gap nonunion

1. MANAGEMENT OF TIBIAL
DIAPHYSIS GAP NON
UNION
DR PRATIK DHABALIA
RESIDENT IN ORTHOPEDICS
Dr DY Patil Hospital, Navi Mumbai

2. CLASSIFICATION

3. GAP NON UNION
• Gap nonunion presents a major challenge to the orthopedic surgeon,
especially when associated with infection, old or active osteomyelitis,
and multiple previous surgeries.
• Management of the gap nonunion is technically difficult, time-
consuming, physically and psychologically demanding for the patient.
• The problem involves bridging or regenerating areas of bone loss
while maintaining limb length and alignment.
• Open fractures with bone loss are most common in the tibia due to
its subcutaneous anatomical site, and a number of patients have
secondary bone loss after surgical debridement of the necrotic bone
or osteomyelitis.

4. • The nonunion may persist despite a series of reconstructive
procedures, with external fixation, internal fixation (plate or
intramedullary rods), bone grafting, and Ilizarov frame application.
• The patient may require multiple surgeries and sometimes the
surgeon is left with no option, but secondary amputation or
disarticulation

5. PRINCIPLES OF TREATMENT OF GAP NON
UNION
1. MANAGEMENT OF INFECTION
2. ACHIEVE UNION AT THE SITE
3. SOFT TISSUE COVERAGE, DEFORMITY CORRECTION AND POST
OPERATIVE JOINT STIFFNESS

6. INFECTION
• Debridement:
-removal of all dead and necrotic soft tissues
-removing the sinus tracts
-sequestrum removal

7. • Antibiotic therapy:
-given intravenously for 4–6 weeks
-then orally for 3–6 weeks.
-After the culture and sensitivity, appropriate antibiotics should be
started intravenously
- Wounds that have been left open for a long time usually have super
infection and mixed infection and generally require Aminoglyocsides

8. • Patient factors:
-control sugar levels
-cessation of smoking
-optimizing nutrition
-treating any chronic liver or renal diseases
• Beads
-management of open contaminated fractures and infected nonunions
-beads are left in place for 2–3 weeks and then removed

9. ACHIEVING UNION
TECHNIQUES:
1. Papineau type of cancellous bone grafting
2. Autogenous Bone Grafting Using the Masquelet Technique
3. Vascularized fibula graft
4. Huntington's procedure
5. Ilizarov technique

10. Papineau Technique
• In patients with bone gap less than 4 cm
• Cancellous bone grafting
• Adequate drainage is provided
• Adequate immobilization is provided
• Antibiotics are used for prolonged period

12. Masquelet technique
• Primary shortening followed by lengthening is favoured
• Area of segmental loss is filled with a PMMA cement
• At 4 to 6 weeks, when an osteogenic membrane has been formed
around the cement, the membrane is surgically reopened, the
cement is removed, and generous cancellous grafting is carried out
• Healing generally occurs slowly but usually by 3 to 6 months.
• This, of course, is done in conjunction with internal stabilization.
• The membrane itself serves to contain the graft, prevent fibrous
ingrowth, and provide growth factors (BMP)

16. Vascularised fibular graft
• Vascularized bone grafts, by virtue of their inherent vascularity, unite
more rapidly with the host bone and are more resistant to infection.
• Protected weight bearing post grafting
• Weight bearing causes remodelling and hypertrophy of graft

18. Huntingtons procedure
• Transposition of the ipsilateral fibula to the tibia
• Provides mechanical strength.
• the fibula is transferred to the tibia as a pedicle graft.
• Due to retained blood supply to one end of the transplant, the graft
easily takes up and hypertrophies upon weightbearing over a period
of time

20. Ilizarov method
• Law of tension stress and distraction osteogenesis
• Corticotomy is done in the fracture fragments and both the fragments
are distracted.
• When the desired length is achieved, distraction is stopped and
consolidation of the new bone formed occurs
• Gold standard in infective gap non union
• Fibular osteotomy

21. • Removal of fixator:
Atleast three cortices should be ossified in AP and Lat view xrays
Protected weight bearing
• Advantages:
no skin incision is made, minimally invasive (wires and pins)
Very little soft tissue handling
Can correct length and deformities in three dimensions
Patient can weight bear early after application

22. • Disadvantages:
Pin tract infective
Cumbersome for patient
Requires sufficient physiotherapy post operatively
Soft tissue contracture
Kinking and stretching of neurovascular structures

30. ADJUNCTS TO OPERATIVE REPAIR
• Autogenous Bone Graft
• Reamer–Irrigator–Aspirator
• Vascularised grafts
• BG substitutes like BMPs, DBM, BM aspirate, PRP
• Allografts

31. Management of Soft Tissue Compromise
Associated with Nonunion
• Vac application
• SSG
• Myocutaneous flaps