvement medullary, superficial, localized, and diffuse The gold standard for diagnosis of infection has been multiple direct cultures of the fracture site Not the skin or sinus tract
- 46. CONVENTIONAL TREATMENT Methodare to convert an infected/draining nonunion into one that has not drained for several months and to promote healing of the nonunion by bone grafting Requires prolonged period of time and many potential operations. External fixation may initially be most appropriate Antibiotics are used parenterally and are based on intraoperative cultures Bone grafting is deferred until the soft tissues have completely healed and become stabilized When infection has subsided, the skin over the bone is good, and nonunion persists, bone grafting is considered Reconstructive operations usually should be delayed until at least 6 months after all signs of infection have disappeared
- 47. ACTIVE TREATMENT Toobtain bony union early and shorten the period of convalescence and preserve motion in the adjacent joints First step is restoration of bony continuity. Absolute priority over treatment of the infection The nonunion is exposed through the old scar and sinuses Ends of the fragments are decorticated subperiosteally, forming many small osteoperiosteal fragments; any grafts that become detached are discarded. All devitalized and infected bone and soft tissues are removed. Fragments are aligned and stabilized, usually by an external fixation
- 48. Compression isapplied across the nonunion if possible. Autogenous cancellous bone grafts can be inserted. Internal fixation with a plate is used only when drainage has ceased
- 49. Antibiotic-impregnated polymethyl methacrylate(PMMA) beads can be used to treat infected nonunions Heat-stable antibiotics, such as tobramycin and gentamicin, can be mixed with PMMA and used locally to achieve 200 times I.V antibiotic Placement of a PMMA spacer is another option that has the ability to provide some stability in an osseous defect situation. The body’s reaction to PMMA beads or a spacer leaves a bioactive Membrane, MASQUELET membrane
- 53. Bifocal treatment with Ilizarovfixator after debridement of necrotic bone and corticotomy
- 55.
- 56. CORTICOTOMY To lengthena bone a special type of percutaneous osteotomy, or corticotomy, is required 5-mm osteotome is used to cut the medial and lateral cortices, extending subperiosteally into the posteromedial and posterolateral corners
- 64. AMPUTATION UNDER THE FOLLOWINGCIRCUMSTANCES Failed reconstruction When a proposed plan of reconstruction would likely result in less satisfactory function than amputation and a properly fitted prosthesis When the danger of major operations outweighs the anticipated benefit When the damaged part, such as a finger, cannot be well enough restored to prevent its interfering with the function of the extremity as a whole When reconstruction is impossible
- 65. THANK YOU… DR. SHAHZAIBRIAZ BALOCH SENIOR RESIDENT ORTHOPEDICS DEPARTMENT DR. ZIAUDDIN HOSPITAL KARACHI NONUNION