infected nonunion of long bones

1. INFECTED NON-UNION
DR SAGAR TOMAR
llrm medical college meerut,up

2. NON UNION
Definition
 A state in which healing process comes to a halt
as judged by clinical & x-ray evidence, beyond
the stipulated period of healing for a particular
bone and fracture pattern due to mechanical or
biological failure

3. CAUSES OF NON UNION

4.  BASED ON THE EXTENT OF INFECTION
NON-INFECTED NON-UNION
INFECTED NON-
UNION
CLASSIFICATION OF NON UNION

5. CLASSIFICATION OF NON-INFECTED NON-UNION
 HYPERTROHIC NON
UNION
 Hypervascular
nonunions have shown
uptake of strontium-85,
which indicates a rich
blood supply in the ends
of the fragments
 ATROPHIC NON
UNION
 strontium-85 uptake in
these nonunions
indicate a poor blood
supply in the ends of
the fragments

6. HYPERTRROPHIC NON-UNION
1 “Elephant foot” nonunions
These are hypertrophic and rich in
callus. They result from insecure
fixation, inadequate immobilization, or
premature weight bearing in a reduced
fracture with viable fragments.
2 “Horse hoof” nonunions
These are mildly hypertrophic and
poor in callus. They typically occur after
a moderately unstable fixation with
plate and screws. The ends of the
fragments show some callus,
insufficient for union, and possibly a
little sclerosis.
3 Oligotrophic nonunions
These are not hypertrophic, but are
vascular, and callus is absent. They
typically occur after major displacement
of a fracture, distraction of the
fragments, or internal fixation without
Hypervascular nonunions.
A, “Elephant foot” nonunion.
B, “Horse hoof” nonunion.
C, Oligotrophic nonunion

7. AVASCULAR NON-UNION
1 Torsion wedge nonunions
These are characterized by the presence
of an intermediate fragment in which the
blood supply is decreased or absent. The
intermediate fragment has healed to one
main fragment but not to the other.
2 Comminuted nonunions
These are characterized by the presence
of one or more intermediate fragments that
are necrotic. The radiographs show absence
of any sign of callus formation.
3 Defect nonunions
These are characterized by the loss of a
fragment of the diaphysis of a bone. The
ends of the fragments are viable, but union
across the defect is impossible. As time
passes, the ends of the fragments become
atrophic.
4 Atrophic nonunions
These usually are the final result when
intermediate fragments are missing and scar
tissue that lacks osteogenic potential is left
in their place. The ends of the fragments
Avascular nonunions.
A, Torsion wedge nonunion.
B, Comminuted nonunion.
C, Defect nonunion.
D, Atrophic nonunion

8. Paley et al.classification of non-union
Type A nonunions
(<1 cm of bone loss)
A1, lax (mobile)
A2, stiff (nonmobile)
A2-1, no deformity
A2-2, fixed deformity.
Type B nonunions
(>1 cm of bone loss)
B1, bony defect, no
shortening
B2, shortening, no bony
defect;
B3, bony defect and
shortening.

9. WEILAND CLASSIFICATION OF INFECTED NONUNION
 Based on the extend of infection
 type 1
characterised by open and exposed bone without
osseous infection but with soft tissue infection
 type 2
characterised by circumferential cortical and
endostesl infection with often and invlocrum
surroundind a sequestrum
 type 3
characterised by cortical-endosteal infection
associated with a segmental bone defect.

10. CIERNY MADAR CLASSIFICATION
 Cierny and Mader developed a classification system for
chronic osteomyelitis, based on physiological and
anatomical criteria, to determine the stage of infection.
 Based on host
class A- NORMAL
class B- COMPROMISED
class C-PROHIBITIVE
 Based on anatomy
type 1-MEDULLARY
type 2-SUPERFICIAL
type 3-LOCALISED
type 4-DIFFUSE
 pairing of these forms 12 clinical stages
 Clinical Stage
(Type+ Class = Clinical Stage)

11. UMIAROV’S CLASSIFICATION OF
INFECTED NON-UNION
 based on the viability of bone ends, the presence of
limb shortening, the presence of bone, and soft
tissue defect.
 - type 1 the nonunion is normotrophic without
shortening
 - type 2 the nonunion is hypertrophic with shortening
 - type 3 the nonunion is atrophic with shortening
 - type 4 the nonunion is atrophic with bone and soft
tissue defect, in general as a result of an
open
fracture

12. G.S KULKARNI CLASSIFICATION OF
INFECTED NON UNION
 Severity of infection
 Apposition of fragments
 Presence or absence of deformity.

