Aseptic Non-Union

AOEAOEAseptic Non Union

Aseptic Non-Union


AO Principles Course

Dr. Enrique Queipo de Llano

Hospital Universitario de Málaga


No bone healing in the normal time

Usually 6 a 8 months

Definition


Do not blame the osteoblasts (Watson

Jones).

Fractures have a spontaneous tendency to heal. (Merle D’Aubigne).

Delayed or non-union is often multifactorial in nature.

Etiology


Disturbed vascularity and instability are the most important factors leading to a non-union.

Etiology


BiologicalCarpal scaphoidNeck of the femurTalusDevitalized fragments

Etiology (Vascularisation)


Etiology (Instability)

Iatrogenic Insufficient orthopaedic treatment Incorrect osteosynthesis (unstable)


Good reduction Contact between fragments Strict immobilization

Orthopaedic treatment

Conditions for a normal bone healing


Anatomic reduction of articular fractures Good alignment of diaphyseal fractures Stable osteosynthesis Absolute asepsis

Surgical treatment

Conditions for a normal bone healing


Non compliant patient The care plan has to be compatible

with the patient’s personality and life style.

Have to be controlled: Inappropriate weight bearing Smoking habit Improper diet Other shortcomings in behaviour


Symptoms Abnormal mobility Abnormal mobility cannot be seen:

When there is an Internal Fixation Intramedullary nailDense fibrous callus

Pain and Limp A healed fracture does not hurt


Radiology Sometimes difficult to see on the X-Rays

Reactive callus = Mechanical instability

Slight instability can be positive


Delayed union In delayed union there are clinical and

radiological signs of prolonged fracture healing

It is important to establish the diagnosis Fracture instability Implant mobilization

To act to achieve a rapid bone healing


Judet-Weber classification

A. Vital (Hypervascular) With biological reaction capacity

B. Avital (Avascular) Without biological reaction

capacity


A. Vital non-union They do not heal because of

instability



B. Avital non-union They do not heal because of biological

deficit



Weber classification

A. VitalI. Hypertrophic non-union (elephant

foot)

II. Hypertrophic non-union (horse hoof)

III. Atrophic non-union (without callus)


A. Vital non-union


A. Vital non-union

Elephant foot Horse hoof Atrophic


Hypertrophic non-union Hypertrophic non-union is frequently

localized in the lower extremities.

Its development largely depends on an impaired mechanical stability.


Experimental non-union

AO3

6

16


Pathology


Pathology


Pathology


Pathology


Bone healing by mechanical stabilization


Ca. marked fracture site

Non-union focus Calcifying focus


Totally calcified focus

Fracture healing trabeculae

Ca. marked fracture site


Stabilized fracture evolution Mechanical stability allows the fibrous

cartilage to calcify and finally ossify after vascular penetration.

Resection of an hypertrophic non-union must be regarded as an error.


Stabilized fracture evolution


Bone healing evolution






PO

Instability (non-union)


Stabilization (bone healing)

4 m 8 m


“Elephant foot” non-union healed after plating stabilization


B. Avital non-union

I. Dystrophic with intermediate wedge fragment

II. Necrotic with conminution

III. Bone loss

IV. Atrophic

Weber classification


B. Avital non-union


Avascular non-union Avascular non-union originates because

of the devascularisation of the bone fragments adjacent to the fracture site due to injury and/or surgery.


Devitalized fragments united by callus to the main fragments without evidence of bone healing

B. Avital non-union


Treatment of aseptic non-union


To achieve a rapid bone healing with complete recovery of articular and muscular function.

Goal of the treatment


To restore bone continuity If possible anatomically

To restore articular and muscular function

In the less possible time

Active treatment


1. Vital Mechanical stabilization (osteosynthesis) Stable osteosynthesis

2. Avital Mechanical stabilization (osteosynthesis) Biological stimulation (autologous bone

grafting)

Treatment according to the type


1. Pediculated vital bone grafts (decortication)

2. Autologous cancellous bone graft3. Bone transplants

Bone grafting

Fibula “pro tibia”Bone transportVascularised bone grafts

Bone loss


Techniques for bone reconstruction

Diaphyseal non-union


It is the simplest and most effective way to expose a non union without producing a substantial devascularization.

Judet osteoperiosteal decortication

This technique is used to enhance the healing response, creating a well vascularised that at the same time stimulates the bone healing process.


Osteoperiosteal decortication


Osteoperiosteal decortication


Cancellous autologous bone graft is the “gold standard” for both biological and mechanical purposes.

