1. Aseptic Non-Union
Aseptic Non Union

2. AO Principles Course Dr. Enrique Queipo de Llano
Hospital Universitario de Málaga
Aseptic Non Union

3. Definition No bone healing in the normal time Usually 6 a 8 months
Aseptic Non Union

4. Etiology Do not blame the osteoblasts (Watson Jones).
Fractures have a spontaneous tendency to heal. (Merle D’Aubigne).
Delayed or non-union is often multifactorial in nature.
Aseptic Non Union

5. Etiology
Disturbed vascularity and instability are the most important factors leading to a non-union.
Aseptic Non Union

6. Etiology (Vascularisation)
Biological
Carpal scaphoid
Neck of the femur
Talus
Devitalized fragments
Aseptic Non Union

7. Etiology (Instability)
Iatrogenic
Insufficient orthopaedic treatment
Incorrect osteosynthesis (unstable)
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8. Good reduction Contact between fragments Strict immobilization
Conditions for a normal bone healing
Orthopaedic treatment
Good reduction
Contact between fragments
Strict immobilization
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9. Conditions for a normal bone healing
Surgical treatment
Anatomic reduction of articular fractures
Good alignment of diaphyseal fractures
Stable osteosynthesis
Absolute asepsis
Aseptic Non Union

10. Non compliant patient
The care plan has to be compatible with the patient’s personality and life style.
Have to be controlled:
Inappropriate weight bearing
Smoking habit
Improper diet
Other shortcomings in behaviour
Aseptic Non Union

11. Symptoms Abnormal mobility Abnormal mobility cannot be seen:
When there is an Internal Fixation
Intramedullary nail
Dense fibrous callus
Pain and Limp
A healed fracture does not hurt
Aseptic Non Union

12. Radiology Sometimes difficult to see on the X-Rays
Reactive callus = Mechanical instability
Slight instability can be positive
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13. Delayed union
In delayed union there are clinical and radiological signs of prolonged fracture healing
It is important to establish the diagnosis
Fracture instability
Implant mobilization
To act to achieve a rapid bone healing
Aseptic Non Union

14. Judet-Weber classification
Vital (Hypervascular)
With biological reaction capacity
Avital (Avascular)
Without biological reaction capacity
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15. Judet-Weber classification
Vital non-union
They do not heal because of instability
Aseptic Non Union

16. Judet-Weber classification
Avital non-union
They do not heal because of biological deficit
Aseptic Non Union

17. Weber classification A. Vital
I. Hypertrophic non-union (elephant foot)
II. Hypertrophic non-union (horse hoof)
III. Atrophic non-union (without callus)
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18. A. Vital non-union
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19. A. Vital non-union
Elephant foot
Horse hoof
Atrophic
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20. Hypertrophic non-union
Hypertrophic non-union is frequently localized in the lower extremities.
Its development largely depends on an impaired mechanical stability.
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21. Experimental non-unionAO 3 6 16
Experimental non-union
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22. Pathology
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23. Pathology
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24. Pathology
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25. Pathology
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26. Bone healing by mechanical stabilization
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27. Ca. marked fracture site
Non-union focus
Calcifying focus
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28. Ca. marked fracture site
Totally calcified focus
Fracture healing trabeculae
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29. Stabilized fracture evolution
Mechanical stability allows the fibrous cartilage to calcify and finally ossify after vascular penetration.
Resection of an hypertrophic non-union must be regarded as an error.
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30. Stabilized fracture evolution
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31. Bone healing evolution
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32. Bone healing evolution
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33. Bone healing evolution
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34. Instability (non-union)PO
Aseptic Non Union

35. Stabilization (bone healing)
4 m
8 m
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36. “Elephant foot” non-union healed after plating stabilization
Aseptic Non Union

37. Weber classification Avital non-union
Dystrophic with intermediate wedge fragment
Necrotic with conminution
Bone loss
Atrophic
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38. B. Avital non-union
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39. Avascular non-union
Avascular non-union originates because of the devascularisation of the bone fragments adjacent to the fracture site due to injury and/or surgery.
Aseptic Non Union

