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PRE OPERATIVE PLANNING

How to work up a Nonunion and

Potential Infection

PRE OPERATIVE PLANNING

How to work up a Nonunion and

Potential Infection

If you could order ONE x-ray study for a the pre-op planning of a tibial nonunion

….it would be???

CT scan to determine if its hypertrophic vs atrophic

MRI to elucidate infection status…infected nonunion???

Long alignment film

PET / CT to determine infection AND biologic status of nonunion

4 cone down views of tibia, A/P, lateral, and 2 oblique views

NON UNION CHARACTERIZATION

DETERMINE TRUE PLANE OF DEFORMITY• METHODOLOGY OF CORRECTIONOSTEOTOMY POSSIBLE? WITH REASONABLE EXPOSURE

• LEVEL OF  DEFORMITYLOCATION OF DEFORMITY

LEVEL OF OSTEOTOMY

• BIOLOGY OF NON‐UNIONHYPERTROPHIC vs ATROPHIC

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ANALYSIS OF NONUNIONBIOLOGY OF NONUNION

• HYPERTROPHIC

• ATROPHIC

• SEPTIC

BIOMECHANICAL CHARACTERIZATION

EVALUATE “STABILITY” OF CONSTRUCT

• MOTION ARTIFACT

• BROKEN..LOOSE SCREWS

• OSTEOLYSIS

• CALLOUS…NO CALLOUS???

• PRIMARY FRACTURE LINE ORIENTATION

CT EVALUATION…..helps in this regard

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OTA MINI SYMPOSIA 2014

Managing Nonunion: Theory   and Practice

Moderator: Christopher G. Moran, FRCS 

Faculty: Pierre Guy, MD;

R. Malcolm Smith, MD

John J. Wixted, MD

STRESS / STRAIN

COMMINUTED FRACTURES NEVER FORM A COMMINUTED NONUNION????

AS FRACTURES HEAL…. A DELAYED 

HEALING SEGMENT SEES MORESTRAIN….THUS CHANGES THE HEALING CURVE FOR THAT SEGMENT

REDUCING STRAIN …….ALLOW SEGMENT TO HEAL…….

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STRAIN

TIME

6‐9 MONTHS

FxHealed?

NON UNION

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TIME

6‐9 MONTHS

FxHealed?

NON UNION

HEALING POTENTIAL 

STRAIN

TIME

6‐9 MONTHS

FxHealed?

NON UNION

HEALING POTENTIAL 

TIME

6‐9 MONTHS

Decrease strain( add stability)

UNIONStrain

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TIME

6‐9 MONTHS

UNION

HEALING POTENTIAL 

Augment healing potential( add graft)

STRAIN

TIME

6‐9 MONTHS

FxHealing?

UNION

HEALING POTENTIAL 

UNION

CRUSH INJURY WITH COMPROMISED TISSUE DISTAL

1/3 TIBIA

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14 weeks post op

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WHEN IN DOUBT..OR TO BUY TIME…….GET A CT

6 WEEKS post lag screw

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PRINCIPLES OF RxHYPERTROPHIC NON-UNION

MECHANICAL STABILIZATION

“BIOLOGIC” SURGICAL APPROACH

LIMITED NEED FOR BONE GRAFT             ADJUVANTS

PRINCIPLES OF RxATROPHIC NON-UNIONMECHANICAL  STABILIZATION

PLUS

PRINCIPLES OF RxATROPHIC NON-UNION

PROVIDE BIOLOGIC STIMULUS

• BMAC GRAFT + DBM

• INDUCTIVE FACTORS  (BMP’s, PDGF, PRP, DBM)

• AUTOGRAFT – RIA, ILIAC CREST 

• VASCULARIZED TRANSPLANT

• BONE TRANSPORT

SMALL DEFECTS

LARGE DEFECTS

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STRAIN

TIME

6‐9 MONTHS

FxHealing?

UNION

HEALING POTENTIAL 

UNION

ANALYSIS OF NON-UNION

PREVIOUS TREATMENT

• NON‐OPERATIVE

• EXTERNAL FIXATION

• IM NAILING

• ORIF (must R/O infection)

DEFORMITY CHARACTERIZATIONDETERMINE MAXIMAL DEFORMITY• METHODOLOGY OF CORRECTION

• ACUTE vs GRADUAL CORRECTION NERVE INJURY > 15O ACUTE CORRECTION UNLESS SHORTENING AT SAME TIME

• CANAL MALALIGNMENTIM NAILING POSSIBLE?

REVISION PLATING???

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ANALYSIS OF NON-UNION

DEFORMITY

• ANGULATION

• MALROTATION

CT EVALUATION

• LEG LENGTH 

DESCREPANCY

• TRANSLATIONRELATIVE ALIGNMENT                   OF MEDULLARY CANALS

A/P ANGULATION

LATERAL ANGULATION

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OBLIQUE PLANE DEFORMITY

38

48

53

30

MAGNITUDE&

DIRECTION

OBLIQUE PLANE DEFORMITY

38

48

53

30

MAGNITUDE&

DIRECTION

TRUE PLANE OF DEFORMITY

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DEFORMITY ANALYSIS

MECHANICAL AXIS DEVIATION

• FRONTAL PLANE DEFORMITIES 

• LEVEL DETERMINED BY INTERSECTION OF MECHANICAL AXIS FEMUR  /  TIBIA

DEFORMITY ANALYSIS

CORA

• CENTER OF ROTATION AND ANGULATION…

INTERSECTION OF ANATOMIC AXIS

INTERSECTION OF MECHANICAL AXIS

RELATIONSHIP OF ANGULATION TO TRANSLATION

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DEFORMITY ANALYSIS

IF THE CORA IS NOT AT THE SAME LEVEL AS THE

APEX OF THE DEFORMITY…..YOU HAVE

A TRANSLATIONAL DEFORMITY AS WELL

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PROBLEMS

PROBLEMS

With any translation……ALWAYS HAS TO BE A COMPENSATORY MAL

ROTATION

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1” block to level pelvis

PROBLEMS

• Malrotation 20 degrees

Problems

• Leg length 1in.• Translation 100%• Angulation 20

degrees• Mechanical axis

deviation lateral• Malrotation 20

degrees• Hypertrophic• Infection

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Hypertrophic, translation, malrotation, angulation, LLD

ANALYSIS OF INFECTIONPREVIOUS TREATMENT

NON‐OPERATIVE

EXTERNAL FIXATION

IM NAILING

ORIF

HOW TO R/O INFECTION???

