Aseptic Non-Union

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Aseptic Non-Union

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AO Principles Course
Dr. Enrique Queipo de Llano Hospital
Universitario de Málaga
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Definition

• No bone healing in the normal time
• Usually 6 a 8 months

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Etiology

• Do not blame the osteoblasts (Watson Jones).
• Fractures have a spontaneous tendency to heal.
  (Merle DAubigne).
• Delayed or non-union is often multifactorial in
  nature.

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Etiology

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

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Etiology (Vascularisation)

• Biological
• Carpal scaphoid
• Neck of the femur
• Talus
• Devitalized fragments

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Etiology (Instability)

• Iatrogenic
• Insufficient orthopaedic treatment
• Incorrect osteosynthesis (unstable)

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Conditions for a normal bone healing
Orthopaedic treatment

• Good reduction
• Contact between fragments
• Strict immobilization

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Conditions for a normal bone healing
Surgical treatment

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

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Non compliant patient

• The care plan has to be compatible with the
  patients personality and life style.
• Have to be controlled
• Inappropriate weight bearing
• Smoking habit
• Improper diet
• Other shortcomings in behaviour

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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

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Radiology

• Sometimes difficult to see on the X-Rays
• Reactive callus Mechanical instability

Slight instability can be positive
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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

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Judet-Weber classification

• Vital (Hypervascular)
• With biological reaction capacity
• Avital (Avascular)
• Without biological reaction capacity

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Judet-Weber classification

• Vital non-union
• They do not heal because of instability

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Judet-Weber classification

• Avital non-union
• They do not heal because of biological deficit

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Weber classification

• A. Vital
• I. Hypertrophic non-union (elephant foot)
• II. Hypertrophic non-union (horse hoof)
• III. Atrophic non-union (without callus)

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A. Vital non-union
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A. Vital non-union
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Hypertrophic non-union

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

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Experimental non-union
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Pathology
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Pathology
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Pathology
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Pathology
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Bone healing by mechanical stabilization
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Ca. marked fracture site
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Ca. marked fracture site
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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.

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Stabilized fracture evolution
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Bone healing evolution
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Bone healing evolution
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Bone healing evolution
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Instability (non-union)
PO
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Stabilization (bone healing)
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(No Transcript)
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Weber classification

• Avital non-union
• Dystrophic with intermediate wedge fragment
• Necrotic with conminution
• Bone loss
• Atrophic

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B. Avital non-union
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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.

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B. Avital non-union
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Treatment of aseptic non-union
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Goal of the treatment

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

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Active treatment

• To restore bone continuity
• If possible anatomically
• To restore articular and muscular function

In the less possible time
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Treatment according to the type

• 1. Vital
• Mechanical stabilization (osteosynthesis)
• Stable osteosynthesis
• 2. Avital
• Mechanical stabilization (osteosynthesis)
• Biological stimulation (autologous bone grafting)

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Bone grafting

• 1. Pediculated vital bone grafts (decortication)
• 2. Autologous cancellous bone graft
• 3. Bone transplants

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Diaphyseal non-union

• Techniques for bone reconstruction

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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.

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Osteoperiosteal decortication
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Osteoperiosteal decortication
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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)

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Autologous cancellous bone graft
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Autologous cancellous bone graft
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Bone grafting indications

• Poor vascularization
• Minimal callus formation
• Atrophic non-union

Cancellous autologous bone graft is Osteogenic,
osteoinductive and osteoconductive
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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.

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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
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Callus distractionFree vascularized bone grafts

• Osteogenesis by callus distraction (Ilizarov) and
  free vascularized bone graft should be taken into
  consideration when dealing with large (gt4-6 cm)
  segmental bone defects.

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Mechanical stabilization is essential!
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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.

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Types of stabilization

• Plating
• Intramedullary nailing
• External Fixation

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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.)

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Plating techniques

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

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Plating
Optional anterior and posterior decortication
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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
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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.

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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

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Intramedullary nailing
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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.

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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

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Methaphyseal non-union

• Bone reconstruction techniques

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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.

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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

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Humerus proximal and distal buttress plates
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Femur and tibia buttress plates
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Femur proximal and distal (DCS)
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Adjuvant treatment
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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.

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Bone losses
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Bone transplant

• 1. Fibula pro tibia
• 2. Bone transport
• 3. Free vascularized bone grafts

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Bone losses (bridging techniques)

• Bridge plate
• External Fixator
• Locked intramedullary nailing

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Humerus and forearm bone losses
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Femur bone losses
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Tibia bone losses

• Tibio fibular synostosis
• Fibula pro tibia
• Bone transport

Plus inter tibio-fibular grafting
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Tibia bone losses
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Tibia bone losses
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Aseptic Non-union Clinical Examples
Aseptic Non Union
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AO Principles Course
Dr. Enrique Queipo de Llano Hospital
Universitario de Málaga
Aseptic Non Union
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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
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V.G.C. - 60 y - Female
Aseptic Non Union
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V.G.C. - 60 y - Female
Aseptic Non Union
90
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

Aseptic Non Union
91
A.M.C. - 35 y - Female
Aseptic Non Union
92
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

Aseptic Non Union
93
G.G.C. - 52 y - Male
Aseptic Non Union
94
G.G.C. - 52 y - Male
Aseptic Non Union
95
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

Aseptic Non Union
96
D.O.J. - 43 y - Male
Aseptic Non Union
97
D.O.J. - 43 y - Male
Aseptic Non Union
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D.O.J. - 43 y - Male
Aseptic Non Union
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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

Aseptic Non Union
100
P.T.M. 27 y Male
Aseptic Non Union
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P.T.M. 27 y Male
Aseptic Non Union
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G.B.P. - 14 year old - FemaleFemur 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
103
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

Aseptic Non Union
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G.B.P. - 14 year old - Female
Aseptic Non Union
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G.B.P. - 14 year old - Female
Tibia healed. Decortication, axial compression
plate fixation.
Aseptic Non Union
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G.B.P. - 14 year old - Female
Aseptic Non Union
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G.B.P. - 14 year old - Female
Aseptic Non Union
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G.B.P. - 14 year old - Female
Aseptic Non Union
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JG.FJ. - 18 year old - MaleMotorcycle 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
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JG.FJ. - 18 year old - Male
Aseptic Non Union
111
JG.FJ. - 18 year old - Male
Aseptic Non Union
112
JG.FJ. - 18 year old - Male
Aseptic Non Union
113
JG.FJ. - 18 year old - Male
Aseptic Non Union
114
JG.FJ. - 18 year old - Male
Aseptic Non Union
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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

Aseptic Non Union
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L.S.C. - 27 year old - Female
Aseptic Non Union
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L.S.C. - 27 year old - Female
Aseptic Non Union
118
Fibula pro tibia
Aseptic Non Union
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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.

Aseptic Non Union
120
P.A.R. - 10 year old - Male
20 m
Aseptic Non Union
121
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

Aseptic Non Union
122
G.S.A. - 15 year old - MaleRun 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
123
G.S.A. - 15 year old - Male
Aseptic Non Union
124
G.S.A. - 15 year old - Male
Aseptic Non Union
125
G.S.A. - 15 year old - Male
Aseptic Non Union
126
G.S.A. - 15 year old - Male
Aseptic Non Union
127
G.S.A. - 15 year old - Male
Aseptic Non Union
128
G.S.A. - 15 year old - Male
5 years
Aseptic Non Union
129
Aseptic Non Union