Welcome AO SEC Trauma

May, 15-17, Chittagong.

Prof. Muhammad Shahiduzzaman

Head, Department of Orthopaedics and Traumatology

Dhaka Medical College Hospital
•Definition
•Etiology
•Evaluation
•Classification
•Treatment principles
• Stabilization
• Biology
•Prevention
Non Union

•9 months elapsed time with no healing progress for 3 months.

•Union is delayed and a fracture has ceased to show any

evidence of healing

Practically,
A fracture that has no potential to heal without further
intervention
Delayed union
Failure to consolidate within the normally expected time for fracture
types and location

Pseudoarthrosis
Formation of a false joint where a fibro-cartilaginous cavity is lined
with synovial membrane
 What does nature do with a
broken bone?

It will heal by callus formation

Indirect Healing
Stages of fracture healing
• Hematoma formation
•Inflammation and cellular
proliferation
bony bridging
•Callus formation
•Consolidation
•Remodeling
• Poor Vascularity (biology)
• Instability
• Infection
• Others
Traumatic Iatrogenic
 Inadequate stabilization:
Resorption of bone at fracture site.

too flexible gap

 Infection:
Infection and loss of soft tissue covering.
• Local Risk factors
– Open Fractures
– High energy fractures
with bone devitalization.
– Severe associated soft
tissue injury
– Bone loss
– Infection
• Iatrogenic Factors:
– Poor reduction
– Unstable fixation
– Bone devitalization
• Systemic Risk Factors
– Malnutrition
– Smoking
– NSAIDs
– Systemic Medical Conditions
like Diabetes, paraplegia.
– Chronic alcoholism.

• Patient Factors
– Non Compliance
Site
- Diaphyseal
- Metaphyseal:
- Extraarticular
- Intraarticular
Callus
- Hypertrophic
- Oligotropic
- Atropic
Infection
- Aseptic
- Infected
 Vascular/Vital Avital? Avital

Hypertrophic Oligotrophic Atrophic Necrotic Defect

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

•Serial Radiological Assessment is

necessary.
•Stress radiograph
gives the status of
stability of the
fixation.

•It also confirm the

clinical diagnosis

Varus stress Valgus stress

•Computed Tomography: A definitive diagnostic tool
 Biology: good
Stability: lacking

Treatment:
•Provide stability
•Correct deformity, if present
•No bone graft required

Elephant foot Horse hoof

 Biology: Poor
Stability: lacking

Treatment:
•Provide stability
•Bone graft

Atrophic
 Biology: None
Stability: lacking?

Treatment:
•Provide stability
•Bone graft
•Other reconstruction

Necrotic Defect
Principle of surgical management

• Cure infection if present

• Correct Deformity if significant
• Provide stability through
implants
• Add biologic stimulus when
necessary
•Treatment principle of infected non union

•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)
• External Fixation
• Plate
• Intramedullary Devices
• Largest indication is a
temporary stabilization
following infection
debridement
• Also useful in correction of
stiff deformity and
lengthening
• 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
• Multiple Indications for plate
– Broken implants require that
removal
– Metaphyseal nonunion
– Significant deformity
Broken
• Technique Plate
– Blade properly positioned in the
distal fragment
– Reduction obtained by bringing
plate to the shaft
– Absolute stability with lag screw
– Nonunion was not exposed
• 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 Broken
to traverse sclerotic canals Plate
• Often unnecessary in hypertrophic cases with sufficient inherent
biologic activity
• Options
– Aspirated stem cells (with or without expansion)
– Demineralized Bone Matrix Broken
– Autogenous Cancellous Graft Plate

– Growth Factors
• Platelet derived
• Recombinant BMPs
• Gene Therapy
Gold standard for biological and mechanical purposes.

Properties of Autograft:
Osteogenic a source of vital bone cells

Osteoinductive recruitment of local mesenchymal cells

Osteoconductive scaffold for ingrowth of new bone

Bone graft can also be allograft.

• Aspirated iliac crest stem cells
has been shown to enhance the
activity of osteoconductive
grafts.

• There are few commercially

available Recombinant BMP
proved to be effective treating
nonunions.
Decortication (Judet, 1972)

Shingling Cancellous bone graft

Muscle pedicle bone graft

Enhance the healing response
creating well-vascularized bed
68-year-old, women

8 months
after injury
68-year-old, women
•Electromagnetic
– Direct Current
– Inductive coupling (PEMF, CMF)
– Capacitive coupling
•Ultrasound
– mechanical energy in the form of low frequency acoustic
waves
30 mW/cm2
 Biological fixation:
Preservation of blood supply to bone and soft tissue
The commonest cause of nonunion is the failure to diagnose and
treat delayed union

- Careful evaluation of abnormal findings clinically and

radiologically

- Adequate regimen of aftertreatment

• Definition of delayed unions/nonunions and natural course of
fracture healing

• Causes of disturbed bone healing such as vascularity,

instability, and infection

• Principles of treatment applied based on types of nonunion:

- stabilization
- enhancement of biology
- eradication of infection if any

• How to prevent delayed unions/nonunions:

- biological fixation in original operation
- early recognition of delayed union