TREATMENT ASEPTIC NON UNION
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Transcript of TREATMENT ASEPTIC NON UNION
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