Aseptic Non-Union Aseptic Non Union

AO Principles Course Dr. Enrique Queipo de Llano Hospital Universitario de Málaga Aseptic Non Union

Definition No bone healing in the normal time Usually 6 a 8 months Aseptic Non Union

Etiology 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. Aseptic Non Union

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

Etiology (Vascularisation) Biological Carpal scaphoid Neck of the femur Talus Devitalized fragments Aseptic Non Union

Etiology (Instability) Iatrogenic Insufficient orthopaedic treatment Incorrect osteosynthesis (unstable) Aseptic Non Union

Good reduction Contact between fragments Strict immobilization Conditions for a normal bone healing Orthopaedic treatment Good reduction Contact between fragments Strict immobilization Aseptic Non Union

Conditions for a normal bone healing Surgical treatment Anatomic reduction of articular fractures Good alignment of diaphyseal fractures Stable osteosynthesis Absolute asepsis Aseptic Non Union

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 Aseptic Non Union

Symptoms Abnormal mobility Abnormal mobility cannot be seen: When there is an Internal Fixation Intramedullary nail Dense fibrous callus Pain and Limp A healed fracture does not hurt Aseptic Non Union

Radiology Sometimes difficult to see on the X-Rays Reactive callus = Mechanical instability Slight instability can be positive Aseptic Non Union

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 Aseptic Non Union

Judet-Weber classification Vital (Hypervascular) With biological reaction capacity Avital (Avascular) Without biological reaction capacity Aseptic Non Union

Judet-Weber classification Vital non-union They do not heal because of instability Aseptic Non Union

Judet-Weber classification Avital non-union They do not heal because of biological deficit Aseptic Non Union

Weber classification A. Vital I. Hypertrophic non-union (elephant foot) II. Hypertrophic non-union (horse hoof) III. Atrophic non-union (without callus) Aseptic Non Union

A. Vital non-union Aseptic Non Union

A. Vital non-union Elephant foot Horse hoof Atrophic Aseptic Non Union

Hypertrophic non-union Hypertrophic non-union is frequently localized in the lower extremities. Its development largely depends on an impaired mechanical stability. Aseptic Non Union

Experimental non-union AO 3 6 16 Experimental non-union Aseptic Non Union

Pathology Aseptic Non Union

Pathology Aseptic Non Union

Pathology Aseptic Non Union

Pathology Aseptic Non Union

Bone healing by mechanical stabilization Aseptic Non Union

Ca. marked fracture site Non-union focus Calcifying focus Aseptic Non Union

Ca. marked fracture site Totally calcified focus Fracture healing trabeculae Aseptic Non Union

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. Aseptic Non Union

Stabilized fracture evolution Aseptic Non Union

Bone healing evolution Aseptic Non Union

Bone healing evolution Aseptic Non Union

Bone healing evolution Aseptic Non Union

Instability (non-union) PO Aseptic Non Union

Stabilization (bone healing) 4 m 8 m Aseptic Non Union

“Elephant foot” non-union healed after plating stabilization Aseptic Non Union

Weber classification Avital non-union Dystrophic with intermediate wedge fragment Necrotic with conminution Bone loss Atrophic Aseptic Non Union

B. Avital non-union Aseptic 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. Aseptic Non Union

B. Avital non-union Devitalized fragments united by callus to the main fragments without evidence of bone healing Aseptic Non Union

Treatment of aseptic non-union

Goal of the treatment To achieve a rapid bone healing with complete recovery of articular and muscular function. Aseptic Non Union

In the less possible time Active treatment To restore bone continuity If possible anatomically To restore articular and muscular function In the less possible time Aseptic Non Union

Treatment according to the type 1. Vital Mechanical stabilization (osteosynthesis) Stable osteosynthesis 2. Avital Biological stimulation (autologous bone grafting) Aseptic Non Union

Bone grafting 1. Pediculated vital bone grafts (decortication) 2. Autologous cancellous bone graft 3. Bone transplants Fibula “pro tibia” Bone transport Vascularised bone grafts Bone loss Aseptic Non Union

Techniques for bone reconstruction Diaphyseal non-union Techniques for bone reconstruction Aseptic Non Union

Judet osteoperiosteal decortication It is the simplest and most effective way to expose a non union without producing a substantial devascularization. This technique is used to enhance the healing response, creating a well vascularised that at the same time stimulates the bone healing process. Aseptic Non Union

Osteoperiosteal decortication Aseptic Non Union

Osteoperiosteal decortication Aseptic Non Union

Autologous cancellous bone graft Cancellous autologous bone graft is the “gold standard” for both biological and mechanical purposes. 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) Aseptic Non Union

Autologous cancellous bone graft Anterior intrapelvic approach Aseptic Non Union

Autologous cancellous bone graft Posterior extrapelvic approach Aseptic Non Union

Bone grafting indications Poor vascularization Minimal callus formation Atrophic non-union Cancellous autologous bone graft is: Osteogenic, osteoinductive and osteoconductive Aseptic Non Union

Allografts and bone graft substitutes 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. Aseptic Non Union

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 Aseptic Non Union

Callus distraction Free vascularized bone grafts 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. Aseptic Non Union

¡Mechanical stabilization is essential! Aseptic Non Union

Stabilization 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. Aseptic Non Union

Types of stabilization Plating Intramedullary nailing External Fixation Aseptic Non Union