40. B. Avital non-union
Devitalized fragments united by callus to the main fragments without evidence of bone healing
Aseptic Non Union

41. Treatment of aseptic non-union

42. Goal of the treatment
To achieve a rapid bone healing with complete recovery of articular and muscular function.
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43. In the less possible time
Active treatment
To restore bone continuity
If possible anatomically
To restore articular and muscular function
In the less possible time
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44. Treatment according to the type
1. Vital
Mechanical stabilization (osteosynthesis)
Stable osteosynthesis
2. Avital
Biological stimulation (autologous bone grafting)
Aseptic Non Union

45. Bone grafting 1. Pediculated vital bone grafts (decortication)
2. Autologous cancellous bone graft
3. Bone transplants
Fibula “pro tibia”
Bone transport
Vascularised bone grafts
Bone loss
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46. Techniques for bone reconstruction
Diaphyseal non-union
Techniques for bone reconstruction
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47. Judet osteoperiosteal decortication
It is the simplest and most effective way to expose a non union without producing a substantial devascularization.
This technique is used to enhance the healing response, creating a well vascularised that at the same time stimulates the bone healing process.
Aseptic Non Union

48. Osteoperiosteal decortication
Aseptic Non Union

49. Osteoperiosteal decortication
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50. Autologous cancellous bone graft
Cancellous autologous bone graft is the “gold standard” for both biological and mechanical purposes.
It is osteogenic (a source of vital bone cells)
It is osteoinductive (recruitment of local mesenchymal cells)
It is osteoconductive (scaffold for ingrowth of new bone)
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51. Autologous cancellous bone graft
Anterior intrapelvic approach
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52. Autologous cancellous bone graft
Posterior extrapelvic approach
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53. Bone grafting indications
Poor vascularization
Minimal callus formation
Atrophic non-union
Cancellous autologous bone graft is:
Osteogenic, osteoinductive and osteoconductive
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54. Allografts and bone graft substitutes
Allografts and bone substitutes such as demineralized bone matrix, hidroxyapatite, tricalcium-phosphate, as welll as osteoinductive substances such as growth factors, bone morphogenetic proteins (BMPs), etc., are currently being intensively explored both experimentally and clinically, but have not yet proved to be significantly superior.
Aseptic Non Union

55. Allografts and bone graft substitutes
All these substances require a vital environment in order to be effective.
In the absence of living cellular elements and blood supply there is no possibility of any healing.
Nothing is superior to autologous bone graft
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56. Callus distraction Free vascularized bone grafts
Osteogenesis by callus distraction (Ilizarov) and free vascularized bone graft should be taken into consideration when dealing with large (>4-6 cm) segmental bone defects.
Aseptic Non Union

57. ¡Mechanical stabilization is essential!
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58. Stabilization
Stabilization of a non-union provides the essential mechanical component to allow calcification of the fibrous cartilage within the non-union.
This prepares the field for development of a first bony bridge.
Aseptic Non Union

59. Types of stabilization
Plating
Intramedullary nailing
External Fixation
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60. Plating
The plate is probably the most adequate and versatile tool for the stabilization of an aseptic non-union.
It allows in a single procedure :
Interfragmentary compression
Correction of any malposition
Reconstructive measures (grafting etc.)
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61. Plating techniques Tension band plating (on the convexity)
Axial compression plating
Buttress plate
Lag screws and neutralization plate
Bridge plate in segmental bone loss
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62. Optional anterior and posterior decortication
Plating
Optional anterior and posterior decortication
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63. Wave plate Increases the functional diameter of the non-union site
Improves the local stability
Allows placement of autografts all around the non-union site
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64. Intramedullary nailing
It is mainly indicated in diaphyseal non-unions of the lower extremity
Nailing has few advantages in the upper extremity and thin unreamed nails are not suitable, as they provide insufficient stability.
Aseptic Non Union

65. Indications of intramedullary nailing
Non displaced mid third femur and tibia non-union
Loose or broken nail
Over-ream not exposing the non-union site
Introduction of a thicker and longer nail
Dynamic interlocking (rotational stability)
Increase of periosteal bone flow promotes union
Aseptic Non Union

