Nonunions of Long Bones

1
Nonunions of Long Bones

• Robert Probe, MD
• Scott White Memorial Hospital
• Texas AM University Health Science Center
• Original Author Matthew J. Weresh, MD March
  2004
• New Author Robert Probe, MD Revised January
  2007

2
Outline

• Treatment Principles
• Stabilization
• Biologic
• Specific Bones
• Clavicle
• Humerus
• Forearm
• Femur
• Tibia

• Definition
• Epidemiology
• Etiology
• Evaluation
• Classification

3
Definition

• FDA 9 months elapsed time with no healing
  progress for 3 months.
• Problems
• Subjective
• Arbitrary
• Pragmatic A fracture that has no potential to
  heal without further intervention

4
Incidence

• Between 5 and 10 of long bone fractures
• Relative Risk depends upon
• Injury
• Bone
• Patient
• Treatment

5
Nonunion under conditions of Absolute Stability

• Fracture gaps that exceed the allowable distances
  for primary or gap healing
• Construct instability that prevents primary
  healing

6
Nonunion under Conditionsof Relative Stability

• Sufficient stability is not imparted at the soft
  callus stage to allow for mineralization of the
  chondroid matrix.
• Instability prevents bringing bone formation
  despite biologic activity

7
Local Risk Factors

• Open Fractures
• High energy fractures with bone devitalization
• Severe associated soft tissue injury
• Bone loss
• Infection

8
Systemic Risk Factors

• Malnutrition
• Smoking
• NSAIDs
• Systemic Medical Conditions

9
Smoking and Tibial Fractures
Adams Injury 2001
10
Non-steroidals and Healing

• 32 femoral nonunions compared with 67 that healed
  uneventfully
• No difference
• Smoking
• Reaming
• Locking
• NSAIDs
• Significant to Plt 0.000001

Giannoudis JBJS-B 2000
11
Iatrogenic

• Poor Reduction
• Unstable fixation
• Bone Devitalization

12
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
13
Diagnosis Suspected When

• Persistent Pain
• Non physiologic motion
• Progressive deformity
• No radiographic evidence of healing
• Failing implants

14
Clinical Exam

• Limb Stability
• Limb alignment and length
• Condition of the soft-tissue envelope
• Neurovascular exam

15
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

16
Clinical diagnosis can be confirmed and
information about stability obtained with stress
radiographs.
Varus
Valgus
17
Computed Tomography

• Clarity when implants or fracture obliquity
  produce doubt

18
Classification

• Is there infection?
• Is there deformity?
• Define the biologic activity and stability

19
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

20
Determine Deviations in

• Angulation
• Length
• Rotation
• translation

21
Define the Level of Osteogenesis along the
Spectrum of Biologic Activity
hypertrophic
oligotrophic
atrophic

Inherent Biology
Weber Cech Pseudarthosis, 1976
22
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

23
Role of Nonoperative Modalities

• All have clinical evidence to support
  effectiveness
• Few comparative studies between modalities
• Few comparative studies between nonoperative and
  operative methods
• Best suited for hypertrophic nonunions with good
  inherent stability
• Does nothing to correct deformity or provide
  immediate stability

24
Surgical TreatmentAlgorithm

• Cure infection if present
• Correct Deformity if significant
• Provide stability through implants
• Add biologic stimulus when necessary

25
Infected Nonunions

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

26

• 24 year male with continued distal osteolysis
  after debridement, antibiotics and local beads

27
Hardware removed and Infected bone debrided.
28
Persistent drainage And gross motion
after Multiple attempts at Surgical treatment
29
Treatment consisted Of resection of Infected
bone, acute Shortening and External fixation
30
Methods of Adding Stability

• Cast/Brace rarely sufficient in nonunions
• External Fixation
• Plates
• Intramedullary Devices

31
External Fixation

• Largest indication is a temporary stabilization
  following infection debridement
• Also useful in correction of stiff deformity and
  lengthening

32
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

33
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
34
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

35
Adding Biology

• Often unnecessary in hypertrophic cases with
  sufficient inherent biologic activity
• Options
• Aspirated stem cells (with or without expansion)
• Demineralized Bone Matrix
• Autogenous Cancellous Graft
• Growth Factors
• Platelet derived
• Recombinant BMPs
• Gene Therapy

36
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

37
Demineralized Bone Matrix

• Osteoinduction has been experimentally
  demonstrated
• Osteoinductive ability appears variable between
  products and donors
• A consecutive series with historic controls has
  demonstrated effectiveness in humeral shaft
  nonunions
• Avoids the morbidity of iliac crest graft
• As effective as iliac crest ????? (doubtful in
  the authors opinion)

Hierholzer et al J Bone Joint Surg 2006
38
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

39
Recombinant Bone Morphogenic Proteins

• BMP-2
• Infuse
• Demonstrated effective in acute open tibial
  fractures
• FDA approved in acute fractures
• BMP-7
• OP-1
• Comparable to autograft in tibia nonunions
• FDA approved under HD exemption

40
BMP-2 for Open Tibial FracturesProspective
Randomized with 450 Patients

• Results
• High dose BMP-2 treatment led to
• 44 reduction in risk of
• nonunion/delayed union
• Significantly fewer invasive interventions
• Significantly faster fracture healing
• Significantly fewer hardware failures and fewer
  infections

