nonunions of long bones akbar
TRANSCRIPT
NONUNION OF LONG BONESNONUNION OF LONG BONES&&
INFECTED NONUNIONINFECTED NONUNION
Dr Mohammed Akbar KhanDr Mohammed Akbar Khan
DefinitionDefinition Healing process come to halt - clinically/radiologically Healing process come to halt - clinically/radiologically
–beyond stipulated period of healing – mechanical or –beyond stipulated period of healing – mechanical or biological failure with a gap being filled with fibrous or biological failure with a gap being filled with fibrous or fibro-cartilagenous tissue usually requiring a change in fibro-cartilagenous tissue usually requiring a change in treatmenttreatment
FDA: FDA: Minimum of 9 months since injury and fracture Minimum of 9 months since injury and fracture shows no visible progressive signs of healing for 3 shows no visible progressive signs of healing for 3 monthsmonths
Fracture that has no potential to heal without further Fracture that has no potential to heal without further interventionintervention
Definition of nonunion should not limit or Definition of nonunion should not limit or prevent appropriate and timely interventionprevent appropriate and timely intervention
– “ “The best treatment for nonunions is The best treatment for nonunions is prevention”prevention”
Sir Sir
John CharnleyJohn Charnley
Waiting 9 months or more is often Waiting 9 months or more is often inappropriate:inappropriate:– Prolonged morbidityProlonged morbidity– Inability to return to workInability to return to work– Narcotic dependenceNarcotic dependence– Emotional impairmentEmotional impairment
Mechanisms for Bone Mechanisms for Bone HealingHealing
Indirect (secondary) - Callus Direct (primary)
Indirect Bone HealingIndirect Bone Healing Mechanism for healing in fractures that are not
rigidly fixed. Bridging periosteal (soft) callus and medullary (hard)
callus re-establish structural continuity Callus - undergoes endochondral ossification Process fairly rapid - weeks
Direct Bone HealingDirect Bone Healing Mechanism of bone healing seen when there is no
motion at the fracture site (i.e. rigid internal fixation) Osteoblasts originate from endothelial & perivascular
cells– lay down lamellar bone behind osteoclasts forming lay down lamellar bone behind osteoclasts forming
a secondary osteona secondary osteon– Healed by formation of numerous secondary Healed by formation of numerous secondary
osteonsosteons Slow process – months to yearsSlow process – months to years
Direct Bone HealingDirect Bone Healing
LOCAL REGULATION OF BONE HEALING
Growth factors Cytokines Prostaglandins/Leukotrienes Hormones Growth factor antagonists
GROWTH FACTORSGROWTH FACTORS
Transforming growth factor Bone morphogenetic proteins Fibroblast growth factors Platelet-derived growth factors Insulin-like growth factors
Transforming Growth FactorTransforming Growth Factor
Serine/Threonine kinase cell wall receptorsSerine/Threonine kinase cell wall receptors Proliferation & differentiation of mesenchymal Proliferation & differentiation of mesenchymal
precursors for osteoblasts, osteoclasts & precursors for osteoblasts, osteoclasts & chondrocyteschondrocytes
Endochondral & intramembranous bone Endochondral & intramembranous bone formationformation
Bone Morphogenetic Proteins Bone Morphogenetic Proteins
Included in the TGF-β family– Except BMP-1
BMP 2-7,9 - Osteoinductive BMP 2,6 & 9 - Osteoblastic Work through the intracellular Smad pathway Follow a dose/response ratio Osteoinductive proteins isolated from Osteoinductive proteins isolated from
demineralized bone matrixdemineralized bone matrix
Bone Morphogenetic ProteinsBone Morphogenetic Proteins Induce cell mesenchymal Induce cell mesenchymal
differentiationdifferentiation– BMP-3 (osteogenin) - boneBMP-3 (osteogenin) - bone
Promote endochondral ossificationPromote endochondral ossification– BMP-2 & BMP-7 - segmental defectsBMP-2 & BMP-7 - segmental defects
Regulate extracellular matrix Regulate extracellular matrix productionproduction– BMP-1 is an enzyme that cleaves the BMP-1 is an enzyme that cleaves the
carboxy termini of procollagens I, II and IIIcarboxy termini of procollagens I, II and III
Fibroblast Growth FactorsFibroblast Growth Factors
Both acidic (FGF-1) and basic (FGF-2) forms Both acidic (FGF-1) and basic (FGF-2) forms Increase proliferation of chondrocytes & Increase proliferation of chondrocytes &
osteoblastsosteoblasts Enhance callus formationEnhance callus formation FGF-2 stimulates angiogenesisFGF-2 stimulates angiogenesis
Platelet-Derived Growth FactorPlatelet-Derived Growth Factor
Dimer of products of two genes PDGF-A & Dimer of products of two genes PDGF-A & PDGF-BPDGF-B
Stimulates bone cell growthStimulates bone cell growth Increases type I collagen synthesis by Increases type I collagen synthesis by
increasing the number of osteoblastsincreasing the number of osteoblasts PDGF-BB stimulates bone resorption by PDGF-BB stimulates bone resorption by
increasing number of osteoclastsincreasing number of osteoclasts
Insulin-like Growth FactorInsulin-like Growth Factor
Two types: IGF-I and IGF-IITwo types: IGF-I and IGF-II– Synthesized by multiple tissuesSynthesized by multiple tissues– IGF-I production in the liver is stimulated IGF-I production in the liver is stimulated
by Growth Hormoneby Growth Hormone Stimulates bone collagen and matrix Stimulates bone collagen and matrix
synthesissynthesis Stimulates replication of osteoblastsStimulates replication of osteoblasts Inhibits bone collagen degradationInhibits bone collagen degradation
CytokinesCytokines Interleukin-1, 4, 6, 11, macrophage and Interleukin-1, 4, 6, 11, macrophage and
