non union and malunion final.pptx

Non union and malunion

1. Presente r Dr . Sheshagiri (M.S.Ortho) Associate professor JSSH Non union and Malunion

2. Non Union NON UNION -Any fracture that is not showing clinical and radiographic signs of progression of union and has not healed in a prescribed time frame. FDA defined nonunion as “established when a minimum of 6 months has elapsed since fracture with no visible progressive signs of healing for 3 months ”

3. Pseudoarthrosis Formation of a false joint where a fibro-cartilaginous cavity is lined with synovial membrane . The patient does not have any pain in case of pseudoarthrosis . DELAYED UNION DELAYED UNON OCCURS WHEN A FRACTURE HAS NOT HEALED COMPLETELY IN EXPECTED TIME BUT STILL HAS POTENTIAL TO HEAL WITH OUT INTERVENTION.IN THIS CASE THE RADIOLOGICAL AND CLINICAL SIGNS OF HEALING OF FRACTURE IS PRESENT.

4. bony bridging Stages of fracture healing Hematoma formation Inflammation and cellular proliferation Callus formation Consolidation Remodeling Fracture healing

5. Bone healing Primary bone healing It occurs in the presence of absolute fracture stability following surgical fixation of fracture. There is no micro motion between fracture fragments. Secondary bone healing It occurs in the presence of relative stability of fracture in the presence of reasonable approximation of fracture fragments. Relative stability signifies controlled motion between fracture fragments under physiological load.

6. Host factors ◦ ◦ ◦ ◦ ◦ ◦ ◦ Dia b e t es Smoking NSAIDS Malnutrition Steroid use Rheumatoid disease Malignancy Causes of non-union

7. Systemic Risk Factors Malnutrition Smoking NSAIDs Systemic Medical Conditions like Diabetes, Chronic alcoholism. Patient related mechanical Factors Non Compliance Risk factors…

8. Causes related to fracture -soft tissue interposition -distraction at fracture site -bone loss at the fracture site(open type fracture) -damage to blood supply of fracture -pathological fracture -infection from open fracture Causes related to treatment -inadequate reduction -inadequate immobilisation -distraction during treatment

9. Local Risk factors Open Fractures High energy fractures with bone devitalization. Severe associated soft tissue injury Bone loss Infection

10. T ra u m a t i c Iatrogenic

11. too flexible gap Inadequate stabilization: Resorption of bone at fracture site. i n s t a b i l i t y

12. Infection: Infection and loss of soft tissue covering or osteomyelitis I n fec t ion

13. Iatrogenic Factors: Poor reduction Unstable fixation Bone devitalization

14. Poor bone quality Patient weight bearing Inability to follow rehabilitation protocol.

15. - Persistent Pain -Inability to bear weights -Pain on palpation at fracture. site. -Pain with fracture site stress examination -motion at fracture site -continued signs of inflammation. -limb shortening might be present in some cases. Clinical presentation

16. Webber and check classification system

17. Atrophic non union When there is minimal or no attempt of callus formation following a fracture the fracture goes into atrophic non union. Hypertrophic nonunion When there callous formation following fracture but it does not bridge the two fracture ends the fracture goes into hypertrophic nonunion.

18. R adio l o gi c e v a l ua t i o n Delayed union The fracture line is visible.There may be inadequate callus bridging formation. Non union The fracture line is visible.There is little bridging callus formation.

19. Oblique views done under fluoroscopy may show an unhealed fracture better than a conventional AP and Lateral view . It is also possible to demonstrate mobility at fracture site by stress xray or weight bearing xray .

20. Computed Tomography: A definitive diagnostic tool having 100% sensitivity but lack of specificity (62%)

21. RUST (radiographic union scale in tibial fractures) -scores each cortex based on the absence or presence of cortex. -where 1 denotes no healing and 3 denotes complete healing -score of 4 indicates no healing and 12 indicates complete healing -A modified rust score was developed where each cortex was scored from 1-4 in the following order,no callus formation,bridging callus formation and callus remodelling. -A score of 11 indicates complete healing and score of 10-13 indicates confident assessment of healing.

