Aseptic Non-Union

Aseptic Non-Union Aseptic Non Union

AO Principles Course Dr. Enrique Queipo de Llano Hospital Universitario de Málaga Aseptic Non Union

Definition • No bone healing in the normal time • Usually 6 a 8 months Aseptic Non Union

Etiology • Do not blame the osteoblasts (Watson Jones). • Fractures have a spontaneous tendency to heal. (Merle D’Aubigne). • Delayed or non-union is often multifactorial in nature. Aseptic Non Union

Etiology • Disturbed vascularity and instability are the most important factors leading to a non-union. Aseptic Non Union

Etiology (Vascularisation) • Biological • Carpal scaphoid • Neck of the femur • Talus • Devitalized fragments Aseptic Non Union

Etiology (Instability) • Iatrogenic • Insufficient orthopaedic treatment • Incorrect osteosynthesis (unstable) Aseptic Non Union

Conditions for a normal bone healing Orthopaedic treatment Good reduction Contact between fragments Strict immobilization Aseptic Non Union

Conditions for a normal bone healing Surgical treatment Anatomic reduction of articular fractures Good alignment of diaphyseal fractures Stable osteosynthesis Absolute asepsis Aseptic Non Union

Non compliant patient • The care plan has to be compatible with the patient’s personality and life style. • Have to be controlled: • Inappropriate weight bearing • Smoking habit • Improper diet • Other shortcomings in behaviour Aseptic Non Union

Symptoms • Abnormal mobility • Abnormal mobility cannot be seen: • When there is an Internal Fixation • Intramedullary nail • Dense fibrous callus • Pain and Limp • A healed fracture does not hurt Aseptic Non Union

Radiology • Sometimes difficult to see on the X-Rays • Reactive callus = Mechanical instability Slight instability can be positive Aseptic Non Union

Delayed union • In delayed union there are clinical and radiological signs of prolonged fracture healing • It is important to establish the diagnosis • Fracture instability • Implant mobilization • To act to achieve a rapid bone healing Aseptic Non Union

Judet-Weber classification • Vital (Hypervascular) • With biological reaction capacity • Avital (Avascular) • Without biological reaction capacity Aseptic Non Union

Judet-Weber classification • Vital non-union • They do not heal because of instability Aseptic Non Union

Judet-Weber classification • Avital non-union • They do not heal because of biological deficit Aseptic Non Union

Weber classification A. Vital I. Hypertrophic non-union (elephant foot) II. Hypertrophic non-union (horse hoof) III. Atrophic non-union (without callus) Aseptic Non Union

A. Vital non-union Aseptic Non Union

Elephant foot Horse hoof Atrophic A. Vital non-union Aseptic Non Union

Hypertrophic non-union • Hypertrophic non-union is frequently localized in the lower extremities. • Its development largely depends on an impaired mechanical stability. Aseptic Non Union

AO 3 6 16 Experimental non-union Aseptic Non Union

Pathology Aseptic Non Union

Bone healing by mechanical stabilization Aseptic Non Union

Calcifying focus Non-union focus Ca. marked fracture site Aseptic Non Union

Totally calcified focus Fracture healing trabeculae Ca. marked fracture site Aseptic Non Union

Stabilized fracture evolution • Mechanical stability allows the fibrous cartilage to calcify and finally ossify after vascular penetration. • Resection of an hypertrophic non-union must be regarded as an error. Aseptic Non Union

Stabilized fracture evolution Aseptic Non Union

Bone healing evolution Aseptic Non Union

Instability (non-union) PO Aseptic Non Union

8 m 4 m Stabilization (bone healing) Aseptic Non Union

“Elephant foot” non-union healed after plating stabilization Aseptic Non Union

Weber classification • Avital non-union • Dystrophic with intermediate wedge fragment • Necrotic with conminution • Bone loss • Atrophic Aseptic Non Union

B. Avital non-union Aseptic Non Union

Avascular non-union • Avascular non-union originates because of the devascularisation of the bone fragments adjacent to the fracture site due to injury and/or surgery. Aseptic Non Union

Devitalized fragments united by callus to the main fragments without evidence of bone healing B. Avital non-union Aseptic Non Union

Treatment of aseptic non-union Aseptic Non Union

Goal of the treatment To achieve a rapid bone healing with complete recovery of articular and muscular function. Aseptic Non Union

Active treatment • To restore bone continuity • If possible anatomically • To restore articular and muscular function In the less possible time Aseptic Non Union

Treatment according to the type 1. Vital • Mechanical stabilization (osteosynthesis) • Stable osteosynthesis 2. Avital • Mechanical stabilization (osteosynthesis) • Biological stimulation (autologous bone grafting) Aseptic Non Union

Fibula “pro tibia” Bone transport Vascularised bone grafts Bone loss Bone grafting 1. Pediculated vital bone grafts (decortication) 2. Autologous cancellous bone graft 3. Bone transplants Aseptic Non Union

Diaphyseal non-union Techniques for bone reconstruction Aseptic Non Union

Judet osteoperiosteal decortication • This technique is used to enhance the healing response, creating a well vascularised that at the same time stimulates the bone healing process. It is the simplest and most effective way to expose a non union without producing a substantial devascularization. Aseptic Non Union

Osteoperiosteal decortication Aseptic Non Union

Autologous cancellous bone graft • Cancellous autologous bone graft is the “gold standard” for both biological and mechanical purposes. • It is osteogenic (a source of vital bone cells) • It is osteoinductive (recruitment of local mesenchymal cells) • It is osteoconductive (scaffold for ingrowth of new bone) Aseptic Non Union

Aseptic Non-Union