granulocyte/macrophage (GM) colony-granulocyte/macrophage (GM) colony-stimulating factors (CSFs) & Tumor Necrosis stimulating factors (CSFs) & Tumor Necrosis FactorFactor
Stimulate bone resorptionStimulate bone resorption– IL-1 is the most potentIL-1 is the most potent
IL-1 and IL-6 synthesis is decreased by estrogenIL-1 and IL-6 synthesis is decreased by estrogen Peak during 1Peak during 1stst 24 hours then again during 24 hours then again during
remodelingremodeling Regulate endochondral bone formationRegulate endochondral bone formation
Specific Factor Stimulation of Specific Factor Stimulation of Osteoblasts and OsteoclastsOsteoblasts and Osteoclasts
CytokineCytokine Bone Formation Bone Formation Bone Bone ResorptionResorption
IL-1IL-1 ++ ++++++TNF-TNF-αα ++ ++++++TNF-TNF-ββ ++ ++++++TGF-TGF-αα ---- ++++++TGF-TGF-ββ ++++ ++++PDGFPDGF ++++ ++++IGF-1IGF-1 ++++++ 00IGF-2IGF-2 ++++++ 00FGFFGF ++++++ 00
Prostaglandins / LeukotrienesProstaglandins / Leukotrienes Effect on bone resorption is species Effect on bone resorption is species
dependent and their overall effects in dependent and their overall effects in humans unknownhumans unknown
Prostaglandins of the E seriesProstaglandins of the E series– Stimulate osteoblastic bone formationStimulate osteoblastic bone formation– Inhibit activity of isolated osteoclastsInhibit activity of isolated osteoclasts
LeukotrienesLeukotrienes– Stimulate osteoblastic bone formationStimulate osteoblastic bone formation– Enhance capacity of isolated osteoclasts Enhance capacity of isolated osteoclasts
to form resorption pitsto form resorption pits
HormonesHormones EstrogenEstrogen
– Stimulates fracture healing - receptor mediated Stimulates fracture healing - receptor mediated mechanismmechanism
– Modulates release of a specific inhibitor of IL-1Modulates release of a specific inhibitor of IL-1 Thyroid hormonesThyroid hormones
– Thyroxine and triiodothyronine - osteoclastic bone Thyroxine and triiodothyronine - osteoclastic bone resorptionresorption
GlucocorticoidsGlucocorticoids– Inhibit calcium absorption from gut - increased PTH Inhibit calcium absorption from gut - increased PTH – increased osteoclastic bone resorptionincreased osteoclastic bone resorption
Parathyroid Hormone -Intermittent exposure Parathyroid Hormone -Intermittent exposure – OsteoblastsOsteoblasts– Increased bone formationIncreased bone formation
Growth HormoneGrowth Hormone– Mediated through IGF-1 (Somatomedin-C)Mediated through IGF-1 (Somatomedin-C)– Increases callus formation and fracture strengthIncreases callus formation and fracture strength
Vascular FactorsVascular Factors
MetalloproteinasesMetalloproteinases– Degrade cartilage & bones to allow invasion of Degrade cartilage & bones to allow invasion of
vesselsvessels Angiogenic factorsAngiogenic factors
– Vascular-endothelial growth factorsVascular-endothelial growth factors Mediate neo-angiogenesis & endothelial-cell Mediate neo-angiogenesis & endothelial-cell
specific mitogensspecific mitogens– Angiopoietin (1&2)Angiopoietin (1&2)
Regulate formation of larger vessels & Regulate formation of larger vessels & branches branches
IncidenceIncidence
Between 5% and 10% of long bone fracturesBetween 5% and 10% of long bone fractures Relative Risk depends upon:Relative Risk depends upon:
– InjuryInjury– BoneBone– Patient Patient – TreatmentTreatment
Metabolic & Nutritional statusMetabolic & Nutritional status Generalized health & activity levelGeneralized health & activity level SmokingSmoking NSAIDsNSAIDs Systemic Medical ConditionsSystemic Medical Conditions
Systemic Risk FactorsSystemic Risk Factors
Local factorsLocal factors – OpenOpen– InfectedInfected– Segmental -impaired blood supply -Middle Segmental -impaired blood supply -Middle
fragment fragment – Comminuted by severe traumaComminuted by severe trauma– Insecurely fixed Insecurely fixed – Immobilized for an insufficient time Immobilized for an insufficient time – Treated by ill-advised open reduction Treated by ill-advised open reduction – Distracted - Traction or Plate and screws Distracted - Traction or Plate and screws – Irradiated bone Irradiated bone
MalnutritionMalnutrition
Adequate protein and energy is required for Adequate protein and energy is required for wound healingwound healing
Causes reduced activity & proliferation of Causes reduced activity & proliferation of osteochondral cellsosteochondral cells
Decreased callus formationDecreased callus formation Albumin less than 3.5 and lymphocytes less Albumin less than 3.5 and lymphocytes less
than 1,500 cells/ml is significantthan 1,500 cells/ml is significant
Diabetes Mellitus
Associated with collagen defects Decreased collagen content Defective cross-linking Alterations in collagen sub-type ratios
SMOKINGSMOKING
Cigarette smoke inhibits osteoblastsCigarette smoke inhibits osteoblasts Nicotine causes vasoconstriction diminishing Nicotine causes vasoconstriction diminishing
blood flow at fracture siteblood flow at fracture site Decreases peripheral oxygen tension & Decreases peripheral oxygen tension &
Dampens peripheral blood flowDampens peripheral blood flow Well documented difficulties in wound healing Well documented difficulties in wound healing
in patients who smokein patients who smoke
Infection
““Of all prognostic factors in tibia fracture care, Of all prognostic factors in tibia fracture care, that implying the worst prognosis was that implying the worst prognosis was infectioninfection””
The inflammatory response to bacteria at the site of the fracture disrupts callus, increases gap between fragments, and increases motion between fragments.
