Bone Healing, Influence of Treatment

2. Bone Healing, Influence of Treatment Reza Sh. Kamrani M.D. TUMS 2ndAOTrauma Hand Course Tehran IRAN 20, Apr. 2012

3. Contents • 1- The importance of the bone healing knowledge • 2- Physiology of bone healing • 3- Interaction between bone healing and treatment • 4- Bone healing in the hand

4. 1- The importance of the bone healing knowledge Bone has a remarkable capacity of healing The result of the treatment depends on the skill of the surgeon in taking the natural healing potential of the tissue Knowledge of bone healing helps the surgeon to better management of the fracture

5. 2010 2004

6. 2- Physiology of bone healing A broken bone heals because... ...it is broken! Mr Alan Apley However it needs a favorable biological and mechanical environment

7. Bone healing classification; • Enchondral ossification, Callus formation • Direct osteonal healing. Non-callus • Contact healing • Gap healing Natural healing

8. Callus formation • Stages of healing • 1- hematoma formation • 2- inflammatory response • 3- reparative phase • 4- remodeling • Fx. Healing is said to be complete when repopulation of the marrow space occure (months to years )

9. Cascade of tissue differentiation following a fracture Hematoma Granulation T. Connective T. Fibrocartilage Mineralized cartilage Bone

10. Fragment motion Füchtmeyer Callus formation depends on • Motion (direction) • A good blood supply

11. Stable situation Hente No bone

12. Necessity of motion Hente 5W Abundant bone 10 cycles per day First stiffness then strength

13. Too much movement Maintained instability leads to nonunion

14. Hypertrophic nonunion Arrest of differentiation Good tissues—poor mechanics

15. Hypertrophic nonunion 0 Weeks Nonunion + Instability

16. Treatment of hypertrophic nonunion 12 Weeks Nonunion + Stability = Healing

17. Bone healing classification; • Enchondral ossification, Callus formation • Direct osteonal healing. Non-callus • Contact healing • Gap healing Treatment (stable fixation)

18. Perfect adaptation (contact healing)

19. ... and stable fixation

20. ... leads to healing by….

21. ... internal remodeling

22. Osteonal remodeling

23. Osteoclast penetrates gap

24. Transitional porosis Lamellar bone formation: 1–2 μm/day

25. Healing in conditions of absolute stability Remodelling occurs when the bone ends are in contact What happens if a small gap is present?

26. Stable gap

27. Stable gap Invasion of blood vesselsand cells

28. Stable gap Bone deposition No cartilage tissue

29. Large gap: partitioning

30. Parallel bone formation

31. Fracture treatment which allows some movement at the fracture site―relative stability―results in healing by callus formation • Callus formation • Resorption of fragment ends • Interfragmentary cartilage

32. 3- Interaction between bone healing and treatment

33. Variables affect on bone healing:

34. Variables affect on bone healing: • Injury variables • Open fx. • Severity of inj. • Intra-articular fx. • Segmental fx. • Soft tissue interposition • Damage of blood supply

35. Variables affect on bone healing: • Injury variables • Patient variables • Diseas, Disorders • Age • Nutrition • Systemic hormons • Nicotin

36. Variables affect on bone healing: • Injury variables • Patient variables • Tissue variables • Type of the bone • Bone necrosis • Bone diseaseC

37. Variables affect on bone healing: • Injury variables • Patient variables • Tissue variables • Treatment variables • Apposition of the frag. • Loading & Micromotion • Stabilization • Soft tissue management

41. 4- Bone healing in the hand

42. Variables affect on bone healing: • Injury variables • Patient variables • Tissue variables • Treatment variables • Type of the bone • Bone necrosis • Bone diseaseC

43. Type of the bone • Bones need rigid fix. • Bones need no fixation

44. Summary • 1- The importance of the bone healing knowledge • 2- Physiology of bone healing • 3- Interaction between bone healing and treatment • 4- Bone healing in the hand

45. Summary • Team approach • Bone biology • Implant mechanics • The surgeon • The patient

46. Bone healing and how it is influenced by treatment I would like to appriciate Dr. Schneider Erich Schneider, CH

47. Thank you for your attention