22. Biology: None . Stability: lacking Treatment: Provide stability Bone graft Other reconstruction Necrotic De f e ct Treatment: Provide stability Bone graft Debridement Excision of non vital bone Biology: Poor , avascular , nonviable Stability: lacking

23. NON OPERATIVE TREATMENT Indirect intervention Weight bearing And external stabilization Electrical stimulation Ultrasound stimulation Extracorporal shock wave therapy Parathyroid harmone Gene therapy

24. Indirect intervention Cesaation of smoking Control of diabetes/ metabolic disorder Maintaining nutrition Long term use of NSAIDS, steroids , chemotherapic agents etc Immunosuppresive drugs Weight bearing and external stabilization o Application of weight bearing in functional brace Mechanism = stimulation of osteoblastic activity by mechanical loading Mainly used in hypertrophic . o External supportive devices have little role in Atrophic non union Pseudoarthrosis Malaligned nonunions Infected non unions

25. Electrical stimulation Internal application Direct current = surgical implantation and potentially surgical removal of stimulation device External application Mechanism = alteration of electrical potential at the fracture site .There by reducing osteoclastic related bone resorpstion , increase osteoid formation and stimulate angiogenesis. (Increases the mechanotransduction at fracture site) Capative coupling – 24 hrs per day Pulsed electromagnetic field stimulation – 12 hrs per day 3. Combined magnetic field - 30` min per day

26. Ultrasound stimulation Low intensity pulsed ultrasound is of low energy Frequency of 1.5mhz a signal burst width of 200 micro sec a repetation 1 mhz an intensity of 300mW/cm Mechanism = stimulate ossification

27. Extracorporal shock wave therapy High energy Requires regional anaesthesia Enhance biomechanical properties of bone and angiogenesis

28. Gene therapy Aspirated iliac crest stem cells has been shown to enhance the activity of osteoconductive grafts. There are few commercially available Recombinant BMP proved to be effective treating nonunions. Regulator of calcium metabolism Pth binds to osteoblasts stimulating release of mediators that in turn stimulate osteoclasts to resorb bone thus help in acute fracture healing and non union Parathyroid hormone

29. Principle of surgical management Cure infection if present Correct Deformity if significant Provide stability through implants Add biologic stimulus when necessary S u r g i ca l m a n a g e m ent

30. Timing of operative intervention Difficulty in establishing the optimal time to intervene surgically in treatment of non union parallels the difficulty in the diagnosis of non union Standardized protocol Waiting for 6 months before reoperation Treat infection before operating

31. Plate and screw fixation Intramedullary Devices External Fixation Choice of internal fixation depends on- Type of nonunion. Condition of the soft tissues and bone Size and position of the bone fragments Size of the bony defect.

32. Plate and screw fixation Plates provide a powerful reduction tool Surgical technique should strive for absolute stability Locking plates have improved stability and fixation strength Other relative indications: Absent medullary canal Metaphyseal nonunions When open reduction or removal of prior implants is required

33. • Multiple Indications for plate Broken implants require that removal Metaphyseal nonunion Significant deformity Technique Blade properly positioned in the distal fragment Reduction obtained by bringing plate to the shaft Absolute stability with lag screw Nonunion was not exposed • Bro k en Plate

34. 3 forms Pre existing nail Exchange nail Dynamization • • Ideal case – Femur or tibia with an existing canal and no prior implants Exchange nailing provides a good option for the tibia and femur Special equipment is often necessary to traverse sclerotic canals

35. • Largest indication is a temporary stabilization following infection debridement Also useful in correction of stiff deformity and lengthening • E x t e r n a l fi x a t i on

36. Illizarov’s Exfix It is fracture fixation system which works on the principle of distraction osteohistongenesis .

37. Monofocal C o mpr e ss ion Sequential distraction-compression Distraction Sequential compression-distraction Bifocal Compression-distraction lengthening Distraction-compression transport (bone transport) Trifocal Various combinations

38. Gold standard for biological and mechanical purposes. Properties of Autograft: Osteogenic a source of vital bone cells Osteoinductive recruitment of local mesenchymal cells Osteoconductive scaffold for ingrowth of new bone Bone graft can also be allograft. BONE GRAFT

39. Decortication (Judet, 1972) Shingling Cancellous bone graft Muscle pedicle bone graft Enhance the healing response creating well-vascularized bed