IatrogenicIatrogenic
Poor ReductionPoor Reduction Unstable fixationUnstable fixation Bone DevitalizationBone Devitalization
– Excessive soft tissue dissection and Excessive soft tissue dissection and periosteal stripping at time of previous periosteal stripping at time of previous fixationfixation
Energy of Fracture Energy of Fracture MechanismMechanism
Initial fracture displacementInitial fracture displacement Fracture pattern Fracture pattern
– comminutioncomminution– bone lossbone loss– segmental patternssegmental patterns
Soft tissue disruption (vascularity and oxygen Soft tissue disruption (vascularity and oxygen delivery)delivery)
CausesCausesMechanical FailureMechanical Failure
Inadequate immobilization & internal fixationInadequate immobilization & internal fixation Hypertrophic type with mobility & pain Hypertrophic type with mobility & pain Stability restored – fracture heals quicklyStability restored – fracture heals quickly Fragments have good blood supplyFragments have good blood supply
CausesCausesBiological FailureBiological Failure
Loss of blood supply to fracture site/ infection/loss of Loss of blood supply to fracture site/ infection/loss of healing factors- BMP / evacuation of haematoma in healing factors- BMP / evacuation of haematoma in ORIFORIF
Addition to restoring stability + stimulation of healing- Addition to restoring stability + stimulation of healing- bone grafting / electrical stimulation / low intensity ultra bone grafting / electrical stimulation / low intensity ultra soundsound
Bone ends are atrophic, with no callus and presence Bone ends are atrophic, with no callus and presence of mobilityof mobility
CLASSIFICATIONCLASSIFICATION Judet and Judet, Müller (AO), Weber and Cech
Hypervascular (Hypertrophic) or viable - Capable of biological reaction.
Avascular (Atrophic) or inert
- Not capable of uniting without intervention.
Hypervascular nonunionsHypervascular nonunions
Elephant foot. Horse hoof Oligotrophic
Torsion wedge Comminuted Defect Atrophic
Avascular nonunions
Classification of Nonunions of TibiaClassification of Nonunions of Tibia Paley et al. Paley et al. Applied to nonunions of other bones Applied to nonunions of other bones Type A - Nonunions with bone loss of less than 1 cm Type A - Nonunions with bone loss of less than 1 cm
– Type A1 - mobile deformityType A1 - mobile deformity– Type A2 - fixed deformity Type A2 - fixed deformity
Type A2-1 - Stiff nonunion without deformity, Type A2-1 - Stiff nonunion without deformity, Type A2-2 - Stiff nonunion with a fixed deformity.Type A2-2 - Stiff nonunion with a fixed deformity.
Type B - Nonunions with bone loss of more than 1 Type B - Nonunions with bone loss of more than 1 cmcm– Type B1 - Bony defect Type B1 - Bony defect – Type B2 - Loss of bone length Type B2 - Loss of bone length – Type B3 - BothType B3 - Both
Modified further by presence or absence of Modified further by presence or absence of infection. infection.
Type AType A
A1-Lax (mobile) A2-1-Fixed+No deformity
A2-2-Fixed deformity
Type B
Bony defect + no shortening Shortening+ no bony defect
Bony defect and shortening
Diagnosis of Nonunion- Diagnosis of Nonunion- HistoryHistory
Nature of original injury (high or low energy)Nature of original injury (high or low energy) Previous open wounds of injury sitePrevious open wounds of injury site Pain present at fracture sitePain present at fracture site Symptoms of infection i.e. Symptoms of infection i.e.
– Antalgic gait or decrease use secondary to Antalgic gait or decrease use secondary to painpain
History of any drainage or wound healing History of any drainage or wound healing difficultiesdifficulties
ExaminationExamination AlignmentAlignment DeformityDeformity Soft tissue integritySoft tissue integrity Erythema, warm, drainageErythema, warm, drainage Vascularity of limbVascularity of limb
– Pulses, transcutaneous oximetryPulses, transcutaneous oximetry Stability at fracture siteStability at fracture site
– Pain assessed during this portion of Pain assessed during this portion of examinationexamination
X-raysX-rays
AP, lateral, and oblique (45degree internal AP, lateral, and oblique (45degree internal and 45 degree external)and 45 degree external)
In majority of cases, this is all that is required In majority of cases, this is all that is required to confirm nonunionto confirm nonunion
Examination under fluoroscopy to check for Examination under fluoroscopy to check for motion can occasionally be helpful alsomotion can occasionally be helpful also
TomographyTomography
Linear tomogramsLinear tomograms– Helpful if metallic hardware presentHelpful if metallic hardware present
Helps to identify persistent fracture line in:Helps to identify persistent fracture line in:– Hyptrophic nonunions in which x-rays are not Hyptrophic nonunions in which x-rays are not
diagnostic and pain persists at fracture sitediagnostic and pain persists at fracture site Computed tomography and MRI are replacing Computed tomography and MRI are replacing
linear tomography if no hardware presentlinear tomography if no hardware present
Computed TomographyComputed Tomography
Radionuclide ScanningRadionuclide Scanning Technetium - 99 diphosphonateTechnetium - 99 diphosphonate
– Detects repairable process in bone ( not specific)Detects repairable process in bone ( not specific) Gallium - 67 citrateGallium - 67 citrate
– Accumulate at site of inflammation (not specific)Accumulate at site of inflammation (not specific) Sequential technetium or gallium scintigraphySequential technetium or gallium scintigraphy
– Only 50-60% accuracy in subclinical ostoemyelitisOnly 50-60% accuracy in subclinical ostoemyelitis Indium III - Labeled Leukocyte ScanIndium III - Labeled Leukocyte Scan
– Good with acute osteomyelitis, but less effective Good with acute osteomyelitis, but less effective chronic or subacute bone infectionschronic or subacute bone infections
