general principles in the assessment and treatment of nonunions fracture
TRANSCRIPT
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General Principles in the Assessmentand Treatment of Nonunions
Fracture
Andriessanto Lengkong
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Previous Definitions of Nonunion
Nonunion: A fracture that is a minimum of 9
months post occurrence and is not healed and
has not shown radiographic progression for 3
months
Orthopaedic Advisory Panel: Food & Drug Administration, 1986
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Waiting 9 months or more is ofteninappropriate:
Prolonged morbidity
Inability to return to work Narcotic dependence
Emotional impairment
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Definitions
Nonunion: A fracture that has not and is not
going to heal
Delayed union: A fracture that requires more
time than is usual and ordinary to heal
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Classification of Nonunions
Two important factors for consideration :
(1) Presence or absence of infection
(2) Vascularity of fracture site
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Classification
(1) Hypertrophic
(2) Oligotrophic
(3) Avascular
Weber and Cech, 1976
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Hypertrophic
Vascularized
Callus formation present on x-ray
Elephant foot - abundant callus Horse hoof - less abundant callus
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Oligotrophic
No callus on x-ray
Vascularity is present on bone scan
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Avascular
Atrophic or similar to oligotrophic on x-ray
Ischemic or cold on bone scan
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Hypertrophic
(elephant foot)Hypertrophic
(horse hoof)
Oligotrophic
or atrophic
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Incidence of Nonunion
Boyd et.al Connolly
No. 842(1965) No.602 (1981)
Tibia 35 % 62%
Femur 19% 23%
Humerus 17.5% 7%
Forearm 15.5% 7%
Clavicle 2% 1%
*Increasing frequency of tibial nonunion over time
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Etiology of Nonunion:
Systemic Malnutrition
Smoking
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Malnutrition
Adequate protein and energy is requiredfor wound healing
Screening test:
serum albumin total lymphocyte count
Albumin less than 3.5 and lymphocytes less
than 1,500 cells/ml is significant
Seltzer et.al. JPEN 1981
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Smoking
Decreases peripheral oxygen tension
Dampens peripheral blood flow
Well documented difficulties in wound healingin patients who smoke
Schmite, M.A. e.t. al. Corr 1999
Jensen J.A. e.t. al. Arch Surg 1991
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Etiology of Nonunion
(Local Factors) Infection
Energy of fracture mechanism
Mechanical factors of fracture configuration Increased motion between fracture fragments
Inadequate fixation
Wolfs Law- lack of physiologic stresses to bone
Anatomic location
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INFECTION
The inflammatory response to bacteria at
the site of the fracture disrupts callus,
increases gap between fragments, and
increases motion between fragments.
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Energy of Fracture Mechanism
Initial fracture displacement
Fracture pattern i.e:
comminution
bone loss
segmental patterns
Soft tissue disruption (vascularity and oxygen
delivery)
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Fracture Pattern
Fracture patterns in higher energy injuries
(i.e.: comminution, bone loss, or segmental
patterns) have a higher degree of soft tissue
and bone ischemia
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Soft Tissue Disruption
1. Iatrogenic
Excessive soft tissue dissection and periosteal
stripping at time of previous fixation
2. Traumatic
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Mechanical Factors
Excessive motion at fracture secondary to
poor fixation, failed fixation, or inadequate
immobilization
Lack of physiologic mechanical stimulation to
fracture area (i.e. nonweight bearing, fracture
fixed in distraction, adynamic environment
with external fixation)
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Diagnosis of Nonunion- History
Nature of original injury (high or low energy)
Previous open wounds of injury site
Pain present at fracture site
Symptoms of infection
History of any drainage or wound healing
difficulties
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Examination
Alignment
Deformity
Soft tissue integrity
Erythema, warm, drainage
Vascularity of limb
Pulses, transcutaneous oximetry
Stability at fracture site
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Treatment
Nonoperative
Operative
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Nonoperative
Ultrasound
Electric stimulator
Bone marrow injection
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Ultrasound
Ultrasound fracture stimulation deviceshave shown ability to increase callus
response in fresh fractures (shortens time
for visible callus on x-ray) Prospective randomized trial in nonunion
population has not been done
Use in nonunions remains theoreticalGoodship & Kenwright JBJS 1985
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Electric Stimulation
Piezoelectric nature of bone - stress generated
electric potentials exist in bone and are related
to callus formationFukada & Yasuda,J Phys Soc Jpn 1957
Busse H CAL e.t. al. Science 1962
Electromagnetic fields influence vascularization
of fibrocartilage, cell proliferation & matrixproduction
Monograph Series,AAOS
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Bone Marrow Injection
Percutaneous bone marrow injected to level of
fracture
9 of 10 delayed tibia fractures united
80% of 100 tibial fracture patients united when
in conjunction with adequate fixation
*Nonradomized and anecdotal studies
Connolly J., CORR. 1995
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Surgical Treatment
Fibular osteotomy
Bone graft Plate osteosynthesis
Intramedullary nailing
External fixation
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Fibular Osteotomy
Fibula can distract or unweight physiologic
forces seen in the tibia Teitz, C.C. e.t.al.JBJS 1980
Often used as adjunctive procedure to assist
with deformity correction and surgical
stabilization of tibia
Dynamizes tibial to augment healing
environment
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Bone Grafting
Osteoinductive - contain proteins or
chemotactic factors that attract vascular
ingrowth and healing
i.e.. demineralized bone matrix & BMPs
Osteoconductive - contains a scaffolding for
which new bone growth can occur
i.e. allograft bone, calcium hydroxyappatite
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Plate Osteosynthesis
Corrects malalignment
Restores function & stabilizes fracture fragments
directly
Compresses fragments in some circumstances toaugment healing
Allows patients to mobilize surrounding joints
and dynamize fracture environment
Requires adequate skin and soft tissue coverage
Often used with adjunctive bone graft
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Intramedullary Nailing
Mechanically stabilizes long bone nonunions as aload sharing implant
Corrects malalignment
Reaming is initially detrimental to intramedullary
blood supply, but it does recover and is believed
to stimulate biologic healing at fracture
Allow patient to mobilize surrounding joints anddynamize fracture environment
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External Fixation
Correct malalignment
Used primarily in management of infected nonunions
Allows for repeated debridements, soft tissue
reconstructive procedures, and adjunctive bone-
grafting
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