TREATMENT ASEPTIC NON UNION

Dr. T . K . Jeejesh kumar

To discuss various treatment options

Merits and demerits of the each options

To arrive a conclusion in the aseptic nonunion treatment

Aim

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

According to vascularity of fracture ends Studied with radiology and strontium 85

uptake study Hypervascular

2 types Avascular

JUDET MULLER WEBER & CECH

Rich blood supply at fracture ends - 3 types

Elephant foot

Horse hoof

Oligo trophic

1.Hyper vascular

Elephant foot

Hypertrophic ends

Rich callus

Rich vascularity

Causes

Increase mobility

Premature weight bearing

Horse hoof

Mildly hypertrophic ends

Poor callus

Little sclerosis

Causes

Moderately unstable fixation with plate

Oligo trophic

Non hypertrophic ends

Vascular

Absent callus

Causes

Major displacement and distraction

Internal fixation without apposition

Deficient vascularity

Incapable of biologic reaction

4 types Torsion wedge

Communated non union

Defect non union

Atrophic non union

2.Avascular

Torsion wedge

Intermediate fragment with decreased blood supply

Communated non union

1 or more intermediate fragment necrotic

Defect non union

Ends are viable with defect in between

Atrophic non union

Fibrous tissue fills defects of bone loss

Ends are osteoporotic and atrophic

Tibial non union based on clinical and

radiological features

2 types

Type A

Type B

Paley et al

Type A – Bone loss < 1cmA1- Mobile deformity

A2 – 1 Without deformity

A2 – Fixed non union A2 – 2 with

deformity

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

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

Nonoperative Operative

Treatment

Electrical stimulation Ultrasound Extracorporeal shock wave therapy

Nonoperative

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

Best Indication -Minimal deformity-Atrophic nonunion with open bone grafting

- No LLD

1.Acute correction

Treatment Options

Best Indication -Large deformity-Stiff nonunion with deformity-Associated LLD-Bone defect

2.Gradual correction

Treatment Options

Best Indication -Metaphyseal/periarticular location

- Excellent soft-tissue envelope - No infection

3.Plate and screw fixation

Treatment Options

Best Indication - Intramedullary nail in place- Need for exchange nailing- Diaphyseal location- No infection

4.Intramedullary nailing

Treatment Options

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

Hypertrophic nonunion Atrophic nonunion Nonunion with deformity Diaphyseal nonunion Metaphyseal nonunion Articular nonunion

Clinical management

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

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

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

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

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

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

Bone graftingGraft Ost

egenic

Ost inductive Ost conduction

Autogenic

Cancellous

Cortical

Bone marrow

+

+

+

+

+

+

+

+

+

Allograft

DBM

-

-

+/-

+

+

+

Collagen - + +

Ceramics - - +

BMP - ++ -

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

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

Cancellous insert graft - Nicoll

Bridging gap of fracture < 2.5cm

Filled with solid cancellous bone

Fixed with plates

Massive slide graft – Gill

Sliding the graft from ½ circumference of bone

Disadvantage later grafting difficult

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

Whole fibular transplant

Bone loss in radius, ulna and SOH

Small size

Closure easy

Free vascularised fibular graft

AVN head of femur

Non onion after radiation

Intramedullary

Fibular allograft

Humoral non

union

Along with DCP

Ostioblaste and progenator cells

Rich in cytokines

Degradable matrix of fibrin

Easily available less morbid

Autogenous bone marrow injection

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

Collagen

Type I collagen of

bovine skin

Graft substitute

Ceramics

Hydroxy apetite

Tricalcium phosphate

Ca sulphate

In combination

Act as scaffold for bone

generation

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

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

No single substrate provides all properties

Composit graft combination of substitutes

LANE et al – rhBMP – 2+ Synthetic matrix +

autogenous BM

Composit graft

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

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

8.Low Intensity Ultra sound

Mechanism Gene stimulation

Angiogenesis

Temperature

Cellular activity

Enzyme modulation

SAFHS Sonic Accelerated # healing system by Exogen CO

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

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

– medullary cavity, early bone to bone contact-“Biological”

- reshaping for stability to axial compression- “Mechanical”

More bone area in contact

Freshening of Bone ends

Corticotomy - site remote from nonunion Restores length Improves vascularity of limb segment Practical only if LLD

Corticotomy & Lengthening

At the nonunion site Both augment stability Distraction - corrects associated deformity Compression - if no deformity

Compression / Distraction

Increased cross sectional area at union site improve healing Is not against Ilizarov “principles”

Bone Grafting

summary

Freshening of Bone ends ? Acute docking ? Corticotomy & Lengthening Compression at NU Site Distraction at NU Site Bone Grafting ?

1.NU - Aseptic, Atrophic

Freshening of Bone ends Acute docking Corticotomy & Lengthening Compression at NU Site Distraction at NU Site Bone Grafting

2.NU - Aseptic, Hypertrophic Stiff, Deformity +

• 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

coclusion

… 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