– Sensitivity 83-86%, specificity 84-86%Sensitivity 83-86%, specificity 84-86%– superior to technetium and gallium to identify superior to technetium and gallium to identify
infectioninfection
MRIMRI
Abnormal marrow with increased signal on T2 and low signal on T1
Can identify and follow sinus tacts and sequestrum
Mason study- diagnostic sensitivity of 100%, specificity 63%, accuracy 93%
Tissue BiopsyTissue Biopsy Antibiotic discontinued for 72 hours prior to Antibiotic discontinued for 72 hours prior to
biopsybiopsy Multiple representative biopsy specimens Multiple representative biopsy specimens
should be obtainedshould be obtained Cultures sent for gram stain, aerobic, anerobic, Cultures sent for gram stain, aerobic, anerobic,
fungal, and acid fast studiesfungal, and acid fast studies Open biopsy techniques can be inconclusive Open biopsy techniques can be inconclusive
due to problem of detecting bacteria protected due to problem of detecting bacteria protected by an external glycocalyxby an external glycocalyx
TreatmentTreatment
NonoperativeNonoperative OperativeOperative
Nonoperative TreatmentNonoperative Treatment
Mechanical stimulationMechanical stimulation UltrasoundUltrasound
– mechanical energy in the form of low frequency mechanical energy in the form of low frequency acoustic waves 30 mW/cmacoustic waves 30 mW/cm22
ElectromagneticElectromagnetic– Direct CurrentDirect Current– Inductive coupling (PEMF, CMF)Inductive coupling (PEMF, CMF)– Capacitive couplingCapacitive coupling
Bone marrow injectionBone marrow injection
Mechanical StimulationMechanical Stimulation
Early weight bearingEarly weight bearing– Facilitate maturation of callus Facilitate maturation of callus – – endochondral ossification in cast braceendochondral ossification in cast brace
Axial MicromotionAxial Micromotion– Acclerates healingAcclerates healing
Low intensity pulsed ultrasound (lipus)Low intensity pulsed ultrasound (lipus)
Dose – low intensity Dose – low intensity
– – 30 m W/cm2 30 m W/cm2
– – 20 minutes a day20 minutes a day
Electric StimulationElectric Stimulation Piezoelectric nature of bone - stress generated
electric potentials exist in bone & are related to callus formation
Electromagnetic fields influence vascularization of fibrocartilage, cell proliferation & matrix production
Three Modalities of Electric bone Growth Stimulators– 1. Direct current - percutaneous or implanted electrodes1. Direct current - percutaneous or implanted electrodes– 2. Electromagnetic stimulation - time varying magnetic 2. Electromagnetic stimulation - time varying magnetic
fieldsfields– 3. Capacitive coupling - electrodes placed on skin3. Capacitive coupling - electrodes placed on skin
ContraindicationContraindication– Synovial pseudoarthrosisSynovial pseudoarthrosis
Surgical TreatmentSurgical Treatment
Cure infection if presentCure infection if present Correct Deformity if significantCorrect Deformity if significant Provide stability through implantsProvide stability through implants Add biologic stimulus when necessaryAdd biologic stimulus when necessary
Surgical TreatmentSurgical Treatment Fibular osteotomyFibular osteotomy Bone graftBone graft Plate osteosynthesisPlate osteosynthesis Intramedullary nailingIntramedullary nailing External fixationExternal fixation
Infected NonunionsInfected Nonunions
Contaminated implants and devitalized implants must Contaminated implants and devitalized implants must be removedbe removed
Infection treated:Infection treated:– Temporary stabilization (external fixation)Temporary stabilization (external fixation)– Culture specific antibioticsCulture specific antibiotics– +/- local antibiotic delivery (antibiobic beads)+/- local antibiotic delivery (antibiobic beads)
Secondary stabilization with augmentation of Secondary stabilization with augmentation of osteogenesis (cancellous grafting)osteogenesis (cancellous grafting)
Methods of Adding StabilityMethods of Adding Stability
Cast/Brace – rarely sufficient in nonunions External Fixation Plates Intramedullary Devices
External FixationExternal Fixation Correct malalignmentCorrect malalignment Used primarily in management of infected Used primarily in management of infected
nonunionsnonunions Allows for repeated debridements, soft tissue Allows for repeated debridements, soft tissue
reconstructive procedures, and adjunctive bone-reconstructive procedures, and adjunctive bone-graftinggrafting
Small wire ring fixators can also allow for bone Small wire ring fixators can also allow for bone transport into large intercalary defectstransport into large intercalary defects
Ring fixators can also generate large compressive Ring fixators can also generate large compressive forces at fracture to allow mobilization of joints forces at fracture to allow mobilization of joints and improve fracture healing environmentand improve fracture healing environment
Plate OsteosynthesisPlate Osteosynthesis Corrects malalignmentCorrects malalignment Restores function & stabilizes fracture Restores function & stabilizes fracture
fragments directlyfragments directly Compresses fragments in some circumstances Compresses fragments in some circumstances
to augment healingto augment healing Allows patients to mobilize surrounding joints Allows patients to mobilize surrounding joints Locking plates - improved stability & fixation strengthLocking plates - improved stability & fixation strength Requires adequate skin and soft tissue Requires adequate skin and soft tissue
coveragecoverage Often used with adjunctive bone graftOften used with adjunctive bone graft
Intramedullary NailingIntramedullary Nailing Mechanically stabilizes long bone nonunions as a Mechanically stabilizes long bone nonunions as a