Autologous cancellous bone graft

It is osteogenic (a source of vital bone cells) It is osteoinductive (recruitment of local mesenchymal cells) It is osteoconductive (scaffold for ingrowth of new bone)


Anterior intrapelvic approach



Posterior extrapelvic approach



Poor vascularization Minimal callus formation Atrophic non-union

Cancellous autologous bone graft is: Osteogenic, osteoinductive and osteoconductive

Bone grafting indications


Allografts and bone substitutes such as demineralized bone matrix, hidroxyapatite, tricalcium-phosphate, as welll as osteoinductive substances such as growth factors, bone morphogenetic proteins (BMPs), etc., are currently being intensively explored both experimentally and clinically, but have not yet proved to be significantly superior.

Allografts and bone graft substitutes


All these substances require a vital environment in order to be effective.

In the absence of living cellular elements and blood supply there is no possibility of any healing.

Nothing is superior to autologous bone graft

Allografts and bone graft substitutes


Osteogenesis by callus distraction (Ilizarov) and free vascularized bone graft should be taken into consideration when dealing with large (>4-6 cm) segmental bone defects.

Callus distractionFree vascularized bone grafts


¡Mechanical stabilization is essential!


Stabilization of a non-union provides the essential mechanical component to allow calcification of the fibrous cartilage within the non-union.

This prepares the field for development of a first bony bridge.

Stabilization


Plating Intramedullary nailing External Fixation

Types of stabilization


Plating The plate is probably the most adequate and

versatile tool for the stabilization of an aseptic non-union.

It allows in a single procedure : Interfragmentary compression Correction of any malposition Reconstructive measures (grafting

etc.)


Plating techniques Tension band plating (on the convexity) Axial compression plating Buttress plate Lag screws and neutralization plate Bridge plate in segmental bone loss


Plating

Optional anterior and posterior decortication


Wave plate

Increases the functional diameter of the non-union site

Improves the local stability

Allows placement of autografts all around the non-union site


It is mainly indicated in diaphyseal non-unions of the lower extremity

Nailing has few advantages in the upper extremity and thin unreamed nails are not suitable, as they provide insufficient stability.

Intramedullary nailing


Indications of intramedullary nailing Non displaced mid third femur and tibia

non-union Loose or broken nail

Over-ream not exposing the non-union site Introduction of a thicker and longer nail Dynamic interlocking (rotational stability) Increase of periosteal bone flow promotes union


Loose nail Over-reaming Locked thicker and longer nail

Intramedullary nailing


In most aseptic non-unions external fixation brings little advantage.

It may be applied in the presence of poor soft-tissue conditions or in complex multiplanar deformities near joints where a single-stage correction appears difficult and hazardous.

External Fixation


Tibia non-union Poor skin coverage Suspicion of latent infection

Shortening with bone loss Callus distraction technique

Arthrodesis non-union Failed knee and ankle arthrodesis

Indications of External Fixation


Bone reconstruction techniques

Methaphyseal non-union


Limited local decortication avoiding devascularization of the joint fragment, correction of the deformities and mechanical adaptation of the main fragments with fixation by interfragmentary compression.

Usually one or two plates are used.

Bone grafting may be necessary.

Metaphyseal non-union


Indications Correct alignment of the articular

surfaces Articular fragment stable fixation

Angle plate Buttress plate

Active mobilization of a stiff joint Avoid forced mobilization before bone

healing


Humerus proximal and distal buttress plates


Femur and tibia buttress plates


Femur proximal and distal (DCS)


Adjuvant treatment


Electromagnetic stimulation and, more recently, ultrasound, have been applied and advocated to stimulate bone healing.

They do appear to generate a certain physical (thermal) effect at the non-union site, but the final outcome is still questionable and real evidence is lacking.

