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Definition Types Causes of non-union Diagnosis of non-union Management/Treatment.

Definition-1

Definition-2

Definition-3

Definition-4 (Current)

(Based on blood supply)

Hypertrophic (elephant foot)

Hypertrophic (horse hoof) Oligotrophic or atrophic

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10

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Causes of Non unions

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Etiology of Nonunion:

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Etiology of Nonunion

Etiology of Nonunion:
(Systemic)

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Etiology of Nonunion

Etiology of Nonunion (Local Factors)

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Etiology of Nonunion
Local Risk FactorsEtiology of Nonunion
(Local Factors)

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Etiology of Nonunion

Etiology of Nonunion (Local Factors)

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Etiology of Nonunion
Traumatic Soft Tissue Disruption 1. During initial trauma 2. Iatrogenic
Etiology of Nonunion (Local Factors)

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Etiology of Nonunion
Etiology of Nonunion (Local Factors)

2
1

5
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Etiology of Nonunion

Etiology of Nonunion (Local Factors)

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Etiology of Nonunion
Etiology of Nonunion (Local Factors)

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Diagnosis of NonunionHistory
Painless abnormal movement at fracture site Pain present at fracture site, but in established non union it is pain free. Symptoms of infection In ability to bear weight.

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Examination

Diagnosis of Nonunion-

Abnormal movements Deformity Evidence of infection Soft tissue abnormality? (scar, atrophied skin, pigmentation etc)
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InvestigationsGeneral: Blood count Biopsy FNAC Wound swab/ pus C/S Specific: Radiologic Evaluation Radionuclide Scanning CT scan MRI
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Diagnosis of NonunionInvestigations:

InvestigationsRadiologic Evaluation
Diagnosis of Nonunion-

Investigations: Specific-

Standard radiographs are often diagnostic 45 degree oblique films can increase diagnostic accuracy Despite additional projections, the potential for false-positive results for fracture healing remains

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X-Ray and Imaging

Diagnosis of Nonunion-

Investigations: Specific-

Usually a plain X-Rays is adequate for diagnosis of Non Union. But rarely stress X-ray, CT scans and MRI is required.

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Valgus Diagnosis of NonunionInvestigations: Specific-

Varus

Clinical diagnosis can be confirmed and information about stability obtained with stress radiographs.
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Radionuclide Scanning
Technetium - 99 diphosphonate Detects repairable process in bone ( not specific) Gallium - 67 citrate Accumulate at site of inflammation (not specific) Sequential technetium or gallium scintigraphy Only 50-60% accuracy in subclinical ostoemyelitis
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Diagnosis of NonunionInvestigations:

Specific-

CT scan
Diagnosis of NonunionInvestigations: Specific-

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CT scan
Diagnosis of NonunionInvestigations: Specific-

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Diagnosis of NonunionInvestigations: Specific-

MRI

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Management/ Treatment-

Nonoperative Operative
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Non-operativeTreatment BMP (Bone morphogenic protein injection) Bone marrow injection Ultrasound Electric stimulation Low Level Laser Therapy.
But in established non union, non operative method rarely helpful. 33

Surgical TreatmentTreatment

A. Hypertrophied non inions unite with good adequate fixation (intramedulary nails, Locking plates or DCP and different types of wiring), may not require bone graft. B. Atrophied non union always needs bone graft with adequate fixation. C. Gap non union needs vascularised fibula graft or bone transportation / lengthening. D. Infected nonunion needs special combined effort. 34

Treatment
Infected nonunion

Contaminated implants and devitalized implants must be removed Infection treated: Temporary stabilization (external fixation) Culture specific antibiotics +/- local antibiotic delivery (antibiotic beads) Secondary stabilization with augmentation of osteogenesis (cancellous grafting)
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Infected Non-unions

Treatment
Atrophied non union

Bone Grafting-

Osteoinductive - contain proteins or chemotactic factors that attract vascular ingrowths and healing i.e.. dematerialized bone matrix & BMPs Osteoconductive - contains a scaffolding for which new bone growth can occur
i.e. allograft bone, calcium hydroxyapatite
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Treatment
Atrophied non union

Bone Grafting Used to stimulate biologic response of healing in nonunion (usually atrophic nonunion) Also used to fill defects in fracture zone
i.e. up to 6 cm intercalary defects of long bones)
Bosse, MJ e.t.al. JBJS 1989
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Autogenous Cancellous Bone

Sites Posterior Iliac Crest (20 cc) Anterior Iliac Crest (10cc) Proximal Tibia (7cc) Distal Radius, Calcaneus, Olecronon (?). All series suggest some incidence of donor morbidity dependent upon harvest site and volume required. Still considered by many to be the most osteogenic graft material.
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Treatment
Atrophied non union

Treatment
Hypertrophied non inions

Locking Plate Technology Will give better fixation in pathologic bone Most likely will prevent early failure
(Occasionally seen with traditional compression plating techniques )39

Treatment
Hypertrophied non inions

Traumatic Bone Loss Reconstructive planning and intervention should begin prior to meeting the time requirements for nonunion Options
Distraction osteogenesis Vascularized bone graft with Iliac crest bone grafting
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Intra-medullary Nailing Mechanically stabilizes long bone nonunion as a load sharing implant Corrects mal-alignment Treatment Reaming is initially detrimental to intra-medullary Hypertrophied blood supply, but it does recover and is believed to non inions stimulate biologic healing at fracture Allow patient to mobilize surrounding joints and dynamize fracture environment.

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Intra-medullary Nailing
Treatment
Hypertrophied non inions

Can be performed without direct exposure or dissection of the fracture soft tissue envelope Non-applicable in articular fractures.
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