presentation about pathophysiology and pathmechanics of delayed and non union of fractures.it shows how to manage different types of bone non union. presentation is by Dr Mohamed ashraf professor and head of orthopaedics,govt TD medical college, alleppey,kerala,india
3. Definition
• ……9 months after fracture!
• ……last 3 months NO biological,clinical and
radiological activity!!
• …..except certain locations!!!
• …..but what about this ?
4. definition
• ……….Its a clinical stage in which all the
biological process of healing has come to a
standstill,[or impossible] characterized
clinically by painless abnormal mobility, and
radiologically by hypertrophic / atrophic
changes or significant gap .
5. To heal or not to heal
• success of these works depends on the mercy
of some specialised cells,
• biolologically active factors and
vascularity.......
• If anything goes wrong ,your beautiful works
go down the drain
6. Fracture and vascularity
• Endosteal
• Inner 2/3rds
• Periosteal
• Outer 1/3rd
• Disrupted by a fracture
• Further damaged by surgery
7. How fracture healing differs
• normally occuring process
• in bone
• in other organs
• in other species
• ....then what is the difference ?
8. Temporary organ
• a " temporary organ" for union
• it is transient[ placenta of bone]
• maximum biological activity at 2nd and 3rd week
[ hence no manipulation]
• initially soft then hard
• more in indirect healing
• less in direct healing
• amount= vascularity x micromotion
9. Union depends on
Patho- anatomy
• local release of energy
• On bone- simple,comminuted, segmental
• On soft tissue- implosion,cavitation,deglove
• On vascular
medullary lost
periosteal lost
• centrifugal change to centripetal
10. HEALING DEPENDS ON
PERREN’S STRAIN THEORY
• Interfragmentary strain determines the subsequent
differentiation of fracture gap tissue
• 10 to 100% - fibrous tissue
• 2 to 10% - cartilage and enchondral ossification
• < 2% - bone
11. Fracture always
heal,but….
• FOUR DESTINATIONS
• NORMAL UNION
• DELAYED UNION
• NON-UNION
• MAL-UNION
• natural healing- by bony union[union]
or
• unnatural healing- by fibrous,fibrocartilage
synovial tissue[non union]
12. What’s lost in non union
• protective
• supportive
• locomotive
13. Bone healing in practice
• natural healing
• supported healing
• instrumented healing
17. LOCAL FACTORS
• antomical region-cortical or cancellous
• local bone abnormality-
avn
radiation necrosis
infection
lytic/porotic lesion
• local denervation
18. Injury variables
• damage to-bone/soft tissue/vascularity
• single/paired bone
• bone loss,segmental,comminution,displaced
• interpositions
• distractions
• IA #
19. TREATMENT VARIABLES
• surgical timing
• surgical trauma
• implant type
• fixation stability
• fragment apposition
• fracture site loading
• bone induction procedures-BG,BGS,BM.etc
20. Surgeon can control….
• vascularity
• stability of fixation
• infection
• quality of reduction
• graft and graft substitute
21. So,surgeon’s job is ….
• PROVIDE NORMAL /NEAR NORMAL
ALIGNMENT
• PROVIDE PROTECTION TILL UNION
• PRSERVE SOFT TISSUE
• MAINTAIN FUNCTION
• Then bone heals by bone
• … otherwise by fibrous tissue
24. diagnosis
• PAINLESS ABNORMAL MOBILITY!!!
• Deformity
• Loss of function
• Shortening
• Loss of transmitted mobility
• Signs of infection
• Asses adjacent joints
• Asses neurovascular status
33. non union-treatment
vital steps
• FRESHEN THE EDGES
• OPEN MARROW CAVITY
• STABLE FIXATION
• HEALING AUGMENTATION
• …………in short convert to a fresh fracture!
34. Healing enhancement
* Bone grafting
* Graft substitutes
* Stem cells
• Magnetic field
• Electrical stimulation
• Ilizarov system
35. Bone graft
• Osteoconduction
• 3D scaffold
• Osteo-induction
• Biological stimulus
• Mesenchymal cells Osteoprogenitor cells
• Osteogenic
• Contains living cells that can differentiate to from
bone
• Structural
37. Bone marrow aspirate
• Non union – 75-95% success
• Aseptic non-unions
• Only works if adequate cell concentration
• Hernigou Pet al Influence of the number and
concentration of progenitor cells. J Bone Joint Surg Am.
2005;87:1430 -7
• Concentrated BM aspirate
• Ongoing multicentre RCT in France
• Open tibial fractures
39. Osteo inductive agents
• Transforming growth factor Superfamily
• BMPs
• GDFs (growth differentiation factors)
• Possibly TGF-β 1, 2, and 3.
• Govender et al Recombinant human bone morphogenetic protein-2 for
treatment of open tibial fractures: a prospective, controlled, randomized
study of four hundred and fifty patients. J Bone Joint Surg Am.
2002;84:2123-34.
41. BMP 7 (OP-1)
• Tibial non-unions
• RCT OP1 v autogenous graft
• No difference in union rate
• Less infections
Friedlaender et al J Bone Joint Surg Am. 2001;83 Suppl 1(Pt 2):S151-8.
• Open Tibia
• OP1 v control
• Less secondary interventions
McKee et al Proceedings of the 18th Annual Meeting of the
Orthopaedic Trauma Association; 2002 Oct 11-13
43. Low intensity pulsatile ultrasound
LIPUS
• May act in stable and viable non-union
• 80% union in 4.5 months if applied 20 mnt /dy
• More effective in post-op delayed and non-
union
• Stimulate osteoblast,chondroblast,stem cells
g.zimmermann,jingushi
trauma
44. Magnetic stimulation
• Biophysical technic
• Stimulate proteoglycan and collagen synthesis
• Accelerate bone formation
• Mainly as adjunct to conventional therapy
51. Fracture healing
• …Complex physiological new bone formation ,temporal and
spatial in nature,initiated by cellular and vascular activity
,controlled by cytokines and signalling proteins………..
but fails in 10% of all #s and 50% of
open #s
52. Fracture healing affected
• Factors before injury
• Factors by injury
• Factors by treatment
• Factors by complications
53. SURGICAL TIPS
• REMOVAL OF DEAD AND DEVITALISED TISSUE
• PRESERVATION OF BLOOD SUPPLY
• STABLE FIXATION
• ALWAYS DO BONE GRAFTING
• PREHABILITATION AND REHABILITATION
54. INFECTED NON UNION
• SEPTIC NONUNION CONVERTED TO ASEPTIC
• THEN FOLLOW THE NONUNION PRINCIPLES
FOR FIXATION
• SINGLE STAGE OR TWO STAGE
• THE BEST WAY TO AVOID SEPTIC NON UNION IS
GOOD INITIAL DEBRIDEMENT
55. Ring fixator
• ILIZAROV SYSTEM IS THE VERSATILE
EX FIX SYSTEM WITH PROVISION FOR
RECONSTRUCTION OF BONE AND SOFT TISSUES ……..
“AND THE INFECTION BURNS OUT IN THE FIRE OF
REGENERATION.”
