Presentation on delayed union and nonunion of fracture for orthopaedics resident and mbbs students

1. DELAYED UNION AND
NON-UNION
PRESENTER : DR. BIJAY MEHTA
MODERATOR : DR. KIRAN KHANAL

2. CONTENTS
Definition
Etiology
Classification
Evaluation
Management
Summary

3. Definition : Delayed Union
 When fracture takes more than usual time to unite
Every fracture has its own timetable
Long Bone shaft fractures – 6-9 months
Femoral neck fractures- 3 months

4. Definition : Non-union
 USFDA
Non-union is said to have occurred when 9 months have elapsed since injury and
there are no visible progressive signs of healing for 3 consecutive months.
Brinker
A fracture, that in the opinion of treating physician, has no possibility of healing
without further intervention.

5. Pseudoarthrosis
 Non-union may be painless if pseudojoint is
formed between fracture ends
Active movements is possible
No synovial capsule

6. Fracture Healing
 Stages:
Stages of hematoma formation
Stage of Inflammation
Stage of Soft callus formation
Stage of Hard Callus formation
Remodeling stage

7. Given by Stephen Perren
States that , “A tissue cannot exist in
the environment where the strain is
greater than yield tolerance of the
tissue.
Yield tolerance –
Bone-2%
Cartilage-2-10%
Granulation tissue/fibrous tissue-
100%
Interfragmentary Strain Theory

8. Primary intention- Absolute stability
Interfragmentary motion- < 0.15mm, fracture gap-<0.1mm
Strain-<2%
Secondary intention- Relative stability
Interfragmentary motion -0.2-1mm
Strain 2-10%
Gap Union
Strain< 2% , gap –upto 1 mm
Fracture Healing : Types

9. Non-union- Etiologies
Multiple
Biologic
Local
Systemic
Mechanical
Malreduction
Inappropriate stabilization

10. Etiologies : Biologic
Systemic
Age
Chronic Disease
Diabetes Mellitus
Manutrition
Medications
Smoking
Local
Excessive soft tissue stripping
Bone loss
Vascular Injury
Infection

11. Smoking and Non-union
Cigarette smoke contains 4800 constituents- 200 toxic
Multifactorial
Nicotine- a vasoconstrictor –reduction in peripheral blood flow
Carbon monoxide reduces oxygen carrying capacity of blood
Hydrogen cyanide- inhibits cytochrome oxidase C – prevents
aerobic metabolism

12. Etiologies : Mechanical
Inappropriate stabilization
Too little fixation
Too rigid fixation
Inappropriate implant choice
Inappropriate implant position
Malreduction
Malposition
Malalignment
Distraction

13. Neck of Femur
Scaphoid
Lower third tibia
Lower 3rd Ulna
Lateral condyle humerus
Common Sites

14. Classification
Broadly – Aseptic and Septic Non union
Aseptic Nonunion-Judet and Muller, Weber and Cech
Based on viability of the bone ends
 Hypervascular : viable and capable of biological reaction
 Stable internal fixation is enough, noi bone graft is required
 Avascular: non viable and are not capable of uniting without
intervention
 Needs rigid internal fixation and bone graft after decortication of
non viable ends

15. Hypervascular Non-union
Elephant foot : Hypertrophic, rich in callus
 Horse Hoop : mildly hypertrophic, poor in callus
Oligotrophic : non hypertrophic
Based on viability of the bone ends

16. Hypervascular Non union : Elephant Foot
Hypervascular Non union : Horse Hoop

17. Avascular Non-union
Torsion Wedge Non-union: Intermediate
fragment has healed at one end and not
at other end
Comminuted Non-union:
Gap Nonunion :
Atrophic Nonunion : ends are thin and
sclerotic with excess scar tissues in
between

