project work FOR STUDENTS IN THEIR DAILY.pptx

PRINCIPLES OF TREATMENT
Angelo Villa
Introduction
Many factors may interfere with normal fracture repair,
resulting in nonunion, the persistence of mobility between
fracture fragments, mechanical and biological factors certainly
contribute to retard fracture healing. Stable osteosynthesis
with early return of normal function motion and load) is felt to
be the biological Stimulus for repair.

Nonunion may be classified according to the local trophism of
the fractured bone ends and the presence or absence of
infection. This classification of nonunion determines the
treatment modality. In simplest terms, nonunions may be
hypertrophic vascular and stiff or hypotrophic avascular and
lax. These two groups can be further subdivided based on the
presence or absence of local sepsis.

The hypertrophic failure of fracture repair is more related to
mechanical factors, while the hypotrophic failure includes poor
local biology.
Traditional methods utilize stable loading internal fixation for
hypertrophic nonunions and local bone graft with fixation for
hypotrophic nonunions.

The presence of an infection further exacerbates the failure of
local-biology to produce osteogenesis. Septic nonunions are
difficult to treat with traditional methods of sequestrectomy and
late bone grafting. Even newer techniques, including antibiotic
beads and osteoinductive substances, have been unreliable.
Axial load is, in fact, the force which the Ilizarov frame, if
correctly applied, can reestablish in bone. After transosseous
osteosynthesis the reintegration of function, in the presence of
renewed vascularization, promotes osteogenesis and local tissue
trophism.
The corticotomy is the biological stimulus for
neovascularization and the correctly applied external fixator
introduces a mechanical environment which facilitates function

The marriage of revascularization and local tissue trophism under
mechanical load has been shown by Ilizarov to reliably heal
infected nonunions and hypotrophic nonunions, the most difficult
challenges.
Additionally deformities such as angulation and shortening can be
corrected with the Ilizarov methods described in this chapter.
A fracture is usually transformed into a nonunion by the absence
of stability, function or vascularization. Thus, in the treatment of
nonunion, these parameters must be regained.
Ilizarov distinguishes between two essential types of nonunion:
Stiff without evident movement and mobile with considerable
movement, between segments. This distinction, which is
essentially clinical, is very important for the type of treatment to

A stiff nonunion radio graphically almost always appears as
hypertrophic. Local vascularity is well-evidenced by voluminous
new bone formation. The soft tissues interposed in the area of
nonunion fibro-cartilage), when submitted to axial compression-
distraction, are directed to transform into solid bone. For the
correct function of a limb, it is necessary to reestablish the load
axis. The nonunion should be exposed to pure compression-
distraction loads shear stress, which is thought to be a detriment
to callus formation, should be completely eliminated.
A mobile nonunion radio logically identified as an atrophic
nonunion is a fracture where there has been devascularization
of the segments. In addition to the reestablishment of fracture
stability, these nonunions often require some form of biologic
stimulation.

According to the Ilizarov method, this stimulation is
represented by a bone corticotomy in distraction and
progressive compression on the nonunion center
Corticotomy, followed by distraction, increases
vascularization in the entire segment, while compression at
the site of nonunion increases the stability of the bone
segments.

CLASSIFICATION AND TREATMENT OF NONUNION
Maurizio Catagni
A. ASEPTIC NONUNION WITHOUT BONE DEFECT
Type A1: Mobile ( Atrophic/Hypotrophic)
The Recommended treatment is bifocal osteosynthesis (Fig. 14.1).
A corticotomy with gradual distraction and simultaneous gradual
compression of the non-union in its proper axis is performed with
the
appropriate frame. Biologically, this technique makes sense and
clinically,
the results have been good.

Type A2: Stiff without Deformity (Hypertrophic)
The biological treatment for hypertrophic nonunion is
monofocal osteosynthesis by compression (Fig. 14.2)
The biology of a stiff nonunion (fibrous union) strongly
resembles the fibrous interzone demonstrated in Chapter 4, “
Biology of distraction osteogenesis.” Osteogenesis should,
therefore be re-stimulated, by primary distraction.

Despite this, Ilizarov recommends ten to twenty days of
primary compression, then distraction and finally compression
to bridge the nonunion. The later sequence makes more sense
for a synovial nonunion which will not respond to primary
distraction but must first be converted to inflammatory tissue
prior to distraction. Our clinical trials following Ilizarov
method had fair results. Therefore, corticotomy is
recommended for bifocal treatment.

Type A3: Stiff With Deformity (Hypertrophic)
The recommended treatment is monofocal osteosynthesis in
distraction and compression with simultaneous correction of
the deformity.
In refractory cases, bifocal treatment by addition of
corticotomy can be used

VARIATIONS IN
TREATMENT HYPERTROPHIC WITH
DEFORMITY
Type A3.1: with hinges
A four-level assembly is preferable, in order to have more
stability and to avoid slipping of the wires. Four olive wires
must be used, two close to the non union on the convex side,
and two far from the nonunion on the concave side (Fig. 14.4).
In the tibia, where this type of assembly is most frequently used,
resection of the fibula equal to at least one centimeter is
required so that it does not oppose correction.