load sharing implantload sharing implant Corrects malalignmentCorrects malalignment Reaming is initially detrimental to intramedullary Reaming is initially detrimental to intramedullary
blood supply, but it does recover and is believed blood supply, but it does recover and is believed to stimulate biologic healing at fractureto stimulate biologic healing at fracture
Allow patient to mobilize surrounding joints and Allow patient to mobilize surrounding joints and dynamize fracture environmentdynamize fracture environment
Can be performed without direct exposure or Can be performed without direct exposure or dissection of the fracture soft tissue envelopedissection of the fracture soft tissue envelope
Nonapplicable in articular fracturesNonapplicable in articular fractures
Adding BiologyAdding Biology Often unnecessary in hypertrophic cases with Often unnecessary in hypertrophic cases with
sufficient inherent biologic activitysufficient inherent biologic activity OptionsOptions
– Aspirated stem cells (with or without expansion) stem cells (with or without expansion)– Demineralized Bone MatrixDemineralized Bone Matrix– Autogenous Cancellous GraftAutogenous Cancellous Graft– Growth FactorsGrowth Factors
Platelet derivedPlatelet derived Recombinant BMPsRecombinant BMPs Gene TherapyGene Therapy
Stem CellsStem Cells
Aspirated iliac crest stem Aspirated iliac crest stem cells has been shown to cells has been shown to enhance the activity of enhance the activity of osteoconductive graftsosteoconductive grafts
Has been studied as an Has been studied as an isolated technique with isolated technique with limited successlimited success
Role of expansion and Role of expansion and delayed implantation may delayed implantation may play a future roleplay a future role
Demineralized Bone MatrixDemineralized Bone Matrix Osteoinduction has been experimentally demonstratedOsteoinduction has been experimentally demonstrated Produced by acid extraction of allograft boneProduced by acid extraction of allograft bone Contains type I collagen, noncollagenous protein & Contains type I collagen, noncollagenous protein &
osteoinductive growth factorsosteoinductive growth factors Effective in humeral shaft nonunionsEffective in humeral shaft nonunions Avoids the morbidity of iliac crest graftAvoids the morbidity of iliac crest graft As effective as iliac crestAs effective as iliac crest
Autogenous Cancellous BoneAutogenous Cancellous Bone SitesSites
– Posterior Iliac Crest (20 cc)Posterior Iliac Crest (20 cc)– Anterior Iliac Crest (10cc)Anterior Iliac Crest (10cc)– Proximal Tibia (7cc)Proximal Tibia (7cc)– Distal Radius, Calcaneus, Olecronon (?)Distal Radius, Calcaneus, Olecronon (?)
incidence of donor morbidity dependent upon harvest incidence of donor morbidity dependent upon harvest site and volume requiredsite and volume required
Still considered by many to be the most osteogenic Still considered by many to be the most osteogenic graft materialgraft material
Bone GraftingBone Grafting Most frequently used method of treatment of
nonunions Used to stimulate biologic response of healing in
nonunions -usually atrophic nonunions Autogenous bone graft, allograft bone, or synthetic
bone substitute, used alone or in conjunction with internal fixation, may help to stimulate bone formation.
Autogenous cancellous bone - gold standard grafting material
osteoconductive (matrix) and osteoinductive (protein) properties and its osteoprogenitor cells make it an ideal substance for nonstructural grafting
Bone Grafting Bone Grafting
Onlay Bone Graft Dual Onlay Graft Cancellous Insert Grafts Massive Sliding Graft Whole Fibular Transplants Vascularized Free Fibular Graft Intramedullary Fibular Allografts
Onlay Bone GraftOnlay Bone Graft Massive cortical grafts combine fixation Massive cortical grafts combine fixation
&osteogenesis&osteogenesis Massive sliding graft - Gill Massive sliding graft - Gill Campbell originated the term onlay graft -Campbell originated the term onlay graft -
modification of Henderson's technique modification of Henderson's technique Phemister - graft is placed subperiosteally Phemister - graft is placed subperiosteally
across the fragments without mobilizing the across the fragments without mobilizing the fragments. fragments. – Blood supply of the fragments and the normal Blood supply of the fragments and the normal
impacting forces of the fracture were not disturbedimpacting forces of the fracture were not disturbed Forbes described a modification of the Forbes described a modification of the
Phemister technique. Phemister technique.
Dual Onlay Graft 1941 Boyd - dual grafts are used. 1941 Boyd - dual grafts are used. Two cortical onlay grafts are placed opposite Two cortical onlay grafts are placed opposite
each other on the host bone across the nonunion each other on the host bone across the nonunion and are fixed with the same set of screwsand are fixed with the same set of screws
Any intervening space at the bone ends is filled Any intervening space at the bone ends is filled with cancellous chips. with cancellous chips.
Dual grafts have been used to fix a nonunited Dual grafts have been used to fix a nonunited fracture near a joint firmly with a short, fracture near a joint firmly with a short, osteoporotic fragment. osteoporotic fragment.
Nonunions near a joint now often are treated by Nonunions near a joint now often are treated by plating and autogenous cancellous bone grafting plating and autogenous cancellous bone grafting or by the application of a circular external or by the application of a circular external fixator. fixator.
Boyd dual onlay grafts
Cancellous Insert Grafts Nicoll - Bridging gaps in long bones with solid Nicoll - Bridging gaps in long bones with solid
blocks of cancellous bone & fixing fragments blocks of cancellous bone & fixing fragments with metal plates.with metal plates.