18. Comminuted Nonunion Gap Nonunion

19. Classification of Infected Non-Union
Umiarov’s Classification
Type 1 : Normotrophic without shortening
Type 2 : Hypertrophic with shortening
Type 3 : Atrophic with shortening
Type 4 : Atrophic with bone and soft tissue
defect
Kulkarni’s Classification
Type 1 : Fragments in apposition with mild
infection and with/without implant
Type 2 : Fragments in apposition with
severe infection with small or large wound
Type 3 : Severe infection with a gap or
deformity or shortening
3A- defect with loss of full circumference
3B- defect in >1/3 of circumference
3c –defect with deformity

20. Paley et al Classification
Type A<1cm of bone loss
A1 (Mobile deformity)
A2 (fixed deformity)
A2-1 stiff w/o deformity
A2-2 stiff w/ fixed deformity
Type B>1cm of bone loss
B1 w/ bony defect
B2 loss of bone length
 B3 both
Classification of Tibial Non-Union

21. Classification of Tibial Non-Union
According to the classification of Paley et al
Type A non-unions can be treated with
restoration of alignment, followed by
compression.
Type B non-unions may require
additional cortical osteotomy and either
internal bone transport or overall
lengthening to obtain the original bone
length.

22. Diagnosis
History
Clinical Examination
Serial X-rays
Blood investigations

23. Diagnosis : History
Symptoms : Minimal/No pain
Loss of Function
Initial velocity of injury
Initial treatment
Co-morbidities
Current Medications
Features suggestive of infections

24. Diagnosis: Examination
Painless abnormal mobility
Shortening
Muscle wasting
Scars/Sinuses
Neurovascular examination
Condition of soft tissues

25. Diagnosis: Investigations
Serial X-rays
CBC, ESR, CRP
Pus/Discharge C/s
CT scan

26. Diagnosis: X-RAY
Gap between fracture fragments
Fragments are rounded and sclerotic
Amount of callus formed could be less or
more
Decreased density of bone is due to
osteoporosis

27. Treatment
Diamond Concept of Fracture
Healing

28. Treatment : Principles
Identify Septic or Aseptic
Control of Infection
Host Optimization
Smoking cessation, Diabetes Control, Improving Nutrition
Classify as Hypertrophic/Oligotrophic/Atrophic
Stabilization +/- Bone graft
Correction of Deformity

29. Treatment of Septic Union
Two approaches used
Classical/Conventional Approach
Active approach
Conventional Approach
Infected and draining non union is converted to one that has not drained for
months
Requires longer duration
Meticulous debridement + temporary stabilization done followed by antibiotics to
eradicate infection
Definite stabilization +/- Bone graft done once infection is controlled

30. Treatment of Septic Union
Active Approach
The objective of the active method is to obtain bony union early and shorten the
period of convalescence and preserve motion in the adjacent joints.
Union takes priority over infection
Meticulous debridement and fixation is done in same setting followed treatment
of infection
Polymethyl Methacrylate Antibiotic Beads-
Heat-stable antibiotics, such as tobramycin and gentamicin, can be mixed with
PMMA and used locally to achieve 200 times the antibiotic concentration achieved
with intravenous administration.

31. Treatment of Aseptic Non-Union
Hypertrophic Non-Union : requires adequate stability
Exchange Nailing
Plate and screw fixation
External Fixators
Atrophic Non-Union:
Decortication, bone grafting and stable fixation
Bone Transport

32. Treatment Options
Conservative
Low Energy Ultrasound Stimulation
Electrical and electromagnetic
Stimulation
IC Bone Marrow Injection
PRP Injection
Operative
Dynamization
Exchange Nailing
Bone grafting
Open reduction-Rigid internal fixation
Bone transport-Ilizarov's technique
Induced Membrane Technique
Amputation

33. Ultrasound
Theories
 stimulates the genes involved in inflammation and bone regeneration.
increases blood flow through dilation of capillaries and enhancement of
angiogenesis, increasing the flow of nutrients to the fracture site.
chondrocyte stimulation is enhanced, which leads to an increase in
enchondral bone formation.
Protocol is to use the ultrasound equipment for 20 minutes once a
day.

