TREATMENT ASEPTIC NON UNION Dr. T . K . Jeejesh kumar

Aim To discuss various treatment options Merits and demerits of the each options To arrive a conclusion in the aseptic nonunion treatment

Non union Hypertrophic – large volume of callus Classification Hypertrophic – large volume of callus Atrophic – little or no callus Fibrous union – fibrous or fibro cartilage fill the gap Pseudo arthrosis -Cartilage over the fracture ends with cavity containing clear fluid

JUDET MULLER WEBER & CECH According to vascularity of fracture ends Studied with radiology and strontium 85 uptake study Hypervascular 2 types Avascular

1.Hyper vascular Rich blood supply at fracture ends - 3 types Elephant foot Horse hoof Oligo trophic

Elephant foot Causes Hypertrophic ends Rich callus Rich vascularity Increase mobility Premature weight bearing

Horse hoof Causes Mildly hypertrophic ends Poor callus Little sclerosis Causes Moderately unstable fixation with plate

Oligo trophic Causes Non hypertrophic ends Vascular Absent callus Major displacement and distraction Internal fixation without apposition

2.Avascular Deficient vascularity Incapable of biologic reaction 4 types Torsion wedge Communated non union Defect non union Atrophic non union

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

Paley et al Tibial non union based on clinical and radiological features 2 types Type A Type B

Type A – Bone loss < 1cm A1- 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

Treatment General Soft tissue Neurovascular status of limb Optimize metabolic and nutritional status Discontinue tobacco and alcohol Consider Soft tissue Neurovascular status of limb Status of bone Complicating factors Infection, deformity, bone loss

Treatment Nonoperative Operative

Nonoperative Electrical stimulation Ultrasound Extracorporeal shock wave therapy

Operative Treatment Autogenous bone graft Bone marrow aspirate Allograft bone Demineralized bone matrix BMP’s Platelet concentrates Debridement and hardware removal Plate osteosynthesis Intramedullary nailing External fixation

Treatment Options 1.Acute correction Best Indication -Minimal deformity -Atrophic nonunion with open bone grafting - No LLD

Treatment Options 2.Gradual correction Best Indication -Large deformity -Stiff nonunion with deformity -Associated LLD -Bone defect

3.Plate and screw fixation Treatment Options 3.Plate and screw fixation Best Indication -Metaphyseal/periarticular location - Excellent soft-tissue envelope - No infection

4.Intramedullary nailing Treatment Options 4.Intramedullary nailing Best Indication - Intramedullary nail in place - Need for exchange nailing - Diaphyseal location - No infection

5.Circular external fixation Best Indication -Large deformity -Stiff nonunion with deformity -Associated LLD -Poor soft-tissue envelope -Concern about infection -Bone defect -Metaphyseal/periarticular location -Diaphyseal location

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

pitfalls Failure to provide adequate fixation Classification Group 1.Hypertrophic nonunion Goal Provide stability Surgical Tactic Plate, nail, external fixation Pearls Does not require grafting, do not disturb biology pitfalls Failure to provide adequate fixation

Provide biological simulation and stability Surgical Tactic 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

3.Nonunion with deformity 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

Maintain axial alignment and length Surgical Tactic 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

Goal Classification group Maintain axial alignment and length 5.Metaphyseal nonunion Goal Maintain axial alignment and length Surgical Tactic Plate, external fixation pearls Carefully plan periarticular fixation pitfalls Maintain angular alignment

Preservation of the reconstructed joint Surgical Tactic Classification group 6. Articular nonunion Goal Preservation of the reconstructed joint Surgical Tactic Rigid internal fixation, arthroplasty Pearls Comminuted nonunions require arthroplasty Pitfalls Prognosis of the joint is poor

Bone grafting Graft Ostegenic Ost inductive Ost conduction Autogenic Cancellous Cortical Bone marrow + Allograft DBM - +/- Collagen Ceramics BMP ++

Sliding inlay Inlay graft by Albee Graft from one segment slide across the non union Inlay graft by Albee Bed in cut across non union Graft from normal side put in the bed

Onlay graft Dual onlay – Boyd Congenital pseudoarthrosis 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 Intramedullary Fibular allograft AVN head of femur Non onion after radiation Intramedullary Fibular allograft Humoral non union Along with DCP

Autogenous bone marrow injection Ostioblaste and progenator cells Rich in cytokines Degradable matrix of fibrin Easily available less morbid

Bone graft substitute 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

Act as scaffold for bone generation Collagen Type I collagen of bovine skin Graft substitute Ceramics Hydroxy apetite Tricalcium phosphate Ca sulphate In combination Act as scaffold for bone generation

Bone growth factor TGF Beta Ostio induction BMP’S BMP subclass 1 – 10 Inhibin etc. FGF Acidic Base PDGF IGF I & II Ostio induction Increased production of matrix Stem cell migration and maturation

BMP BMP BMP - initiates endochondral ossification 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

Composit graft No single substrate provides all properties Composit graft combination of substitutes LANE et al – rhBMP – 2+ Synthetic matrix + autogenous BM

6.Gene Therapy 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

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

Decision making 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 ?

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

Freshening of Bone ends – medullary cavity, early bone to bone contact-“Biological” - reshaping for stability to axial compression- “Mechanical” More bone area in contact

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

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

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

summary

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  Distraction at NU Site  Bone Grafting 

3.NU - Aseptic, Hypertrophic Stiff, No Deformity Freshening of Bone ends  Acute docking  Corticotomy & Lengthening  Compression at NU Site  Subsequent Distraction at NU Site (if LLD) ? Bone Grafting 

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

Thank you