After progressive correction has been carried out (either in
distraction or neutral or in compression pending on the
position of the hinges), it is possible to further increase
stability by progressive compression equal to 1/4 millimeter
twice weekly until bone f callus occurs at the site of nonunion
(see chapter 7).

Type A3.2: with transverse wires
After proximal and distal fixation of the segment, two ;
wires are inserted exactly perpendicular to the plane Of
the deformity. Using two half-rings and a long connection
plate, we push progressively from the convex )side of the
deformity. To help direct this movement, two hinges push
on the assembly (Fig. 14.5). This assembly is preferred for
the correction of the femur

Type A3.3: with olive wire alone
This technique is used for thin bones where the de
formity does
not exceed five to eight degrees, for inst
ance in the forearm
where forceful loading of the seg
ment is not required.
Dynamometric tensioners are used on the intermediate wires
until the axis is corrected during surgery. The intermediate
wires are fixed and compression is carried out during the days
that follow at 1/4 millimeter twice weekly (Fig. 14.6).

B.ASEPTIC NONUNION WITH BONE DEFECT:
Bone defects are defined as losses of length or inter
calary
substance exceeding four centimeters. In most cases, nonunion
with loss of substance results in a mobile nonunion (atrophic)
because of significant soft tissue injury resulting I poor
vascularity and excessive instability. Secondary operations
performed in order to eliminate the nonunion (e.g., resections,
grafts) often increase local scarring. In these cases, there are
three main problems: nonunion, discrepancy in length, and
atrophy of the segments. Thus, in all types of treatment, a bifocal
method must used to gain back the length of the bone and to
increase the vascularization of the segments (Fig. 14.7).

Variations in treatment - Length of Limb Preserved with
Bone Gap
Type Bl.l
For loss of substance up to five centimeters, we proceed with
proximal and distal fixation and bone transportation. A single
corticotomy creates a mobile bone fragment with good
vascularity that can be transported linearly along the gap by
transverse wire fixation.
Distraction osteogenesis fills the trailing gap while the
nonunion is reunited by compression at eventual bone contact.
Transportation is carried out at one millime
ter per day in four
increments and compression of the nonunion continued at 1/4
millimeter every three days to maintain stability until callus is
visible radiographically. Fibulotomy is not required with this

Type B1.2
For loss of substance exceeding five centimeters, in order to
accelerate healing time, two levels of corticotomy may be
performed with centripetal bifocal bone transportation. The
transport segments are generally each held by two transverse
wires (1.5 millimeter) tensioned to the ring (Fig. 14.8b).

Type B1.3
If the loss of substance is considerable (exceeding eight to ten
centimeters) or local scarring may inter
fere with bone
transport using transverse wires, the transport may be
performed by means of crossed lon
gitudinal olive or bent
(corkscrew) wires to increase surface area (Fig. 14.8c). When
the nonunion frag
ments come into contact, the crossed
transportation wires must be substituted for by transverse
wires as in treatment B 1.1 in order to increase stability and
inter-
fragmentary compression forces. Free rings should be left
in the initial construct for this eventuality.

Variations in treatment - Segments in Contact with
Shortening of the Limb
TypeB2.1
In case of shortening up to five centimeters, a bifocal
osteosynthesis is performed, with compression of the nonunion
and lengthening by means of corticotomy. For the tibia, it is
necessary to perform an osteotomy and fixation of the fibula, in
order to allow for adequ
ate lengthening of the segment. In
addition to the reestablishment of fracture stability, these
nonunions often require some form of biologic stimulation.

This is most often performed distally because of the re
latively
easy surgical access. The fibula is fixed with wires only at the
proximal- and distal-most rings, thus allowing distraction at
the distal corticotomy (Fig. 14.9a).

Type B2.2
If the shortening exceed five centimeters, the healing time
may be accelerated by performing a double cor
ticotomy,
carrying out trifocal osteosynthesis by dou
ble distraction
osteogenesis and compression at the nonunion. In this case,
also, it is necessary to carry out partial fibulectomy. Note that
only the tibia is fixed by wires at the central two rings (Fig.
14.9b).

Variation in treatment • Combined-Shortening With Gap
Type B3.
This type of nonunion requires treatment similar to that in Type
Bl. The only difference is that after bone transportation
eliminates the gap, distraction must be continued at the site of
the corticotomy, in order to eliminate the shortening of the
segment. Nonunion compression is continued as in Types Bl and
B2. For the tibia, lengthening should be initiated before
compression, so as to avoid premature consolidation of the
fibula. If this occurs further lengthening would be impossible,
and a second fibular osteotomy would be necessary (Fig. 14.9c).