66. Locked thicker and longer nail
Intramedullary nailing
Loose nail
Over-reaming
Locked thicker and longer nail
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67. External Fixation
In most aseptic non-unions external fixation brings little advantage.
It may be applied in the presence of poor soft-tissue conditions or in complex multiplanar deformities near joints where a single-stage correction appears difficult and hazardous.
Aseptic Non Union

68. Indications of External Fixation
Tibia non-union
Poor skin coverage
Suspicion of latent infection
Shortening with bone loss
Callus distraction technique
Arthrodesis non-union
Failed knee and ankle arthrodesis
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69. Methaphyseal non-union
Bone reconstruction techniques
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70. Metaphyseal non-union
Limited local decortication avoiding devascularization of the joint fragment, correction of the deformities and mechanical adaptation of the main fragments with fixation by interfragmentary compression.
Usually one or two plates are used.
Bone grafting may be necessary.
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71. Indications Correct alignment of the articular surfaces
Articular fragment stable fixation
Angle plate
Buttress plate
Active mobilization of a stiff joint
Avoid forced mobilization before bone healing
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72. Humerus proximal and distal buttress plates
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73. Femur and tibia buttress plates
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74. Femur proximal and distal (DCS)
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75. Adjuvant treatment
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76. Aseptic non-union
Electromagnetic stimulation and, more recently, ultrasound, have been applied and advocated to stimulate bone healing.
They do appear to generate a certain physical (thermal) effect at the non-union site, but the final outcome is still questionable and real evidence is lacking.
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77. Bone losses
Aseptic Non Union

78. Bone transplant 1. Fibula “pro tibia” 2. Bone transport
3. Free vascularized bone grafts
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79. Bone losses (bridging techniques)
Bridge plate
External Fixator
Locked intramedullary nailing
Plus bone grafting
Cortico-cancellous
Vascularized
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80. Humerus and forearm bone losses
Aseptic Non Union

81. Femur bone losses
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82. Tibio fibular synostosis Fibula “pro tibia” Bone transport
Tibia bone losses
Tibio fibular synostosis
Fibula “pro tibia”
Bone transport
Plus inter tibio-fibular grafting
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83. Tibia bone losses
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84. Tibia bone losses
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85. Aseptic Non-union Clinical Examples

86. AO Principles Course Dr. Enrique Queipo de Llano
Hospital Universitario de Málaga
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87. V.G.C. - 60 year old - Female Distal tibia non-union - 10-74
Distal tibia fracture no-union
The fracture was treated in other Hospital
Simple screw fixation without IF compression
No neutralization plate
Lag screw and DCP plating with deformity correction
Bone healing in 2 months
Aseptic Non Union

88. V.G.C y - Female PO
1 m
Aseptic Non Union

89. V.G.C y - Female
1 m
36 m
Aseptic Non Union

90. A.M.C. - 35 year old - Female Radius non-union - 11.75
Left forearm fracture (radius and ulna)
Treated in other Hospital
Ulna nailing
Plating of the radius with only three screws
Treatment
Ulna nail removal (ulna fx. was healed)
Radius DCP compression plating + Bone grafting
Bone healing in 3 months
Aseptic Non Union

91. A.M.C y - Female PO
4 m
Aseptic Non Union

92. G.G.C. - 52 year old - Male Femur non-union - 12.76
Sub-trochanteric fracture
Incomprehensible wiring cerclage
Treatment
Angle plate (95º) with axial compression fixation
Bone grafting
Bone healing in 2 months
Aseptic Non Union

93. G.G.C y - Male PO
1 m
Aseptic Non Union

94. G.G.C y - Male
9 m
Aseptic Non Union

95. D.O.J. - 43 year old - Male Distal femur non-union - 1.78
Distal femur metaphyseal non-union
Previous orthopaedic treatment in traction
Angle plate (95º) fixation
Bone healing in 3 months
Aseptic Non Union