Defects less than 2.5 cm long.Defects less than 2.5 cm long. Ordinary plates are used but compression Ordinary plates are used but compression
plates are preferable.plates are preferable. Aftertreatment Aftertreatment
– cast is applied and worn for 2 or 3 months,
Massive Sliding Graft
Gill - uses a sliding graft about one half the Gill - uses a sliding graft about one half the circumference of the bone and 10 to 15 cm long circumference of the bone and 10 to 15 cm long
Flanagan and Burem revised and improved this Flanagan and Burem revised and improved this technique for nonunion of the tibia and femurtechnique for nonunion of the tibia and femur
Useful for bridging bone defects, but when a Useful for bridging bone defects, but when a massive sliding graft fails, later grafting is massive sliding graft fails, later grafting is difficult. difficult.
Gill massive sliding graft
Whole Fibular Transplants
whole fibular transplant may be useful for bridging defects in the radius or ulna
As it is tubular, it is stronger than a tibial graft with same amount of cortical bone and need not be as large
used to bridge defects in the humeral shaft & Distal radius
Vascularized Free Fibular Graft Treatment of osteonecrosis of the femoral head Treat defects associated with tumor resections Duffy et al. - vascularized free fibular grafting for
nonunions of shaft fractures of bones that had been irradiated to treat a malignancy
Used the graft in an “onlay” manner in association with other forms of fixation, such as intramedullary nailing or plating.
Bone graft substitutesBone graft substitutes
Osteoconductive propertyOsteoconductive property Calcium phosphate, calcium sulphate, Calcium phosphate, calcium sulphate,
hydroxyapatite, other calcium based ceramicshydroxyapatite, other calcium based ceramics
Recombinant Bone Morphogenic Recombinant Bone Morphogenic ProteinsProteins
BMP-2BMP-2
Infuse™Infuse™
Demonstrated effective in acute open tibial Demonstrated effective in acute open tibial fracturesfractures
FDA approved in acute fracturesFDA approved in acute fractures BMP-7BMP-7
–OP-1™OP-1™–Comparable to autograft in tibia nonunionsComparable to autograft in tibia nonunions–FDA approved under HD exemptionFDA approved under HD exemption
INFECTED NON UNION
Sir Reginald Watson JonesSir Reginald Watson Jones
Infection is not a cause of nonunions If nonunions allowed to occur, it is due not
infections, but to adequate immobilization permitted by reason of infection
Mobility at fracture site is more likely to promote or sustain infection than a metal foreign body
DefinitionDefinition
Fracture un-united for less than 6 months with Fracture un-united for less than 6 months with wound is open & infected with exposed dead wound is open & infected with exposed dead bone or metalbone or metal
Fracture un-united for more than 6 months with Fracture un-united for more than 6 months with apparent clinical motion at fracture site, apparent clinical motion at fracture site, formation of sinus, indicating sequestration or formation of sinus, indicating sequestration or extensive osteomyelitisextensive osteomyelitis
-Dendrinos 1995-Dendrinos 1995
IncidenceIncidence
Gustilo’s study – 44% of open segmental Gustilo’s study – 44% of open segmental fracture with periosteal stripping and fracture with periosteal stripping and fragmentation of bone developed infectionsfragmentation of bone developed infections
Commonest in tibia followed by femur, humerus Commonest in tibia followed by femur, humerus & forearm bones& forearm bones
Rosen’s ClassificationRosen’s Classification
Non-draningNon-draning– Quiescent dry for three monthsQuiescent dry for three months– Active abscessActive abscess
Draining - Sinus with sequestrum or cavityDraining - Sinus with sequestrum or cavity
Cierny and Mader StagingCierny and Mader StagingAnatomical Type I Medullary Endosteal disease II Superficial Cortical surface infected because of
coverage defect III Localized Cortical sequestrum that can be excised
without compromising stability IV Diffuse Features of I, II, and III plus mechanical
instability before or after débridement
Physiological Class A host Normal Immunocompetent with good local
vascularity B host Compromised Local (L) or systemic (S) factors that
compromise immunity or healing C host Prohibitive Minimal disability, prohibitive morbidity
anticipated, or poor prognosis for cure
PathogenesisPathogenesis Microbial adhesion to the damaged tissue or metal
implants Occurs in open fractures with implant applied has
become loose Necrotic bone or implants are covered by avascular
material – glycocalyx(slime) – hydrated mucopolysaccharide layer
Slime protects bacteria in a sessile state increasing their resistance to destruction by a factor of 500
Increased bacterial surface adherence isolating them from effects of antibiotics, antibodies & immune directed phagocytosis
Infection persist due to thrombosis of Haversian canal– avascular zone of fibrosis of local tissue & bone
marrow– causing reduction in antibiotic perfusion and
protecting the microorganisms Inadequate perfusion
– leads to inadequate supply of antibiotics – resulting in failure of antibiotic action & resistance of
organisms
InvestigationsInvestigations Routine blood investigation including ESR & CRPRoutine blood investigation including ESR & CRP X- Rays – helpful in identifying necrotic areas & X- Rays – helpful in identifying necrotic areas &
sequestrasequestra CT scan – extent of sequestration underneath a CT scan – extent of sequestration underneath a
periosteal new bone formationperiosteal new bone formation MRI – information on soft tissue & marrow MRI – information on soft tissue & marrow
involvementinvolvement Skeletal scintigraphy – sub-clinical infectionSkeletal scintigraphy – sub-clinical infection
– 111 Indium labeled leukocyte imaging111 Indium labeled leukocyte imaging– Te 99m methylene diphosphonate imagingTe 99m methylene diphosphonate imaging– Gallium -67 scanGallium -67 scan– Sulphane blue – identify infected areas of bone while Sulphane blue – identify infected areas of bone while
doing debridementdoing debridement
PRINCIPLES OF TREATMENT
Conversion of infected into asceptic nonunion– Debridement, local antibiotics
Stabilisation of fracture by internal or ext. fixation Adequate soft tissue coverage
DEBRIDEMENT Devitalized bone and soft tissue – barriers for
eradication of infection Intramedullary debridement - Reaming I M Canal Removal of implant Carcinogenic resection of infected bone
– Wide resection of entire infected bone with infected scarred soft tissue with clearence of margin of 5 mm in bone
Resect bony ends till punctuate bleeding(Paprika sign)
Lautenbach’s principles of infection control
Radical resection & removal of infected marrow – gentle reaming & washing marrow out
Antiobiotic solution are instilled 4 th hourly, kept for 4 hours and sucked out for 4 weeks
Irrigation solution contains chlorhexidine(antiseptic) teicoplanin(antibiotic) & streptokinase(anticoagulant)
Local Antibiotic delivery system
Treatment by AB impregnated intramedullary nail & beads
kill bacteria protected in Biofilm local concentration > 100 times serum conc.
