Tibial Nonunion

Principles and BEST EVIDENCE

Dr Hitesh Gopalan U

Clinical Asst Professor, MOSCMM, Cochin

Editor, Orthopaedic Principles

Expert Advisor, OrthoEVIDENCE

Tibial Nonunion

Significant Morbidity

Infection will complicate management

Defects: Challenging

Gap Nonunion

Technical challenges Time-consuming Psychologically

demanding for Patients

No Guarantee of Success

(Pain, Stiffness, NV Deficits)

Categories

Simple

Defect

Infective

Definition of Bone Loss

Bone loss 1. Extrusion of a

bone fragment during injury

2. Removal of bone during debridement

Bone Loss- Epidemiology

Significant bone loss—RARE Edinburgh- 10 year audit all

fractures

Fracture with bone loss= 0.4% Open Fractures=11.2%

Gustilo Type IIIB or C injuries

71% males, aged 30-40 years

Epidemiology of Bone Loss

Common Location Tibia (68%) Diaphyseal (69%)

Less Circumferential Soft Tissue –MORE susceptible

2 of every 3 fractures with BONE LOSS will occur in the

Tibial Diaphysis

Why Worry About Bone Loss?

Bhandari et al..J Orthop Trauma 2003

Risk Factors: Re-operation

Open fracture wound: RR=4.32, 95% CI:

1.76-11.26

Fracture Gap: RR=8.33, 95% CI:

3.03-25.0

Transverse Fracture RR=20.0, 95%CI:

4.34-142.86

Risk of Re-operation

NO Risk Factors 4%

1 Risk Factor 20%

2 Risk Factors 40%

3 Risk Factors 90%

Risk for Nonunion

Location: more distal

Skin injury > 5cm in length

Postoperative Fracture gap

Audige, Bhandari et al..CORR 2005

Classification of Defects

Defects Diaphyseal Metaphyseal Articular

Size of Defect Length of segment Partial or Complete Circumferential

Evaluation

X-rays

CT scans: Very sensitive, poor specificity

Bhattacharyya T, J Bone Joint Surg Am 2006;88(4):692-697.

Weber and Cech Classification

Hypertrophic

Oligotrophic

Atrophic(?Avascular)

Brownlow HC: The vascularity of atrophic non-unions.Injury 2002;33(2):145-150.

Investigate

Rule out occult infection

WBC count?, ESR, CRP

MRI Bone marrow changes: metal, postoperative changes

Bone scan and Infection Rx

Indium labelled WBC scan, Tc scan

False positive in unstable and periarticular nonunion

Withhold preoperative antibiotics and obtain deep cultures

Non Surgical Management

Well aligned stable nonunion

Surgically unfit

Associated Deformity

Malalignment Test and preoperative planning for deformity correction

Paley’s Principles of Deformity Correction

Hypertrophic Nonunion

BIOLOGY is good.

Axial compression OR Lag screw fixation

ESWT

bone mass, strength, angiogenesis, and differentiation of mesenchymal stem cells

126 patients, ESWT Vs Surgery

Useful in hypertrophic nonunionsCacchio A, J Bone Joint Surg Am 2009;91(11)LEVEL 1

PEMF

Recent Level 1 study showed no difference (259 patients)

Sam Adie et al.. J Bone Joint Surg Am.  2011(level 1)

LIPUS

Possible healing by transmission of acoustic waves

Jingushi S et al..(level IV) Nolte et al..(level IV)

No Level 1 studies published upto date

Bone Marrow Injection

Variability of Osteoprogenitor cells among patients

Quality with age

Connolly JF, CORR 1991

Hernigou , JBJS A 2005 LEVEL IVGoel A, Injury 2005 Muschler GF,JBJS A2007

Functional Cast Brace

Stable nonunion

Fibulectomy(Connolly JF: CORR Level V)

Sarmiento A, Int Orthop 2003;27(1): LEVEL IV

Surgical Options

Exchange reamed nailing

Adjunctive plate fixation

Conversion to plate fixation

External fixation

Exchange Reamed Nailing

Diaphyseal nonunion

Compression by reverse impaction,

Nails with internal compression devices

Zelle BA et al, J Trauma 2004; 57(5)- Level IVOh JK, et al.. Injury 2008;39(8)-Level IV

Exchange Reamed Nailing

Contraindication:

1. Bone loss >2cm 2. >50% of circumference 3. Infection

Court Brown, Keating JBJS Br 1995

Dynamisation

To Dynamise or not

Not recommended 1.unstable tibial shaft 2.SegmentalWu et al. Can J Surg 1993 LEVEL IVCourt Brown et al..JBJS 1990 LEVEL IV

Adjunctive Plate Fixation

Hypertrophic Nonunions

Metadiaphyseal Nonunion(endosteal contact is limited in IM nails)

Ueng SW,et al.. J Trauma 2002; 53(3)

Nail Removal and Plating

Metaphyseal nonunions (endosteal contact)