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INFECTED NONUNION??

HOW TO MAKE DIAGNOSIS PRE – OP• POTENTIAL STAGED RECONSTRUCTION

The workup for a “suspected” infected non-union should routinely include

Indium labeled WBC scan

Intra‐op path (WBC per HPF)

Gallium subtraction bone scan

MRI with and without contrast

PET / CT to determine infection AND biologic status of nonunion

WBC, WSR, CRP

WBC, WSR,CRP, intra‐op path

PRE –OP STUDIES SPECIFIC FOR INFECTION?

RADIOGRAPHIC STUDIES

• PLAIN FILMS

• CT SCANS

• MRI

• NUCLEAR MEDICINE

BONE SCAN

WBC  / INDIUM LABELED

GALLIUM 

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BONE SCAN

INDIUM SCAN

GALLIUM SCAN?MRI…..SENSITIVE…….

…BUT NOT SPECIFIC FOR INFECTION

PRE – OP - INTRA –OP STUDIES

LABORATORY STUDIES• WBC

• WSR

• CRP

PATHOLOGY

• SINUS TRACT CULTURE

• INTRA‐OP GRAM STAIN

• INTRA‐OP BIOPSY

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….WHAT SHOULD I ORDER?

WHAT TESTS MAKE THE MOST SENSE…………

PERI-OPERATIVE DIAGNOSIS OF INFECTION IN NONUNIONS / ACUTE Fx

PRE OP BLOOD WORK

• WBC

• CRP

• ESR 

COMBINED INDIUM WBC / BONE SCAN

INTRA OP gm STAIN

INTRA OP DEEP CULTURESTORNETTA  et. al….AAOS 2011

WHAT DO THE RESULTS MEAN?

PPV…POSITIVE PREDICTIVE VALUE

• PROBABILITY THAT THE pt. HAS THE INFECTION  COMPARED TO ALL THE PTS THAT AREINFECTED

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WHAT DO THE RESULTS MEAN?

NPV…NEGATIVE  PREDICTIVE VALUE

PROBABILITY THAT THE pt. DOES NOT HAVE INFECTION ….. COMPARED TO THE ALL PTS THAT ARE NOT INFECTED

WBC SCAN RESULTS

PPV……50%

NPV…..72%

CRP RESULTS

PPV……54%

NPV…..75%

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ESR RESULTS

PPV……58%

NPV…..80%

WBC > 11,000

PPV……50%

NPV…..70%

PATH WBC’S >3 HPF

PPV……40%

NPV…..81%

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RESULTS

NO SINGLE TEST WAS INDEPENTLY ACCURATE……..

COMBINATION OF RISK FACTORS USED TO CALCULATE OVERT INFECTION RISK

RESULTSRISK FACTORS

ELEVATED WBC, ESR, CRP, AND +SCAN

FOR 0,1,2,3 RISK FACTORS BEING +PPV…O‐22%, 1‐36%, 2‐57%, 3‐83%

RESULTS

ELIMINATED NUCLEAR SCANS

WBC, ESR, AND CRP

PPV….O‐25%, 1‐27%. 2‐58%, 3‐100%

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RECOMMEND

SIMPLE  BLOOD TEST ‘s

‐ CRP, ESR, WBC’’s

‐ INTRA‐OPERATIVE  WBC/HPF

Stucken C, Olszewski DC, Creevy WR, Murakami AM, Tornetta P.   Preoperative Diagnosis Of Infection In Patients With Nonunions. 

J Bone Joint Surg Am. 2013 Aug 7;95(15):1409‐12

FACTORS AFFECTING BONE HEALING

STEROIDS

DIABETES

HYPERVITAMINOSIS A & D

CASTRATION

ANEMIA

RADIATION

Ca++ METABOLISM

PHYSIOLOGIC

BRINKER et.al

FACTORS AFFECTING BONE HEALING

SMOKING!!!!!• NICOTINE….DIRECT TOXIN TO OSTEOBLASTS

• INHIBIT COLLAGEN SYNTHESIS

• DECREASE OXYGEN CARRYING CAPACITY

• PERIPHERAL VASCULAR EFFECT

PHYSIOLOGIC

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MAKE PROBLEM LIST

CHARACTERIZE NONUNION TYPE

• BIOLOGIC

• BIO‐MECHANICAL

DETERMINE DEFORMITY PARAMETERS

EVALUATE POTENTIAL INFECTION STATUS

METABOLIC QUALIFIERS

Infected distal nonunion with LLD, malrotation, deformity, mechanical axis deviation

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BONE LOSS

INFECTED 

DEFORMITY

LEG LENGTH 

DESCREPANCY

PRE-OP PROBLEM LIST

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Vert Mooney….Chair U.T. Southwest 1987

WHEN TREATING A NON UNION……..IT’S PROBABLY BETTER NOT TO SCREW UP IF YOU DON’T HAVE TO…….

PMD007379-1.0

Busch Stadium,

Busch Stadium,

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CONSTRUCT INSTABILITY

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