40. BONE GRAFT SUBSTITUTES Often unnecessary in hypertrophic cases with sufficient inherent biologic activity Options Aspirated stem cells (with or without expansion) Demineralized Bone Matrix Autogenous Cancellous Graft Platelet rich plasma Growth Factors Platelet derived Recombinant BMPs

41. Articular non union Potential causative factor is inadequate compression of the articular fracture gap leading to prolonged exposure to synovial membrane Ideal situation of repair 1. Joint arthrosis 2. Joint instability 3. Stiffness Therefore soft tissue contracture release or early post operative rom exercise

42. Segmental bone loss They are due to high velocity injury or infected non union Surgical options include 1. Autogenous bone graft 2. Free vascularized bone graft 3. Bone transport A critical sized defect is generally regarded as the that requires surgery It depends on particular bone involved , location within the bone , surrounding tissue , host biological response

43. Infected non union Contaminated implants and devitalized implants must be removed Infection treated: Temporary stabilization (external fixation) Culture specific antibiotics • +/- local antibiotic delivery (antibiobic beads) Secondary stabilization with augmentation of osteogenesis (cancellous grafting)

44. Active Treatment – The objective of the active method is to obtain bony union early and shorten the period of convalescence and preserve motion in the adjacent joints. Polymethyl Methacrylate Antibiotic Beads- Heat-stable antibiotics, such as tobramycin and gentamicin, can be mixed with PMMA and used locally to achieve 200 times the antibiotic concentration achieved with intravenous administration.

45. Prevention Good reduction Bone grafting Firm stabilization biomechanical stability and biological vitality of the bone.

46. Principles of treatment applied based on types of nonunion: stabilization enhancement of biology eradication of infection if any How to prevent delayed unions/nonunions: biological fixation in original operation early recognition of delayed union

47. Malunion When a fracture heals in a non anatomical posterior it is said to have malunited . A slight amount of malunion occurs in large portion of fractures but in practice the term Malunion is reserved for cases resulting in disability that is of clinical significance.

48. Site upper vs lower extremity spine / pelvis Location intra-articular extra-articular » m e t a p h y se a l » di ap h y s e al combined

49. Types simple - » s kel e t a l m a l a lig n m e nt complex - » s kel e t a l m a l a lig n m e nt w ith, » soft-tissue &/or articular abnormality Direction – angular – rotational – tr a ns l a t i o n – length

50. Etiology : Failure of nonoperative treatment Failure of operative treatment incomplete surgical correction inadequate stability of fixation noncompliance of the patient

51. Importance of Limb Alignment Detrimental effects of malalignment Immediate Functional limitations Pain Chronic Joint related ( arthritis)

52. Management Overview Anatomical assessment – Limb » assessment of deformity » status of surrounding joints Patient expectations Available Literature on expected outcome Surgeon experience

53. Management - History and Physical Examination Injury mechanism energy Fracture location pattern bone loss ROM of surrounding joints Soft-tissues status incisions Defects Previous treatment type stability complication(s)

54. Common sites of non union Supracondylar fracture of humerus Colles fracture

55. Management: Investigations Plain Radiographs CT - scanogram rotational / length deformities MRI intraarticular pathology

56. Assessment of Limb Alignment Comparison with contralateral limb important Arthroscopy Assesment of joints M R I

57. Alternates for Nonsalvagble Joint De bri d e m e nt Arthrodiesis Arthroplasty

58. Biomechanical Principles Effect of Surgery on: joint function alignment soft tissues limb length

59. Deformity Correction General Considerations: Functional assessment – disability GOAL: Anatomical correction of deformity UL - upto 3 to 4 cm shortening well tolerated. LL – upto 2 cm shortening treated with Shoe Raise.

60. Timing for Deformity Correction Extra-articular - controversial Intra-articular - ASAP

61. Surgical Overview Preoperative Plan: selection of , surgical approach / exposure osteotomy - location / type fixation technique(s) intraoperative use of, femoral distractor bone graft / substitute

62. Surgical Overview Osteotomy site of deformity closed vs open simple vs multi planar technique - Predrill / osteotome Saw (irrigate)

63. Osteotomy Type of deformity length rotational angular complex Type of osteotomy Transverse Transverse Oblique W e d ge ( o penin g / c losi n g) Bi- / Tri- planar Crescentic (Dome)