Aseptic non-union


Bone losses


Bone transplant

1. Fibula “pro tibia”2. Bone transport3. Free vascularized bone grafts


Bone losses (bridging techniques) Bridge plate

External Fixator Locked intramedullary nailing

Plus bone grafting Cortico-cancellousVascularized


Humerus and forearm bone losses


Femur bone losses


Tibia bone losses

Tibio fibular synostosis Fibula “pro tibia” Bone transport

Plus inter tibio-fibular grafting


Tibia bone losses


Tibia bone losses


Aseptic Non-union Clinical Examples


AO Principles Course

Dr. Enrique Queipo de Llano

Hospital Universitario de Málaga


V.G.C. - 60 year old - Female Distal tibia non-union - 10-74

Distal tibia fracture no-union The fracture was treated in other Hospital

Simple screw fixation without IF compression No neutralization plate

Lag screw and DCP plating with deformity correction

Bone healing in 2 months


V.G.C. - 60 y - Female

PO

1 m


1 m 36 m

V.G.C. - 60 y - Female


A.M.C. - 35 year old - FemaleRadius non-union - 11.75

Left forearm fracture (radius and ulna) Treated in other Hospital

Ulna nailing Plating of the radius with only three screws

Treatment Ulna nail removal (ulna fx. was healed) Radius DCP compression plating + Bone

grafting Bone healing in 3 months


A.M.C. - 35 y - Female

PO 4 m


G.G.C. - 52 year old - MaleFemur non-union - 12.76 Sub-trochanteric fracture Incomprehensible wiring cerclage Treatment

Angle plate (95º) with axial compression fixation

Bone grafting Bone healing in 2 months


G.G.C. - 52 y - Male

PO 1 m


9 m

G.G.C. - 52 y - Male


D.O.J. - 43 year old - MaleDistal femur non-union - 1.78 Distal femur metaphyseal non-union Previous orthopaedic treatment in

traction Angle plate (95º) fixation Bone healing in 3 months


D.O.J. - 43 y - Male

PO


2 m



10 m 16 m



P.T.M. – 27 year old – MaleDistal de tibia non-union - 5.97

Distal de tibia fx. treated in another Hospital UTN nailing Technical defect (only one distal bolt)

Non-union with angular deformity Treatment

Decortication + Osteotomy LC-DCP tibia and fibula plate fixation

Excellent result


P.T.M. – 27 y – Male

PO 1 m


4 m

24 m

P.T.M. – 27 y – Male


Motorcycle accident (Right femur and tibia fractures)

Treated in another Hospital Kirschner wire nailing of femur and tibia

At 6 months post-op Femur angulation with a broken K wire Femoral non-union Tibia fracture was healed

G.B.P. - 14 year old - FemaleFemur diaphysis non-union - 11.01


Surgical treatment Femur and tibia nails removal Decortication + LC-DCP axial compression

plating Cancellous bone screws were used

(osteoporosis) Autologouu bone grafting

Excellent result at 12 and 24 months

G.B.P. - 14 year old - FemaleFemur diaphysis non-union - 11.01


G.B.P. - 14 year old - Female


0 m 0 m

Tibia healed. Decortication, axial compression plate fixation.



3 m 6 m



12 m



24 m



Left femur B2.2 fracture Operation: 6.5.02

UFN locked nailing with satisfactory reduction 9.02 - Small wedge resorption and instability 25.11.02 Operation

Decorticatión and LCP fixation without nail removal Bone grafting

Bone healing in 4 months (10 months since the accident)

Complete function at 12 months.

JG.FJ. - 18 year old - MaleMotorcycle accident - 5.5.02


JG.FJ. - 18 year old - Male

PO0 m 6 s


4 m 6 m




6 m7 m



10 m 12 m



15 m


L.S.C. - 27 year old - FemaleFemoral non-union - 5.89 Right femur transverse fracture

Primary reamed IM nailing No callus formation at 15 months Nail failure at 16 months Treatment

Nail removal without opening the fracture site

New reamed thicker nailing Bone healing in 2 months


L.S.C. - 27 year old - Female

0 m 15 m


L.S.C. - 27 year old - Female

16 m 24 m


Fibula “pro tibia”


P.A.R. - 10 year old - MaleAcute osteomyelitis secualae - 9.66 Diaphyseal segmental bone loss Fibula “pro tibia” proximal and distal Fibula tibialization Excellent result at 3 years.


0 m 36 m

P.A.R. - 10 year old - Male

20 m


G.S.A. - 15 year old - MaleRun over by a car – 3.97 Polytrauma patient Right tibia open IIIB fracture Peroneal muscles and nerve loss Extensive skin loss Immediate External Fixation Dorsalis free vascularized transfer


Atrophic proximal tibia aseptic non-union

Osteoporotic bone Fibula “pro tibia” (lateral approach) Medial LC-DCP buttress plate fixation Autologous cancellous bone grafting

G.S.A. - 15 year old - MaleRun over by a car – 3.97


G.S.A. - 15 year old - Male

PO 1 m 6 m 8 m



12 m



36 m





5 years



5 years


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Aseptic Non-Union