Special Variations (Limited Indications)
Type A2.4
Monofocal osteosynthesis with compression and suc
cessive
distraction, is carried out when there is a mo
derate amount of
shortening with good preservation of local vascularity
evidenced by voluminous callus. Compression (as in Treatment
A2) is applied until bone callus appears. Distraction is carried
out at the nonunion which, under, the effect of tension, will
transform into solid bone tissue, For the tibia, it is necessary to
carry out resection of the fibula at theTime of distraction so
that it opposes neither compres
sion nor distraction (Fig. 14.10).

Based upon the experience of the Lecco Hospital, this
treatment must be used exclusively in cases where there is
good vascularization of the segments and in patients who
have not previously submitted to open surgery.
Even when these criteria are met, extended periods of
compression often do not produce sufficient cal
lus to allow for
distraction osteogenesis. In these ca
ses a second surgical
procedure with corticotomy must be resorted to bifocal
treatment.

Type B1.3
Lateral bone transportation may be used in two-bone
segments such as the forearm or lower leg for massive loss of
bone substance. When the bone ends are short and atrophic,
bone regeneration by longitudinal trans
port is unlikely. Thus,
for the tibia, the fibula or part of the fibula is transported
laterally for the recon
struction of the loss; in the forearm,
depending upon which bone is deficient, longitudinal
segments of the intact bone are transported transversely to
eliminate the gap (Fig. 14.11).

The technical execution of this method presents con
siderable
difficulties, so that it is best to use it only in cases where it is
absolutely impossible to apply other variations. This method
is recommended for use in the leg to reinforce a tibia which
is thin due to longi
tudinal bone loss.

C. TREATMENT OF INFECTED NONUNION
Selection of a treatment technique for an infected non-
union depends on various factors such as the type of
nonunion (usually atrophic), the extent of the infection and
trophic skin changes.
Traditional concepts dictate that devitalized bone is I more
prone to infection; the wider the bone necrosis, I the more
widespread will be the infection. According to Ilizarov, to
eliminate the infection, vascularization of the osteomyelitic
center must be in
creased by the biological stimulation of a
corticoto
my. "Osteomyelitis burns in the fire of
regeneration."

In our clinical application of this concept, there was healing of
the nonunion but, unfortunately, infection was not always
eliminated. Thus, to be sure that in
fection is eliminated, in
cases of massive necrosis, we now routinely perform open
debridement to totally remove the necrotic and infected
segments and then proceed with bifocal osteosynthesis, in
order to elimi
nate the bone gap (Fig. 14.12).

The treatment for hypertrophic nonunion with a mini
mum
amount of infection and no sequestered bone is monofocal
compression (Treatment A2). The stabili
zation of nonunion
favors the formation of repair cal
lus and thus there is a
revascularization of the seg
ments with an increase in the local
humoral and cellu
lar defenses, with the spontaneous elimination
of in
fection.

In infected hypertrophic nonunion with deformity, treatment by
monofocal compression is used with eli
mination of the
deformity at the same time (Treat-ment A3). For the reason
stated above, the regenera
ted bone callus also eliminates the
infection. In atrophic nonunion with diffuse infection or the
presence of sequestered bone, open resection of the infected
segments must be carried out so as to trans
form the type of
nonunion into a loss of substance (Type Bl or B3). Therefore,
bifocal methods are most suitable for treatment.

In some cases, where resection does not exceed one to two
centimeters, it is possible to carry out acute shortening,
placing the resection segments in contact and in
compression and thus acting as in Type B2.
When an infected nonunion also has poor skin quality with
numerous fistulae, stabilization with the appara
tus
following necrotic bone resection is enough. The skin is not
closed, but rather is cleansed daily with peroxide and
betadine followed by wound packing, leaving the skin
defect to heal on its own.

When the skin conditions have improved and the in
fection has
regressed, we proceed with corticotomy and bifocal treatment. The
skin defect may close with a depression so that it becomes
interposed like a pocket between the two segments of nonunion,
thus ob
structing contact. If this is the case, skin resection must be
performed and, if necessary, further bone re
section carried out so
as to make the segments of non
union more congruent for wider
surface contact (Fig. 14.13).

To increase the stability of the assembly, during bifo
cal
treatment following bone resection, and to decrease the risk of
displacement of the bone fragments dur
ing transportation, we
sometimes place a central guide wire. During open surgery, we
place a percutaneous olive wire (1.5 millimeter diameter) from
later
al to medial into the medullary cavity of the frag
ments of
nonunion, crossing the defect. This wire is maintained until
there is contact between the bone fragments and callus forms at
the nonunion center (Fig. 14.14).

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