64. Intraoperative Fixation Open fixation: If stable - IM nail vs plate vs circular fixation lag screw with plate Closed fixation : IM nail percutaneous plate circular fixation

65. Examples Proximal humerus Distal radius Proximal femur Femoral shaft Tibia Ankle Distal Humerus Clavicle

66. 1. Proximal Humerus Deformity: varus extension Problem: reduced ROM impingement Treatment: Osteotomy: » Biplanar Fixation: Blade plate

67. 2. Distal radius 42 year male Swollen arm: x-rays taken, conservatively treated with cast

68. Healed at 8 weeks: Complaints of wrist and DRUJ pain, decreased motion

69. Correction of post-traumatic wrist deformity in adults by osteotomy, bone-grafting, and internal fixation. Fernandez DL, JBJS 64(8), 1982

70. Osteotomy , bone graft ing and fixation with plate and screws

71. 3. Proximal Femur Following femoral neck fracture: Varus Malunion AVN Treatment: valgus intertrochanteric osteotomy Fixation: blade plate

72. Femoral Diaphysis Malunion Most common rotation and/or length Preop CT Determines rotational malalignment Osteotomy with IM saw Stabilization IM nail/plate

73. 4. Tibial Diaphysis Malunion Definition: Co n tro v e r s i a l!! Shortening > 1cm Varus > 5º Valgus > 5 - 10º Internal / External rotation > 5 - 10º Recurvatum / Procurvatum > 10º

74. Tibial Diaphysis Malunion Options for Fixation: IM Nail Plate Circular Fixator

75. 5. Malunion of Ankle Fractures Radiographic exam

76. Malunion Ankle Fractures STEPS: » f ib u l a r ost eo to m y - a s ses s l e n g th » osteotomy medial malleollus and/or post malleollus if necessary » reduce syndesmosis / joint » temporary fixation » stabilize fibula

77. 6. Malunited Humerus CUBITUS VARUS “ Gun-stock Deformity” – Looks like a loading stock of old long barrel guns

78. T R EATMENT Lateral closing wedge osteotomy Easiest Safest Most stable inherently Medial open wedge osteotomy with bone graft Oblique osteotomy with derotation

79. C U BITUS VA R US French Osteotomy Detach whole of triceps Ulnar nerve explored Medial cortex broken Modified French Osteotomy (Bellemore) P o s t. Lo n g i t u di na l a p pr o ac h ➢ P os t e r o lat e r a l a p p r oa ch Lateral half of triceps detached Ulnar nerve Not explored Medial cortex intact so more stability

80. Target normal clavicle 7. MALUNITED CLAVICLE Double- osteotomy planned and practiced on solid Real Bone models Planned correction Abnormal clavicle

81. TREATMENT PLAN Closing wedge osteotomy peformed at mid-clavicle, bone wedge removed Opening wedge osteotomy performed in lateral third, grafted with bone wedge

82. BONE REMODELING in CHILDREN Fractures close to ends of long bones remodel much faster than fractures in mid-shaft. Hence remodeling is faster in PHYSEAL > METAPHYSEAL >DIAPHYSEAL INJURIES. UL- most active growth plate is at PROXIMAL HUMERUS AND DISTAL RADIUS AND ULNA, hence injuries of Proximal Humerus and Wrist remodel faster than injuries of elbow and proximal forearm. Inverse for the LL- remodeling is faster at the Knee- Distal Femur and Proximal Tibia than in Proximal Femur and Distal Tibia.

83. ACCEPTABLE DEFORMITY Distal Radius Metaphyseal # – 15 degrees of primary angulation and 1cm of shortening in boys upto 14 years and girls upto 12 years. Radius-Ulna shaft # -upto 10 degrees of plastic deformation acceptable. Radius neck # -upto 30 degrees angulation, 2mm translocation remodel. Sup r a c o nd y lar H u m e ru s # - u p to 20 d e g re e s a n gu l a tion in sagital plane remodel but no angular remodeling in coronal plane Humerus shaft # - 20 degrees angulation and upto 2 cm bayonet shortening acceptable.

84. ACCEPTABLE DEFORMITY Femur shaft # - Tibia shaft # -

85. Malunion Treatment Goals Improve function Decrease pain Prevent arthrosis Conclusion: Corrective osteotomy has a definite role in the treatment of malunited fractures.

86. TH A NK YO U