13. G.S KULKARNI CLASSIFICATION OF
INFECTED NON UNION
 TYPE I:
 fragments in apposition with mild infection and
with or with out implant
 TYPE II:
 Fragments in apposition with severe infection
with large or small wound.
 TYPE III:
 Severe infection with a gap or deformity or
shortening.
3A  defect with loss of full circumference
3B  defect in > 1/3 of cortex
3C  infected nonunion with deformity.

14. GORDON’S CLASSIFICATION
 TYPE A
Tibial defects and non unions without significant
bone
loss
 TYPE B
tibial defects greater than 3 cm with an intact fibula
 TYPE C
tibial defect greater than 3 cm without intact fibula

15. MAY’S CLASSIFICATION
-it focuses on the status of tibia after bone and soft tissue
debridement
-it helps to estimate the length of rehabilitation period before
ambulation

16.  NON-DRAINING/
 DRY/QUIESCENT
-- nondraining for at least
3 months
-- requires 1 stage
treatment
 DRAINING/ACTIVE
--drainig with abscess and
fever
-- Requires 2 stage
treatment
-- stage 2 after a period
of 10-20 days

17. How infection causes non union??
1. Dissection of pus through planes and periosteum-
devascularising th ends
2. Fragmentation and dissolution of fracture
haematoma
3. Inflammatory mediators promotes fibrous tissue
formation
4. If fixation was done then implant failure occurs
destabilization the fragments
5. Increase catabolic response at # ends

18. PATHOGENESIS
OSTEOMYELITIS
thrombosis of blood vessel
of haversian canals
bone sclerosis and dead
bone.
Butterfly fragments become sequestrii,
isolated & devitalized by pus &
INFECTED GRANULATION TISSUE

19. Infection granulation tissue
OSTEOLYIS
GAP NON UNION
Osteolysis occurs around the implants 
loosening  instability of fixation 
nonunion.

20. DIAGNOSIS OF INFECTED NON UNION
1. Pain and mobility at fracture site
2. Raised local temperature
3. Discharging sinus
4. Scar healed by secondary intension with
“puckering”
5. Irregularity of bone showing osteomyelitis

21. INVESTIGATIONS
 Include - complete blood count
- erythrocyte sedimentation rate (ESR)
- C- reactive protein (CRP)
 Plain radiogarphy
 Sinography
 Radionucleotide scan
 MRI
 CT-scan
 Culture sensitivity
 usg

22.  goals
Treatment of Infected non-union…
ERADICATE
INFECTION
ACHIEVE UNION
SOLVE:soft tissue
problem,deformity,joint
stiffness
GOAL 1
GOAL 2
GOAL 3

23. GOAL 1 : ERADICATE INFECTION
 INCREASE HOST RESISTANCE :
 Correct host morbidity
-control blood sugar level in diabetic
-smoking cessation
-treatment of liver or renal malfunction
-optimising nutrition
-treatment of chronic disease
 Antibiotic therapy according to culture sensitivity
reports.
- systemic antibiotic therapy

24. LOCAL CONTROL OF INFECTION
DECREASE INFECTION LOAD:
• thorough debridement of dead and necrotic tissue
• closed suction antibiotic ingress and egress irrigation systems.
• negative suction drainage system.
INCREASE LOCAL HOST RESISTANCE:
• PMMA antibiotics beads
• biodegradable antibiotic delivery system

25. GOAL 2 : TO ACHIEVE UNION
• ADDING BIOLOGY
– Aspirated stem cells (with or without expansion)
– Demineralized Bone Matrix
– Autogenous Cancellous Graft
– Growth Factors
• Platelet derived
• Recombinant BMPs
• Gene Therapy
EXTERNAL STIMULI
-low intensity ultrasound therapy
-electric and electromegnetic therapy

26. • 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.