BESTT Study Group, et al. J Bone Joint Surg 84A
2123, 2002.
41
OP-1 in Tibial Nonunions

• Prospective, randomized study
• 122 patients with 124 tibial nonunions

• Treatment
• IM nail
• 70 exchange nail
• 20 new 1º nail
• 10 maintained prior nail
• OP-1/collagen vs. ICBC
• Clinical success
• 81 BMP7
• 85 ICBG

Friedlaender GE et al, J Bone Joint Surg, 2001
83A, Suppl 1 S1-151.
42
Ongoing Osteoinductive Research will likely
change the future-

• Improved understanding of BMPs
• Optimize BMP carriers
• Explore role of expanded stem cell lines
• Role of gene therapy
• Reduce the cost of production of inductive agents

43
Osteoinduction Summary

• The diversity and limited numbers of nonunions
  make Level 1 studies rare
• Personal Opinion
• Nothing in hypertrophic or rodded nonunions
• DBM in biologically friendly environments
  (humerus)
• Autologous cancellous graft in challenging cases
• BMP when ABG has failed or is not feasible

44
Specific Anatomic Sites

• Clavicle
• Humerus
• Forearm
• Femur
• Tibia
• Metaphyseal

45
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

Ballmer J Shoulder Elbow Surg 1998
46
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

• Ring et al, CORR 425, 2004

47
Humeral Failed Intramedullary Treatment

• Avoid the temptation to
• Perform exchange nailing

• Union rates with exchange nailing
• McKee 60
• Robinson 40
• Flinkkilla 46

48
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

49
Forearm Nonunion with Bone Loss
Grafted defect

• 35 patients, both bones 8, ulna 11, radius 16
• All with segmental defects
• Treatment
• 3.5 plates, autologous cancellous bone graft
• All nonunions healed
• Improved function

• Ring et al. JBJS 86A 2004

50
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

51
Exchange Nailing

• 12 series in English Literature between 1975 and
  2006 (462 pts)
• Success Rates
• Average succcess of 89
• Range of 53-100
• Necessary to change from retrograde to antegrade?

Retrograde nail
52
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
53
Plating of Femoral Nonunion

• 10 English series between 1969 and 2006 (195
  patients)
• Success Rate
• Average 89
• Range 63 to 100

54
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
55
All Paths are Reasonable under Clinical
Circumstances
Plate Nail
Plate Nail
56
Femoral Nonunion Guidelines

• ORIF and bone graft
• Deformity
• Absent medullary canal
• Atrophic
• Exchange nailing
• well aligned
• Hypertrophic
• Limited concern over infection

57
Tibial Intramedullary Nailingfor Nonunion

• Indications
• Correctable alignment
• Demonstrated biology
• Reconstructable canal
• Relative Contraindications
• Previous infected pin sites
• History of infection

58
Exchange Nailing for Tibial Nonunion

• Indicated for isthmic fractures that are not
  infected
• Increase nail diameter by 2mm
• 95 success rate
• Bone loss gt50 circumference is a relative
  contraindication

Zelle et al J Trauma 2004
59
Addition of Posterolateral ICBG when there is
Substantial Bone Loss
Healed
2 years post fracture
Exchange nail with ICBG
60
Plating Tibial Nonunions

• Indications
• No canal
• Stiff deformity
• Prior external fixation
• Need for graft
• Relative Contraindications
• Poor soft-tissues
• Note the plate used as a reduction tool in this
  case

61
Compression Plating for Tibial Nonunions

• 50 patients with nonunion following external
  fixation
• External fixation averaged 8 weeks
• Injury to plating averaged 8 months
• Average deformity of 15 degrees
• Post-op
• 92 union
• 4 deg angulation

Wiss JBJS-A 1992
62
Unique Challengesof Metaphyseal Nonunions

• Small articular segments
• Joint contracture
• Post-traumatic chondral changes
• Residua from prior surgery
• Devitalized bone
• Infection
• Fractured implants
• Implant tracts

63
This implant is failing under the high bending
forces in the subtrochanteric zone.
64
Hypertrophic nonunion With 30 degree
sagital deformity
65
Articular nonunions present challenges of
arthrofibrosis and small fragments
66
Metaphyseal nonunion with significant chondral
loss
67
In certain nonunions, a deleterious mechanical
environment may lead to nonunion
68
In other instances, bone loss and osteopenia may
make prosthetic replacement a preferable option.
This is particularly true in the proximal femur
69
..and increasingly in other joints as prosthetic
replacements continue to improve.
70
Traumatic Bone Loss

• Reconstructive planning and intervention should
  begin prior to meeting the time requirements for
  nonunions
• Options
• Distraction osteogenesis
• Iliac crest bone grafting
• BMP reconstruction

71
Tibial Bone Defects Tx withIlizarov Techniques

• 27 tibial defects ave size 8.3 cm
• Docking grafting in 25
• Acute shortening in 10
• Ave time of fixation was 8 months
• Bone union in all cases

Song International Orthopaedics 1998
72
Diaphyseal Nonunion Summary

• Careful assessment
• Infection
• Deformity
• Biologic activity
• Create viable bone and soft tissue
• Correct the deformity
• Provide stability
• Osteoinduction when necessary

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