General Principles in the Assessment and Treatment of Nonunions Fracture

8/11/2019 General Principles in the Assessment and Treatment of Nonunions Fracture

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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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General Principles in the Assessment and Treatment of Nonunions Fracture

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