96. D.O.J y - Male PO
Aseptic Non Union

97. D.O.J y - Male
2 m
Aseptic Non Union

98. D.O.J y - Male
10 m
16 m
Aseptic Non Union

99. P.T.M. – 27 year old – Male Distal de tibia non-union - 5.97
Distal de tibia fx. treated in another Hospital
UTN nailing
Technical defect (only one distal bolt)
Non-union with angular deformity
Treatment
Decortication + Osteotomy
LC-DCP tibia and fibula plate fixation
Excellent result
Aseptic Non Union

100. P.T.M. – 27 y – Male PO
1 m
Aseptic Non Union

101. P.T.M. – 27 y – Male
4 m
24 m
Aseptic Non Union

102. G.B.P. - 14 year old - Female Femur diaphysis non-union - 11.01
Motorcycle accident
(Right femur and tibia fractures)
Treated in another Hospital
Kirschner wire nailing of femur and tibia
At 6 months post-op
Femur angulation with a broken K wire
Femoral non-union
Tibia fracture was healed
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102

103. G.B.P. - 14 year old - Female Femur diaphysis non-union - 11.01
Surgical treatment
Femur and tibia nails removal
Decortication + LC-DCP axial compression plating
Cancellous bone screws were used (osteoporosis)
Autologouu bone grafting
Excellent result at 12 and 24 months
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103

104. G.B.P year old - Female
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105. G.B.P year old - Female
0 m
Tibia healed. Decortication, axial compression plate fixation.
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106. G.B.P year old - Female
3 m
6 m
Aseptic Non Union

107. G.B.P year old - Female
12 m
Aseptic Non Union

108. G.B.P year old - Female
24 m
Aseptic Non Union

109. JG.FJ. - 18 year old - Male Motorcycle accident - 5.5.02
Left femur B2.2 fracture
Operation:
UFN locked nailing with satisfactory reduction
Small wedge resorption and instability
Operation
Decorticatión and LCP fixation without nail removal
Bone grafting
Bone healing in 4 months (10 months since the accident)
Complete function at 12 months.
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110. JG.FJ year old - Male PO
0 m
6 s
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111. JG.FJ year old - Male
4 m
6 m
Aseptic Non Union

112. JG.FJ year old - Male
6 m
7 m
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113. JG.FJ year old - Male
10 m
12 m
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114. JG.FJ year old - Male
15 m
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115. L.S.C. - 27 year old - Female Femoral non-union - 5.89
Right femur transverse fracture
Primary reamed IM nailing
No callus formation at 15 months
Nail failure at 16 months
Treatment
Nail removal without opening the fracture site
New reamed thicker nailing
Bone healing in 2 months
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116. L.S.C year old - Female
0 m
15 m
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117. L.S.C year old - Female
16 m
24 m
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118. Fibula “pro tibia”
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119. P.A.R. - 10 year old - Male Acute osteomyelitis secualae - 9.66
Diaphyseal segmental bone loss
Fibula “pro tibia” proximal and distal
Fibula tibialization
Excellent result at 3 years.
Aseptic Non Union

120. P.A.R year old - Male
0 m
36 m
20 m
Aseptic Non Union

121. G.S.A. - 15 year old - Male Run over by a car – 3.97
Polytrauma patient
Right tibia open IIIB fracture
Peroneal muscles and nerve loss
Extensive skin loss
Immediate External Fixation
Dorsalis free vascularized transfer
Aseptic Non Union

122. G.S.A. - 15 year old - Male Run over by a car – 3.97
Atrophic proximal tibia aseptic non-union
Osteoporotic bone
Fibula “pro tibia” (lateral approach)
Medial LC-DCP buttress plate fixation
Autologous cancellous bone grafting
Aseptic Non Union

123. G.S.A year old - Male PO
1 m
6 m
8 m
Aseptic Non Union

124. G.S.A year old - Male
12 m
Aseptic Non Union

125. G.S.A year old - Male
36 m
Aseptic Non Union

126. G.S.A year old - Male
Aseptic Non Union

127. G.S.A year old - Male
5 years
Aseptic Non Union

128. G.S.A year old - Male
5 years
Aseptic Non Union

129. Aseptic Non Union