27. Bone grafting in infected non union
 Onlay bone grafting:
 graft applied or laid on the surface
of a bone
 Inlay bone grafting:
 By the inlay technique a slot or
rectangular defect is created in the
cortex of the host bone, usually A graft
the same size or slightly smaller is then
fitted
 into the defect.
Single onlay dual onlay
Cancellous
Insert graft

28. Papinaeu method of bone grafting
 Stage I: Radical debridement
 Stage II: bone grafting
 Stage III: skin coverage.

29. HARMONS’ POSTEROLATERAL GRAFT
 Bone grafting on the
interosseous membrane
to obtain a long
synostosis with fibula,
spanning the tibial
defect.

30. Free vascularised bone transfer
 Rib, fibula, iliac crest.
 Isolation of a segment
of contra lateral fibula
with attached nutrient
artery and vein.
 Length of graft should
be 4 cm longer than
defect to allow 2 cm
overlap at the proximal
and distal ends.

31. ULTRASOUND THERAPY
 it cause increases in cellular activity at osteotomy
sites and increases in mineralization of the bone and
metabolic activity.
 It promotes bone healing because it stimulates the
genes involved in inflammation and bone
regeneration.
 It increases blood flow through dilation of capillaries
and enhancement of angiogenesis, increasing the
flow of nutrients to the fracture site.
Used : for 20 min / day

32. ELECTRICAL AND ELECTROMAGNETIC
STIMULATION
 used for 3 or more hours per day has been
successful in healing nonunions of long and short
bones, open or closed fractures, long-standing
nonunions, infected nonunions, and those with
fracture gaps up to 1 cm.

33.  The three methods of administering
electric stimulation are shown in this
diagram.
 (a) Direct current (DC): A cathode is
implanted at the fracture site which is
attached to either a subcutaneous
power source or an external power
source to generate an electric field at
the fracture site.
 (b) Capacitive coupling(CC): Two
capacitive coupled electrodes are
situated on the skin on either sides of
the fracture site. An external power
source is then attached to the
electrodes, which induces an electric
field at the fracture site.
 (c) Inductive coupling (IC): An
electromagnetic current carrying coil is
placed on the skin overlying the
fracture site, which is attached to an
external power source. The coil
generates a magnetic field, which
induces an electrical field at the fracture
site.

34. GOAL NO.3
 SOFT TISSUE PROBLEMS:
The transfer of vascularized muscle tissue improves
the local biological environment by bringing in a
blood supply that is important in the host's defense
mechanisms and for antibiotic delivery and osseous
and soft tissue healing
 DEFORMITY AND SHORTENING:
- Ilizarov is the gold standard treatment to correct
deformity and shortening and eradicate infection at
the same time

35. TREATMENT PROTOCOL (AO BASED)
queiscent nonunion
use of short term antibiotic prophylaxis
excise dead bone and scarred ,non vascularised soft tissue
remove loose hardware
correct alignment
perform cancellous bone grafting if required
stabilise using plate or intramedullary devise or external
fixator
mobilise adjacent joints by physiotherapy
QUEISCENT NON
UNION

36. ACTIVE NON UNION
 STAGE 1
thorough debridement
- excise and debride
- drain using closed suction irrigation
- antibiotics beads and i.v. antibiotics
- stabilize with external fixator
 STAGE 2 after 10-20 days
shingling and cancellous bone auto graft.
 STAGE 3
additional bone graft ,muscle or skin pedicle flap can
be used

37. Shingling and cancellous bone
grafting
Shingling Cancellous bone graft
Shingling:a process by which ends of the fracture
Fragments are decorticated subperiosteally forming many
Small osteoperiosteal flaps.

38. ELIMINATION OF INFECTION IN ILIZAROV
METHOD
 Resection of infected bone and subsequent
intercalary bone lengthening
 gradual bone transport of one wall of the cavity
 Controlled osteogenesis, filling of cavities by newly
formed tissue

39. A corticotomy is performed to fracture the bone into two segments, and
the two bone ends of the bone are gradually moved apart during the
distraction phase, allowing new bone to form in the gap.
When the desired or possible length is reached, a consolidation phase
follows in which the bone is allowed to keep healing.

40. CONCLUSION : general approach to
infection

41. Thank you