Interfragmentary screws, DCP, External compression device

Additional Surgical Trauma

Internal Fixation

Posterior Plating: distal half of tibia(Posterolateral bone graft)

Fibrous union(take down)

Rodriguez-Merchan EC Clin Orthop Relat Res 2004;(419) LEVEL V

External compression device, lag screw fixation and posterior plating

External Fixation

Deformity correction

Compression

Distraction Osteogenesis

Union Rates: 93%

García-Cimbrelo E, Clin Orthop Relat Res 2004; LEVEL IV

Ilizarov Method

Distraction

Allows Full Weight Bearing

>60 years

Brinker MR et al.. J Orthop Trauma 2007;21(9) LEVEL IV

Compression at # site, distal corticotomy and distraction osteogenesis

Classification of Defects

OTA Classification of Bone Loss

Type I Bone Loss

<50% bone diameter

Classification of Defects

OTA Classification of Bone Loss

Type 2 Bone Loss

>50% bone diameter

Classification of Defects

OTA Classification of Bone Loss

Type 3 Bone Loss

Missing bone segment

Management Strategies

Reamed IM Nail

Court-Brown et al, JBJSBr 1991 41 Open fractures 2cm, <50%

diameter Union rates (1o or 2o

Nailing)

Type I Bone Loss

Management Strategies

Adjunctive Bone Grafting of Defect

Type 2 Bone Loss

Management Strategies

IM Nail or Ex-fix +bone grafting

Bone transport Acute shortening

+ subsequent bone lengthening

Vascularized bone grafts

Type 3 Bone Loss

Defects <2 cm

Exchange Reamed Nailing

Keating et al..JBJS

Defects 2-6 cm

Bone grafts

Bonegraft alternatives

Keating JF et al..JBJS Br 2005

Induced Membrane philosophy

Reactive membrane- Growth factors

Temporary cement spacer

Bone graft

Masquelet AC et al..Orthop Clin North Am 2010;41(1):

Oedekoven G ,Chirurg. 1996

Mono-Rail System

Osteotomy, either proximal or distal, of the bone defect

Segmental transport via an anteromedially (tibia) mounted external fixation

Over an IM Nail

RIA

Segmental defects: 2 to 14.5 cm

Pain scores at harvest site

McCall et al.. OCNA2010;41(1): LEVEL IVBelthur et al.. Clin Orthop Relat Res 2008;466(12)

Induced Membrane-RIA

David J. Hak, J Am Acad Orthop Surg Sept 2011

Stem cells

Expand the harvested cells in culture and reimplant

Dennis JE et al.. Stem Cells 2007;25(10)Jimenez ML,., OTA Meeting 2007 Boston, MA

Defects > 6cm

Individualized treatment

1.Vascularised fibular graft2.Bone transport using Ilizarov3.Lengthening over nail

Infected Nonunion

Radical Debridement

Antibiotic beads

Systemic antibiotics

One stage or two stage Revision

One stage Revision

Ilizarov Method

Fine wires: Vascular pedicle

Full weight bearing

Two Stage Revision

Stage 1: Radical debridement, ALBC, External fixator

Stage 2: Reamed nailing and bone grafting

>6 cm defects: Contraindicated

Infected Nonunion

One stage Revision Vs Two stage revision

16 level IV one stage Vs 18 level IV two stage

Cannot recommendStruijs PA, J Orthop Trauma 2007;21(7):507-511 LEvEL I

Infected Nonunion: Soft tissue

Local flaps Vs Free Flaps

Local flaps: Already damaged muscle

Usually as secondary procedure after initial debridement

Anthony JP, Plast Reconstr Surg 1991; 88:

rhBMP

rhBMP- 7 Vs ICBG

124 tibial nonunions

90% - reamed nailings

FDA- not approvedFriedlaender GE: J Bone Joint Surg Am 2001;83 LEVEL 1

rhBMP-7

100% union rate in 45 patients (17 tibial nonunions)

Synergistic effect with ICBG

Giannoudis PV et al.. Clin Orthop LEVEL IVRelat Res 2009;467(12):

rhBMP-2

Lack of clinical evidence in nonunion

US FDA approved for open tibial fractures after nailing

Off label use

Efficacy Vs Cost effectiveness

David Hak JAAOS Sept 2011

Vascularized Grafts

large infected tibial defects radical debridement and staged double-

rib composite free transfer Ueng J et al, Trauma 1996

vascularized bone graft transfers with the donor bone fibula or ilium

Minami et al, J Reconstr Microsurg. 1992

Ipsilateral vascularised fibular transport Atkins et al,JBJSBr 1999

double-strut, free vascularized fibular bone grafting Chang et al, Orthopedics, 1999

Results dependent upon Technical Expertise with Approach

Conclusion

Small defect nonunions: exchange nailing, ORIF or bone grafting

Nonunions > 6 cm require individualized treatment

Conclusion

Infective nonunions are more challenging to treat

Individualise: One stage or Two stage

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