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.) Aseptic Non Union

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

Optional anterior and posterior decortication Plating Optional anterior and posterior decortication Aseptic Non Union

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 Aseptic Non Union

Intramedullary nailing 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. Aseptic Non Union

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 Aseptic Non Union

Locked thicker and longer nail Intramedullary nailing Loose nail Over-reaming Locked thicker and longer nail Aseptic Non Union

External Fixation 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. Aseptic Non Union

Indications of 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 Aseptic Non Union

Methaphyseal non-union Bone reconstruction techniques Aseptic Non Union

Metaphyseal 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. Aseptic 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 Aseptic Non Union

Humerus proximal and distal buttress plates Aseptic Non Union

Femur and tibia buttress plates Aseptic Non Union

Femur proximal and distal (DCS) Aseptic Non Union

Adjuvant treatment Aseptic Non Union

Aseptic non-union 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 Aseptic Non Union

Bone transplant 1. Fibula “pro tibia” 2. Bone transport 3. Free vascularized bone grafts Aseptic Non Union

Bone losses (bridging techniques) Bridge plate External Fixator Locked intramedullary nailing Plus bone grafting Cortico-cancellous Vascularized Aseptic Non Union

Humerus and forearm bone losses Aseptic Non Union

Femur bone losses Aseptic Non Union

Tibio fibular synostosis Fibula “pro tibia” Bone transport Tibia bone losses Tibio fibular synostosis Fibula “pro tibia” Bone transport Plus inter tibio-fibular grafting Aseptic Non Union

Tibia bone losses Aseptic Non Union

Tibia bone losses Aseptic Non Union

Aseptic Non-union Clinical Examples

AO Principles Course Dr. Enrique Queipo de Llano Hospital Universitario de Málaga Aseptic Non Union 86

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 Aseptic Non Union

V.G.C. - 60 y - Female PO 1 m Aseptic Non Union

V.G.C. - 60 y - Female 1 m 36 m Aseptic Non Union

A.M.C. - 35 year old - Female Radius 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 Aseptic Non Union

A.M.C. - 35 y - Female PO 4 m Aseptic Non Union

G.G.C. - 52 year old - Male Femur 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 Aseptic Non Union

G.G.C. - 52 y - Male PO 1 m Aseptic Non Union

G.G.C. - 52 y - Male 9 m Aseptic Non Union

D.O.J. - 43 year old - Male Distal femur non-union - 1.78 Distal femur metaphyseal non-union Previous orthopaedic treatment in traction Angle plate (95º) fixation Bone healing in 3 months Aseptic Non Union

D.O.J. - 43 y - Male PO Aseptic Non Union

D.O.J. - 43 y - Male 2 m Aseptic Non Union

D.O.J. - 43 y - Male 10 m 16 m Aseptic Non Union

P.T.M. – 27 year old – Male Distal 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 Aseptic Non Union

P.T.M. – 27 y – Male PO 1 m Aseptic Non Union

P.T.M. – 27 y – Male 4 m 24 m Aseptic Non Union

G.B.P. - 14 year old - Female Femur diaphysis non-union - 11.01 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 Aseptic Non Union 102

G.B.P. - 14 year old - Female Femur 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 Aseptic Non Union 103

G.B.P. - 14 year old - Female Aseptic Non Union

G.B.P. - 14 year old - Female 0 m Tibia healed. Decortication, axial compression plate fixation. Aseptic Non Union

G.B.P. - 14 year old - Female 3 m 6 m Aseptic Non Union

G.B.P. - 14 year old - Female 12 m Aseptic Non Union

G.B.P. - 14 year old - Female 24 m Aseptic Non Union

JG.FJ. - 18 year old - Male Motorcycle accident - 5.5.02 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. Aseptic Non Union

JG.FJ. - 18 year old - Male PO 0 m 6 s Aseptic Non Union

JG.FJ. - 18 year old - Male 4 m 6 m Aseptic Non Union

JG.FJ. - 18 year old - Male 6 m 7 m Aseptic Non Union

JG.FJ. - 18 year old - Male 10 m 12 m Aseptic Non Union

JG.FJ. - 18 year old - Male 15 m Aseptic Non Union

L.S.C. - 27 year old - Female Femoral 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 Aseptic Non Union

L.S.C. - 27 year old - Female 0 m 15 m Aseptic Non Union

L.S.C. - 27 year old - Female 16 m 24 m Aseptic Non Union

Fibula “pro tibia” Aseptic Non Union

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

P.A.R. - 10 year old - Male 0 m 36 m 20 m Aseptic Non Union

G.S.A. - 15 year old - Male Run 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 Aseptic Non Union

G.S.A. - 15 year old - Male Run over by a car – 3.97 Atrophic proximal tibia aseptic non-union Osteoporotic bone Fibula “pro tibia” (lateral approach) Medial LC-DCP buttress plate fixation Autologous cancellous bone grafting Aseptic Non Union

G.S.A. - 15 year old - Male PO 1 m 6 m 8 m Aseptic Non Union

G.S.A. - 15 year old - Male 12 m Aseptic Non Union

G.S.A. - 15 year old - Male 36 m Aseptic Non Union

G.S.A. - 15 year old - Male Aseptic Non Union

G.S.A. - 15 year old - Male 5 years Aseptic Non Union

G.S.A. - 15 year old - Male 5 years Aseptic Non Union

Aseptic Non Union