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1、General Principles in the Assessment and Treatment of Nonunions,Hobie Summers, MD and Daniel S. Chan, MD Revised April 2011Previous Authors: Peter Cole, MD; March 2004Matthew J. Weresh, MD; Revised August 2006,Definitions,Nonunion: (somewhat arbitrary) A fracture that has not and is not going to hea
2、l Delayed union: A fracture that requires more time than usual to heal Shows progression over time,Definitions,Nonunion: A fracture that is a minimum of 9 months post occurrence and is not healed and has not shown radiographic progression for 3 months (FDA 1986)Not pragmatic Prolonged morbidity Narc
3、otic abuse Work-related and/or emotional impairment,Definitions (pragmatic),Nonunion: A fracture that has no potential to heal without further intervention,“The designation of a delayed union or nonunion is currently made when the surgeon believes the fracture has little or no potential to heal.”Don
4、ald Wiss M.D. & William Stetson M.D.Journal American and Orthopedic Surgery 1996,Classification,Hypertrophic Oligotrophic Atrophic = Avascular Pseudarthrosis Weber and Cech, 1976,Hypertrophic,Vascularized Callus formation present on x-ray Elephants foot - abundant callus Horses hoof - less abundant
5、callusTypically only needs stability to consolidate!,Oligotrophic,Some/minimal callus on x-ray Not an aggressive healing response, but not completely void of biologic activity Vascularity is present on bone scan,Atrophic,No evidence of callous formation on x-ray Ischemic or cold on bone scan,Pseudar
6、throsis,Typically has adequate vascularity Excessive motion/instability False joint forms over significant time,Hypertrophic (elephant foot),Hypertrophic (horse hoof),Oligotrophic or atrophic,Classification of Nonunions,Important factors for consideration Biologic and Mechanical environment Presence
7、 or absence of infection Septic vs Aseptic Vascularity of fracture site Stability mechanical environment Deformity Bone involved,Etiology of Nonunion,Host factors Fracture/Injury factors Initial treatment of injury factorsComplicating factor = Infection,Etiology of Nonunion Host Factors,Smoking Diab
8、etes/Endocrinopathy Thyroid/ parathyroid disorders, hypogonadism testosterone deficiency, Vit D deficiency, others Malnutrition Medications Steroids, Chemotherapy, Bispohosphonates Bone quality, vascular status Balance, compliance with weight bearing restrictions Psychiatric conditions, dementia,Smo
9、king,Decreases peripheral oxygen tension Dampens peripheral blood flow Well documented difficulties in wound healing in patients who smokeSchmite, M.A. e.t. al. Corr 1999Jensen J.A. e.t. al. Arch Surg 1991,Smoking vs. Fracture Healing,Most information is anecdotal and retrospective No prospective ra
10、ndomized studies on humans Retrospective studies show time to union Higher infection and nonunion rates More basic science studies concerning nicotine effects are currently underway,Schmitz, M.A. e.t.al. CORR 1999 McKee et al, JOT 2003 Struijs et al, JOT 2007 Chen et al, Int Orthop 2011,Diabetes (Ne
11、uropathic Fractures),Best studied in ankle and pilon fractures: Complicated diabetics those with end organ disease neuropathy, PVD, renal dysfunction Increased rates of infection and soft tissue complications Increased rates of nonunion, time to union significantly longer Prolonged NWB required Inab
12、ility to control response to trauma can result in hyperemia, osteopenia, and osteoclastic bone resorption Charcot arthropathy,Kline et al , Foot Ankle Int. 2009 Wukick et al, JBJS, 2008,Malnutrition,Adequate protein and energy is required for wound healing Screening test: serum albumin total lymphoc
13、yte count Albumin less than 3.5 and lymphocytes less than 1,500 cells/ml is significantSeltzer et.al. JPEN 1981,Etiology of Nonunion Fracture/Injury Factors,High energy injury Fracture mechanism MVC vs fall from standing Open or closed fracture Bone loss Soft tissue injury Bone involved and anatomic
14、 locationOpen tibial shaft fx with bone loss vs closed nondisplaced proximal humerus fx,Think about the personality of the fracture!,Fracture Pattern,Fracture patterns in higher energy injuries (i.e.: comminution, bone loss, or segmental patterns) have a higher degree of soft tissue and bone ischemi
15、a,Traumatic Soft Tissue Disruption,Incidence of nonunion is increased with open fractures More severe open fracture (i.e. Gustillo III B vs Grade I) have higher incidence of nonunionGustilo et.al.Jol 1984Widenfalk et.al.Injury 1979Edwards et.al. Ortho Trans 1979Velazco et.al. TBJS 1983,Tscherne Soft
16、 Tissue Classification,Not all high energy fractures are open fractures. This classification emphasizes the importance of viability of the soft tissue envelope at the zone of injury. Fractures with Soft Tissue Injuries Springer Verlag 1984,Tscherne Classification: closed fractures,Grade 0: Soft tiss
17、ue damage is absent or negligibleGrade I: Superficial abrasion or contusion caused by fragment pressure from withinGrade II: Deep, contaminated abrasion associated with localized skin or muscle contusion from direct traumaGrade III: Skin extensively contused or crushed, muscle damage may be severe. Subcutaneous avulsion, possible artery injury, compartment syndrome,
