tibial nonunion gopalan latest
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Tibial Nonunion
Principles and BEST EVIDENCE
Dr Hitesh Gopalan U
Clinical Asst Professor, MOSCMM, Cochin
Editor, Orthopaedic Principles
Expert Advisor, OrthoEVIDENCE
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Tibial Nonunion
Significant Morbidity
Infection will complicate management
Defects: Challenging
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Gap Nonunion
Technical challenges Time-consuming Psychologically
demanding for Patients
No Guarantee of Success
(Pain, Stiffness, NV Deficits)
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Categories
Simple
Defect
Infective
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Definition of Bone Loss
Bone loss 1. Extrusion of a
bone fragment during injury
2. Removal of bone during debridement
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Bone Loss- Epidemiology
Significant bone loss—RARE Edinburgh- 10 year audit all
fractures
Fracture with bone loss= 0.4% Open Fractures=11.2%
Gustilo Type IIIB or C injuries
71% males, aged 30-40 years
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Epidemiology of Bone Loss
Common Location Tibia (68%) Diaphyseal (69%)
Less Circumferential Soft Tissue –MORE susceptible
2 of every 3 fractures with BONE LOSS will occur in the
Tibial Diaphysis
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Why Worry About Bone Loss?
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Bhandari et al..J Orthop Trauma 2003
Risk Factors: Re-operation
Open fracture wound: RR=4.32, 95% CI:
1.76-11.26
Fracture Gap: RR=8.33, 95% CI:
3.03-25.0
Transverse Fracture RR=20.0, 95%CI:
4.34-142.86
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Risk of Re-operation
NO Risk Factors 4%
1 Risk Factor 20%
2 Risk Factors 40%
3 Risk Factors 90%
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Risk for Nonunion
Location: more distal
Skin injury > 5cm in length
Postoperative Fracture gap
Audige, Bhandari et al..CORR 2005
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Classification of Defects
Defects Diaphyseal Metaphyseal Articular
Size of Defect Length of segment Partial or Complete Circumferential
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Evaluation
X-rays
CT scans: Very sensitive, poor specificity
Bhattacharyya T, J Bone Joint Surg Am 2006;88(4):692-697.
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Weber and Cech Classification
Hypertrophic
Oligotrophic
Atrophic(?Avascular)
Brownlow HC: The vascularity of atrophic non-unions.Injury 2002;33(2):145-150.
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Investigate
Rule out occult infection
WBC count?, ESR, CRP
MRI Bone marrow changes: metal, postoperative changes
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Bone scan and Infection Rx
Indium labelled WBC scan, Tc scan
False positive in unstable and periarticular nonunion
Withhold preoperative antibiotics and obtain deep cultures
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Non Surgical Management
Well aligned stable nonunion
Surgically unfit
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Associated Deformity
Malalignment Test and preoperative planning for deformity correction
Paley’s Principles of Deformity Correction
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Hypertrophic Nonunion
BIOLOGY is good.
Axial compression OR Lag screw fixation
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ESWT
bone mass, strength, angiogenesis, and differentiation of mesenchymal stem cells
126 patients, ESWT Vs Surgery
Useful in hypertrophic nonunionsCacchio A, J Bone Joint Surg Am 2009;91(11)LEVEL 1
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PEMF
Recent Level 1 study showed no difference (259 patients)
Sam Adie et al.. J Bone Joint Surg Am. 2011(level 1)
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LIPUS
Possible healing by transmission of acoustic waves
Jingushi S et al..(level IV) Nolte et al..(level IV)
No Level 1 studies published upto date
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Bone Marrow Injection
Variability of Osteoprogenitor cells among patients
Quality with age
Connolly JF, CORR 1991
Hernigou , JBJS A 2005 LEVEL IVGoel A, Injury 2005 Muschler GF,JBJS A2007
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Functional Cast Brace
Stable nonunion
Fibulectomy(Connolly JF: CORR Level V)
Sarmiento A, Int Orthop 2003;27(1): LEVEL IV
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Surgical Options
Exchange reamed nailing
Adjunctive plate fixation
Conversion to plate fixation
External fixation
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Exchange Reamed Nailing
Diaphyseal nonunion
Compression by reverse impaction,
Nails with internal compression devices
Zelle BA et al, J Trauma 2004; 57(5)- Level IVOh JK, et al.. Injury 2008;39(8)-Level IV
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Exchange Reamed Nailing
Contraindication:
1. Bone loss >2cm 2. >50% of circumference 3. Infection
Court Brown, Keating JBJS Br 1995
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Dynamisation
To Dynamise or not
Not recommended 1.unstable tibial shaft 2.SegmentalWu et al. Can J Surg 1993 LEVEL IVCourt Brown et al..JBJS 1990 LEVEL IV
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Adjunctive Plate Fixation
Hypertrophic Nonunions
Metadiaphyseal Nonunion(endosteal contact is limited in IM nails)
Ueng SW,et al.. J Trauma 2002; 53(3)
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Nail Removal and Plating
Metaphyseal nonunions (endosteal contact)
Interfragmentary screws, DCP, External compression device
Additional Surgical Trauma
