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Long Bones
Robert Probe, MD
Scott & White Memorial Hospital
Texas A&M University Health Science Center
Original Author: Matthew J. Weresh, MD; March 2004;
New Author: Robert Probe, MD; Revised January 2007
Outline
Treatment Principles
Definition
Epidemiology
Etiology
Evaluation
Classification
Stabilization
Biologic
Specific Bones
Clavicle
Humerus
Forearm
Femur
Tibia
Definition
FDA: 9 months elapsed time with no healing
progress for 3 months.
Problems
Subjective
Arbitrary
Incidence
Between 5% and 10% of long bone fractures
Relative Risk depends upon:
Injury
Bone
Patient
Treatment
Non-smokers
Healing Time
32 wk
28 wk
Bone Graft
Required
26%
18%
Exchange Nail
Required
38%
26%
NSAIDs
Significant to P< 0.000001
Giannoudis JBJS-B 2000
Iatrogenic
Poor Reduction
Unstable fixation
Bone Devitalization
Iatrogenic Stripping
Indiscriminate devitalization (1)
Leads to limited healing potential and implant failure
(2,3)
Occasionally requiring resection and reconstruction
prior to healing (4,5)
1
Clinical Exam
Limb Stability
Limb alignment and length
Condition of the soft-tissue
envelope
Neurovascular exam
Radiologic Evaluation
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
Varus
Valgus
Computed Tomography
Clarity when implants or fracture obliquity produce
doubt
Classification
Is there infection?
Is there deformity?
Define the biologic
activity and stability
Infection
MRI can play a role in identifying soft tissue
component; however, bone edema is too
sensitive to be accurate
Reliance on clinical diagnosis augmented by
CRP
Low virulence infection may require aspirate
or operative culture for diagnosis
Indium scan carries only moderate sensitivity
and specificity
oligotrophic
atrophic
Inherent Biology
Nonoperative Treatment
Electromagnetic
Direct Current
Inductive coupling (PEMF, CMF)
Capacitive coupling
Ultrasound
mechanical energy in the form of low frequency
acoustic waves
30 mW/cm2
Surgical Treatment:
Algorithm
Cure infection if present
Correct Deformity if significant
Provide stability through
implants
Add biologic stimulus when
necessary
Infected Nonunions
Contaminated implants and devitalized
implants must be removed
Infection treated:
Temporary stabilization (external fixation)
Culture specific antibiotics
+/- local antibiotic delivery (antibiobic beads)
Persistent drainage
And gross motion after
Multiple attempts at
Surgical treatment
Treatment consisted
Of resection of
Infected bone, acute
Shortening and
External fixation
Followed by proximal
Corticotomy and
Distraction to restore
length
External Fixation
Largest indication is a
temporary stabilization
following infection
debridement
Also useful in correction
of stiff deformity and
lengthening
Plate Stabilization
Plates provide a powerful reduction tool
Surgical technique should strive for absolute
stability
Locking plates have improved stability and
fixation strength
Other relative indications:
Absent medullary canal
Metaphyseal nonunions
When open reduction or removal of prior implants
is required
Plate Stabilization
Multiple Indications for plate
Broken implants require that
removal
Metaphyseal nonunion
Significant deformity
Technique
Blade properly positioned in the
distal fragment
Reduction obtained by bringing
plate to the shaft
Absolute stability with lag screw
Nonunion was not exposed
Broken
plate
Nail Stabilization
Ideal case Femur or tibia with an
existing canal and no prior implants
Exchange nailing provides a good
option for the tibia and femur
Special equipment is often necessary
to traverse sclerotic canals
Adding Biology
Often unnecessary in hypertrophic cases with sufficient
inherent biologic activity
Options
Stem Cells
Aspirated iliac crest stem
cells has been shown to
enhance the activity of
osteoconductive grafts
Has been studied as an
isolated technique with
limited success
Role of expansion and
delayed implantation may
play a future role
tibial fractures
FDA approved in acute fractures
BMP-7
OP-1
Comparable to autograft in tibia
nonunions
FDA approved under HD exemption
BESTT Study Group, et al. J Bone Joint Surg 84A: 2123, 2002.
randomized study
122 patients with 124
tibial nonunions
Treatment
IM nail
70 % exchange nail
20 % new 1 nail
10 % maintained
prior nail
OP-1/collagen vs. ICBC
Clinical success:
81% BMP7
85% ICBG
adenoviral
vector carrying
growth factor
gene
cell
making
ribosomes
growth factors
nucleus
Osteoinduction Summary
The diversity and limited numbers of nonunions make
Level 1 studies rare
Personal Opinion:
Clavicle Nonunions
Middle 1/3 treated with
compression plating +/graft
Anterior or superior plate
position
95% union reported*
Lateral 1/3 treated with
ORIF or excision and
ligament reconstruction
HUMERAL NONUNION
24 patients age 52-86yrs
(ave 72yrs)
Locking compression
plate with bone graft or
DBM
All healed 2 of the
DBM cases needed
secondary surgery for
bone grafting
Forearm
Compression plating for hypertrophic
nonunions
Critical attention to preservation of radial bow
and radio-ulnar relationship
Cancellous graft for atrophic nonunion or bone
loss
Grafted defect
Femoral Nonunions
Low incidence with
good primary surgery
Stabilization may be
performed with either
plate or rod
Despite the rarity, cases
can become challenging
as evidenced by this
case
Dynamization
Plating
Revision
failed
plating
failed
to
work
to
work
Primary
surgery.
A short
Femoral
nailing
and
Failed
tohas
work
Nail Grafting
was
chosen
because
failed to
of intertrochanteric
work fracture.
Exchange Nailing
12 series in English
Literature between 1975 and
2006 (462 pts)
Success Rates
Average succcess of 89%
Range of 53%-100%
Retrograde
nail
Antegrade
exchage
Healed
Plate to Nail
Jackson, 2001 - 13/14 (93%)
healed
Wu et al., Arch Ortho Trauma
Surg 1999
21 nailings after failed plating
21 / 21 healed
PLATING FEMORAL
NONUNIONS AFTER FAILED
NAILING
23 NONUNIONS
BLADE PLATE
4.5 LCDCP
BONE GRAFT
21 HEALED BY 12
WEEKS
2 REQUIRED REVISION
Bellabarba et al.J Ortho Trauma 2001; 254-63
Plate
Plate
Nail
Nail
Exchange nailing
well aligned
Hypertrophic
Limited concern over infection
Relative Contraindications
Previous infected pin sites
History of infection
Healed
No canal
Stiff deformity
Prior external fixation
Need for graft
Relative
Contraindications
Poor soft-tissues
Unique Challenges
of Metaphyseal Nonunions
Small articular segments
Joint contracture
Post-traumatic chondral changes
Residua from prior surgery
Devitalized bone
Infection
Fractured implants
Implant tracts
This implant is
failing under the
high bending
forces in the
subtrochanteric zone.
An intramedullary
implant was chosen
because of the reduced
bending moment.
Hypertrophic nonunion
With 30 degree sagital
deformity
Correction of
Deformity with
Absolute stability.
No graft was used
In this hypertrophic
case
Articular nonunions
present challenges
of arthrofibrosis and
small fragments
however, they
may be successfully
reconstructed if
satisfactory cartilage
remains.
Metaphyseal nonunion
with significant
chondral loss
In certain nonunions,
a deleterious
mechanical environment
may lead to nonunion
..and increasingly
in other joints as
prosthetic replacements
continue to improve.
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