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

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

3. 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

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

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

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

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

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

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

10. Torsion wedge
Intermediate fragment with decreased blood supply

11. Communated non union
1 or more intermediate fragment necrotic

12. Defect non union
Ends are viable with defect in between

13. Atrophic non union Fibrous tissue fills defects of bone loss
Ends are osteoporotic and atrophic

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

15. Type A – Bone loss < 1cm
A1- Mobile deformity
A2 – 1 Without
deformity
A2 – Fixed non union
A2 – 2 with deformity

17. 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

18. 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

19. Treatment
Nonoperative
Operative

20. Nonoperative Electrical stimulation Ultrasound
Extracorporeal shock wave therapy

21. 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

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

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

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

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

29. 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

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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

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

38. 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

39. 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

41. Cancellous insert graft - Nicoll
Bridging gap of fracture < 2.5cm
Filled with solid cancellous bone
Fixed with plates

42. Massive slide graft – Gill
Sliding the graft from ½ circumference of bone
Disadvantage later grafting difficult

43. 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

44. Whole fibular transplant
Bone loss in radius, ulna and SOH
Small size
Closure easy

45. Free vascularised fibular graft Intramedullary Fibular allograft
AVN head of femur
Non onion after radiation
Intramedullary Fibular allograft
Humoral non union
Along with DCP

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

47. 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

48. 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

49. 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

50. 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

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

52. 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

53. 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

54. 8.Low Intensity Ultra sound
Mechanism
Gene stimulation
Angiogenesis
Temperature
Cellular activity
Enzyme modulation
SAFHS
Sonic Accelerated # healing system by Exogen CO

55. 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 ?

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

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

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

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

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

61. summary

62. 1.NU - Aseptic, Atrophic Freshening of Bone ends ? Acute docking ?
Corticotomy & Lengthening 
Compression at NU Site 
Distraction at NU Site 
Bone Grafting ?

63. 2.NU - Aseptic, Hypertrophic Stiff, Deformity +
Freshening of Bone ends 
Acute docking 
Corticotomy & Lengthening 
Compression at NU Site 
Distraction at NU Site 
Bone Grafting 

64. 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 

65. coclusion

66. … 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

67. Thank you