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Internal Fixation
Posterior Plating: distal half of tibia(Posterolateral bone graft)
Fibrous union(take down)
Rodriguez-Merchan EC Clin Orthop Relat Res 2004;(419) LEVEL V
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External compression device, lag screw fixation and posterior plating
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External Fixation
Deformity correction
Compression
Distraction Osteogenesis
Union Rates: 93%
García-Cimbrelo E, Clin Orthop Relat Res 2004; LEVEL IV
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Ilizarov Method
Distraction
Allows Full Weight Bearing
>60 years
Brinker MR et al.. J Orthop Trauma 2007;21(9) LEVEL IV
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Compression at # site, distal corticotomy and distraction osteogenesis
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Classification of Defects
OTA Classification of Bone Loss
Type I Bone Loss
<50% bone diameter
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Classification of Defects
OTA Classification of Bone Loss
Type 2 Bone Loss
>50% bone diameter
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Classification of Defects
OTA Classification of Bone Loss
Type 3 Bone Loss
Missing bone segment
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Management Strategies
Reamed IM Nail
Court-Brown et al, JBJSBr 1991 41 Open fractures 2cm, <50%
diameter Union rates (1o or 2o
Nailing)
Type I Bone Loss
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Management Strategies
Adjunctive Bone Grafting of Defect
Type 2 Bone Loss
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Management Strategies
IM Nail or Ex-fix +bone grafting
Bone transport Acute shortening
+ subsequent bone lengthening
Vascularized bone grafts
Type 3 Bone Loss
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Defects <2 cm
Exchange Reamed Nailing
Keating et al..JBJS
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Defects 2-6 cm
Bone grafts
Bonegraft alternatives
Keating JF et al..JBJS Br 2005
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Induced Membrane philosophy
Reactive membrane- Growth factors
Temporary cement spacer
Bone graft
Masquelet AC et al..Orthop Clin North Am 2010;41(1):
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Oedekoven G ,Chirurg. 1996
Mono-Rail System
Osteotomy, either proximal or distal, of the bone defect
Segmental transport via an anteromedially (tibia) mounted external fixation
Over an IM Nail
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RIA
Segmental defects: 2 to 14.5 cm
Pain scores at harvest site
McCall et al.. OCNA2010;41(1): LEVEL IVBelthur et al.. Clin Orthop Relat Res 2008;466(12)
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Induced Membrane-RIA
David J. Hak, J Am Acad Orthop Surg Sept 2011
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Stem cells
Expand the harvested cells in culture and reimplant
Dennis JE et al.. Stem Cells 2007;25(10)Jimenez ML,., OTA Meeting 2007 Boston, MA
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Defects > 6cm
Individualized treatment
1.Vascularised fibular graft2.Bone transport using Ilizarov3.Lengthening over nail
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Infected Nonunion
Radical Debridement
Antibiotic beads
Systemic antibiotics
One stage or two stage Revision
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One stage Revision
Ilizarov Method
Fine wires: Vascular pedicle
Full weight bearing
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Two Stage Revision
Stage 1: Radical debridement, ALBC, External fixator
Stage 2: Reamed nailing and bone grafting
>6 cm defects: Contraindicated
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Infected Nonunion
One stage Revision Vs Two stage revision
16 level IV one stage Vs 18 level IV two stage
Cannot recommendStruijs PA, J Orthop Trauma 2007;21(7):507-511 LEvEL I
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Infected Nonunion: Soft tissue
Local flaps Vs Free Flaps
Local flaps: Already damaged muscle
Usually as secondary procedure after initial debridement
Anthony JP, Plast Reconstr Surg 1991; 88:
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rhBMP
rhBMP- 7 Vs ICBG
124 tibial nonunions
90% - reamed nailings
FDA- not approvedFriedlaender GE: J Bone Joint Surg Am 2001;83 LEVEL 1
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rhBMP-7
100% union rate in 45 patients (17 tibial nonunions)
Synergistic effect with ICBG
Giannoudis PV et al.. Clin Orthop LEVEL IVRelat Res 2009;467(12):
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rhBMP-2
Lack of clinical evidence in nonunion
US FDA approved for open tibial fractures after nailing
Off label use
Efficacy Vs Cost effectiveness
David Hak JAAOS Sept 2011
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Vascularized Grafts
large infected tibial defects radical debridement and staged double-
rib composite free transfer Ueng J et al, Trauma 1996
vascularized bone graft transfers with the donor bone fibula or ilium
Minami et al, J Reconstr Microsurg. 1992
Ipsilateral vascularised fibular transport Atkins et al,JBJSBr 1999
double-strut, free vascularized fibular bone grafting Chang et al, Orthopedics, 1999
Results dependent upon Technical Expertise with Approach
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Conclusion
Small defect nonunions: exchange nailing, ORIF or bone grafting
Nonunions > 6 cm require individualized treatment
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Conclusion
Infective nonunions are more challenging to treat
Individualise: One stage or Two stage
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