IDEAL LOCAL DRUG DELIVERY SYSTEM
High concentration locallyHigh concentration locally No systematic toxicityNo systematic toxicity Satisfactory elution Satisfactory elution Easily placed, removed & changedEasily placed, removed & changed InexpensiveInexpensive Broad spectrumBroad spectrum ThermostableThermostable
AntibioticsAntibiotics Antibiotic Commonly UsedAntibiotic Commonly Used
– VancomycinVancomycin– GentamycinGentamycin– TobramycinTobramycin
Other antibioticsOther antibiotics– CefazolinCefazolin– CiprofloxacinCiprofloxacin– ClindamycinClindamycin– TicarcillinTicarcillin– TeicoplaninTeicoplanin– ErythromycincolistinErythromycincolistin– CefotaximeCefotaxime– Amphoteracin BAmphoteracin B
Preparation of Dough for Beads and Rod
40 gm. Cement plus– Tobramycin 3.6 gm.– Vancomycin 4 gm. – Cefepime 4 gm. – Cefezolin 4 gm.– Nafcillin 4 gm.– Brittle Beads size 7 mm.
ADVANTAGES OF AB ROD & BEADS Local high concentration -AB Primary wound closure – reduced post operative
morbidity No systemic toxicity Painful inflammatory response subsides rapidly –
increased patient comfort. No daily dressing. No secondary infection Gram negative over growth (wet Germs) seen with
irrigation suction drainage are avoided Bacterial cross seeding avoided (Hospital infections) Hospitalization is shortened Cost effective
DISADVANTAGES OF AB ROD & BEADS
Cannot adjust antibiotic when wound flora changes Not as effective as irrigation Spent beads may act as nide for infection Only limited number of antibiotics are available in the
form in which it can be used in beads Requires surgery for removal Complications have occurred with use of PMMA
beads when they were left too long or placed near major places
STABILIZATION & RECONSTRUCTION STABILIZATION & RECONSTRUCTION METHODSMETHODS
Aim of stabilization– Bring about bony bridging– Allow functional after treatment– Allow easy wound care & to support eradication of
infection– Allow later reconstructive surgery if necessary
STABILIZATION & RECONSTRUCTION STABILIZATION & RECONSTRUCTION METHODSMETHODS
Skeletal Reconstruction– Ilizarov’s method– Vascularised bone graft– Corticocancellous bone graft– Papineau cancellous bone graft– Bypass graft (tibiofibular grafting)– Tibio fibular synostosis
ILIZAROV’S CONCEPT FOR INFECTED ILIZAROV’S CONCEPT FOR INFECTED NONUNIONNONUNION
Osteomylitis burns in the fire of regenerationOsteomylitis burns in the fire of regeneration Cyclic axial telescoping mobility, not rigidity, at Cyclic axial telescoping mobility, not rigidity, at
the union site is important for formation of the union site is important for formation of reparative callusreparative callus
Activate biosynthetic process, increasing local Activate biosynthetic process, increasing local resistant to infectionresistant to infection
Three ways of elimination of Three ways of elimination of infection in Ilizarov methodinfection in Ilizarov method
Controlled osteogenesis, filling of cavities by Controlled osteogenesis, filling of cavities by newly formed tissuenewly formed tissue
Resection of infected bone and subsequent Resection of infected bone and subsequent intercalary bone lengtheningintercalary bone lengthening
Gradual bone transport of one wall of the cavityGradual bone transport of one wall of the cavity
Ilizarov methodIlizarov method Distraction osteogenesisDistraction osteogenesis Tension-stress effectTension-stress effect Mechanical induction of new bone formationMechanical induction of new bone formation NeovascularizationNeovascularization Stimulation of biosynthetic activityStimulation of biosynthetic activity Activation and recruitment of osteoprogenitor Activation and recruitment of osteoprogenitor
cellscells Intramembranous ossificationIntramembranous ossification
Ilizarov`s plan depends on Ilizarov`s plan depends on
Size and thickness of bone fragmentSize and thickness of bone fragment Degree and type of displacementDegree and type of displacement The extent of mobilityThe extent of mobility Amount and character of scar tissueAmount and character of scar tissue Prevalence of purulent processPrevalence of purulent process Characteristics of the individual caseCharacteristics of the individual case
Ilizarov Treatment ModesIlizarov Treatment Modes Monofocal
– Compression– Sequential distraction-compression Distraction– Sequential compression-distraction
Bifocal – Compression-distraction lengthening– Distraction-compression transport (bone transport)
Trifocal – Various combinations
Monofocal longitudinal Monofocal longitudinal compressioncompression
Hypertrophic nonunion Hypertrophic nonunion Minimal infectionMinimal infection No sequestrum, smallest sequester left in place, No sequestrum, smallest sequester left in place,
they are assimilated in the process of active they are assimilated in the process of active osteogenesisosteogenesis
spontaneous eradication of infection and spontaneous eradication of infection and achievement of unionachievement of union
Monofocal osteosynthesis with Ilizarov fixator for hypertrophic nonunions with minimal infection, as recommended by Catagni.
