TREATMENT ASEPTIC NON UNION

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 • 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 • Hypertrophic ends • Rich callus • Rich vascularity • Causes • Increase mobility • Premature weight bearing

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

8. Oligo trophic • Non hypertrophic ends • Vascular • Absent callus • Causes • 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 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. Treatment Options 3.Plate and screw fixation • Best Indication -Metaphyseal/periarticular location - Excellent soft-tissue envelope - No infection

27. 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 Goal Provide stability Surgical Tactic Plate, nail, external fixation Pearls Does not require grafting, do not disturb biology 1.Hypertrophic nonunion

32. 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 isa must pitfalls Failure to provide biological stimulation

33. 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. Classification group 4. Diaphyseal nonunion Goal Maintain axial alignment and length Surgical Tactic Nail, externalfixation, plate pearls Exchange nailingisprimary technique pitfalls Maintain length, rotation, and axial alignment

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

36. 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

38. Sliding inlay • 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. 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 • Onlay graft • Described by Campbell • Modification of Henderson • Bed prepared over the non union, cortical graft put and fixed with 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. Intramedullary Fibular allograft • Humoral non union • Along with DCP • Free vascularised fibular graft • AVN head of femur • Non onion after radiation

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

49. Bone growth factor • TGF Beta • 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 • 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