34. Electromagnetic Stimulation
Bone growth stimulators - used in conjunction.
External electrical stimulation -advantageous in infected
nonunion or when surgery is contraindicated

35. Dynamization
Involves removal of proximal or distal screws
of statically locked Intramedullary nail
Stimulates osteogenesis at the fracture site
by increasing the contact area and enhanced
compression force
Screws from larger fragment usually removed
Ideal time : 3-6 months

36. Exchange Nailing
Removal of the current intramedullary nail, debridement of the
medullary canal followed by insertion of a larger nail.
Has advantage of reaming which provides some bone graft at
fracture site and also allows larger nail size

37. Bone Graft
Standard for treatment of atrophic non-unions
Used to stimulate biologic response of healing in nonunion
Also used to fill defects in fracture zone
i.e. up to 6 cm intercalary defects of long bones
Bone Grafting origins:
Autogenous “the golden standard”
Allograft
Synthetic bone substitute
Vascularised bone grafting

38. Bone Graft
Has osteogenic , osteoinductive and osteoconductive properties
Osteogenic – provides a source for vital bone cells
Osteoinductive - contain proteins or chemotactic factors that attract
vascular ingrowths and healing
i.e.. dematerialized bone matrix & BMP’s
Osteoconductive - contains a scaffolding for which new bone growth can
occur
i.e. allograft bone, calcium hydroxyapatite

40. Open Reduction and Plate fixation
Non union site opened , fracture ends freshened and fixed
along with bone graft.
External Fixators
relatively noninvasive and does not disturb soft tissues
surrounding the nonunion.
ability to correct deformity and provide stable fixation.

41. Illizarov’s Technique – Bone Transport
Best for infected nonunions
Corrects deformity + bone
loss
In hypertrophic - gradual
compression
Avascular-corticotomy ,
Bone transport and
compression

42. Induced Membrane Technique
Masquelet Technique
Usually useful for segmental bone loss
Two staged procedure
Fracture part debrided and filled with bone cement which
induces an osteogenic membrane
Secondly, membrane opened, bone cement removed and
filled with cancellous bone graft

43. Amputation
A reconstructive procedure rather than failure of treatment.
Properly fitted prosthesis after amputation better than a
painful functionless limb.
Indications in Non-union
When reconstruction has failed
When a proposed reconstructed limb would result in less
functional limb than a properly fitted prosthesis
When danger of major operation outweighs benefits
Ehen reconstruction is not possible

44. Recent Advances
Reverse Dynamization
Newer perspective of Stephan
Perren’s Interfragmentary Strain
Theory
Initial flexible fixation, resulting in
cartilaginous model formation
followed by rigid fixation at 2-4
weeks, resulting in woven bone
formation

45. Recent Advances
Bone Stimulants : BMPs, PRP, FGF
Mesenchymal Stem Cells : Bone-marrow derived MSCs seeded on ceramic scaffold
Gene Therapy: involves transfer of genetic material into the target genome.
Transfer of genes for BMPs under study
Bone tissue engineering
Use of Systemic stimulants such as Teriparatide(recombinant Parathyroid Hormone)
Studies have shown daily subcutaneous injection of teriparatide 20mcg enhances fracture healing

46. TAKE HOME MESSAGE
 Delayed union and non-union are common complication of fracture
Multifactorial etiology
Mechanical stability as well of biological environment is required for fracture
healing

47. REFERENCES :
 Rockwood and Green’s Fractures in Adults , 8th Edition
Campbell’s Operative Orthopaedics , 13th Edition
Apley and Solomon’s System of Orthopaedics , 10th Edition
Concepts and Cases in Nonunion Treatment, AOTRAUMA
Andrzejowski P, Giannoudis PV. The 'diamond concept' for long bone non-union
management. J Orthop Traumatol. 2019 Apr 11;20(1):21. doi: 10.1186/s10195-019-
0528-0. PMID: 30976944; PMCID: PMC6459453.
Emara KM, Diab RA, Emara AK. Recent biological trends in management of fracture
non-union. World J Orthop. 2015;6(8):623-628. Published 2015 Sep 18.
doi:10.5312/wjo.v6.i8.623

48. The Best Treatment for Non-Union is Prevention.
-John Charnley
Thank You