Bifocal MethodBifocal Method
Atrophic nonunion with diffuse infection & Atrophic nonunion with diffuse infection & sequestrum sequestrum
Infected segment should be resectedInfected segment should be resected Creating an intercalary defectCreating an intercalary defect Acute shortening, opposing ends under Acute shortening, opposing ends under
compression; 1-2 Cm defectcompression; 1-2 Cm defect Poor skinPoor skin Big necrotic bone Big necrotic bone Numerous fistulaNumerous fistula
Bilocal simultaneous compression-Bilocal simultaneous compression-distraction osteosynthesisdistraction osteosynthesis
Small gap & substantial bone shorteningSmall gap & substantial bone shortening
Treatment consistedOf resection of Infected bone, acuteShortening and External fixation
Followed by proximalCorticotomy andDistraction to restorelength
Bifocal osteosynthesis with Ilizarov fixator after débridement of necrotic segments, as recommended by Catagni
Bilocal consecutive distraction-Bilocal consecutive distraction-compression osteosynthesiscompression osteosynthesis
Large gapLarge gap
ADVANTAGES ADVANTAGES Surgical morbidity is minimalSurgical morbidity is minimal Soft tissue reconstruction is rarely requiredSoft tissue reconstruction is rarely required Functional weight bearing is started earlyFunctional weight bearing is started early Progressive correction of angulatory & torsional Progressive correction of angulatory & torsional
deformitiesdeformities Ability to apply compression distraction or Ability to apply compression distraction or
angulatory correctionat multiple levelsangulatory correctionat multiple levels Diffuse osteoporosis is minimal – early Diffuse osteoporosis is minimal – early
functional wt bearingfunctional wt bearing Near bloodless & minimally invasive methodNear bloodless & minimally invasive method Eliminates secondary bone harvestingEliminates secondary bone harvesting
CONTRAINDICATIONS CONTRAINDICATIONS
Severe damage of tibial nerve with motor & Severe damage of tibial nerve with motor & sensory losssensory loss
Mental disease including senile dementiaMental disease including senile dementia Anticipated poor co- operation by patientAnticipated poor co- operation by patient
Ilizarov is a golden method for the Ilizarov is a golden method for the management of nonunion management of nonunion osteomylitis for both achieving union osteomylitis for both achieving union and eradication of infection, however and eradication of infection, however generous, careful sequential generous, careful sequential debridement and hardware/dead debridement and hardware/dead tissue removal and bone grafting is tissue removal and bone grafting is also an option for some selected also an option for some selected cases.cases.
Four basic methods of immediate, Four basic methods of immediate, biological management of dead space biological management of dead space using living tissue or cancellous bone using living tissue or cancellous bone grafts grafts
TREATMENT OF DEAD SPACE
Four basic methods of immediate, biological management of Four basic methods of immediate, biological management of
dead space using living tissue or cancellous bone graftsdead space using living tissue or cancellous bone grafts
Open Bone Grafting Papineau et al - open bone grafting - Papineau et al - open bone grafting -
chronic osteomyelitis.chronic osteomyelitis. principles:principles:
– granulation tissue markedly resists infection granulation tissue markedly resists infection – autogenous cancellous bone grafts are autogenous cancellous bone grafts are
rapidly revascularized and are resistant to rapidly revascularized and are resistant to infection infection
– infected area is completely excised infected area is completely excised – adequate drainage is provided adequate drainage is provided – adequate immobilization is provided adequate immobilization is provided – antibiotics are used for prolonged periods.antibiotics are used for prolonged periods.
Chronic osteomyelitis.
After débridement and development of granulation tissue.
Open bone graft.
Blood clot in place
Other treatment optionsOther treatment options
Free vascularized bone graftFree vascularized bone graft Posterolateral bone grafting (harmon’s Posterolateral bone grafting (harmon’s
technique)technique) Tibiofibular synostosisTibiofibular synostosis Free microvascular soft tissue flaps for Free microvascular soft tissue flaps for
coveragecoverage Local soft tissue rotational flapLocal soft tissue rotational flap Monolateral external fixatorMonolateral external fixator
Tibia and fibula have been approached posterolaterally. Tibia and fibula have been approached posterolaterally. Posterior aspect of tibia (or tibia and fibula) is roughened and grafted Posterior aspect of tibia (or tibia and fibula) is roughened and grafted with autogenous iliac bonewith autogenous iliac bone
Bone is approached anteriorly and is Bone is approached anteriorly and is saucerized, incision is closed,saucerized, incision is closed, and infection is treated with antibiotics by and infection is treated with antibiotics by irrigation and suctionirrigation and suction
Tibia is grafted posteriorly-Skin incision.Tibia is grafted posteriorly-Skin incision.
Treatment of nonunion of tibia in which sequestration or gross infection is presentTreatment of nonunion of tibia in which sequestration or gross infection is present
BIBILOGRAPHYBIBILOGRAPHY
CAMPBELL’S OPERATIVE ORTHOPAEDICSCAMPBELL’S OPERATIVE ORTHOPAEDICS APLEY’S ORTHOPAEDICSAPLEY’S ORTHOPAEDICS ORTHOPAEDIC TRAUMA ASSOCIATIONORTHOPAEDIC TRAUMA ASSOCIATION Prof. Mani & Prof Sudhkar Shetty, Prof. Mani & Prof Sudhkar Shetty,
Mangalore Orthopaedic CourseMangalore Orthopaedic Course
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