non union orthopaedics

1. NON UNION
PRESENTER-Dr RAVI VARMA V N
MODERATOR-Dr RAVI KIRAN
JSS MEDICAL COLLEGE

3. DEFINITION
US FDA PANEL DEFINED NON UNION AS
“when a minimum of 9 months has elapsed since injury
with no visible healing progressive signs for 3 months”.
•On a cellular level, nonunion occurs when there is cessation of a reparative process antecedent
to bony union
Practically,
Nonunion occurs when a fracture has failed to heal in the expected time and is not likely to
heal without new intervention
Diagnosing involves
Both radiological and clinical criteria

4. Causes
Diabetes
53%
Vasculopathy
59%
Smoking
81%

5. Host factors
1. Smoking-81%
Directly inhibit osteoblasts early stages of fracturehealing
Inhibits expression of BMP
vasoconstriction
inhibit tissue
differentiation
normal angio-
genic responses

6. 1. Diabetes -59%
• In early stages-Decreased cellular proliferation
• Decreased callus strength at the later phases
• Most importantly diabetes increases the chance of
infection as it is a hyperglycemic state
alterations
in bone
metabolism
microvasc
ular
disease
neuropathy
immunoco
mpetence

7. Nonsteroidal Anti-Inflammatory Drugs
Prostaglandins are inflammatory mediators present during the initial phases
of fracture healing
Selective cox 2 and NSAIDS interfere with PG’s synthesis inhibiting cox
Yet the issue is controversial and better to avoid NSAIDS in fracture
management

8. Other host factors
• Age
• gender, nutritional status, bone quality, endocrine disorders, fracture energy,
location and pattern, associated injuries,
• Bisphosphonates- increased incidence of stress fractures and affect union of
the same
• Chronic health conditions
• Steroids
• Rheumatoid immunosupression
• Malignancy

9. Treatment factors
• Mechanical stability – difficult to define and quantify
• In nature, fractures can heal without stabilization, but stabilization can
reduce the risk of nonunion
• Medical practice has similarly evolved to understand that fractures heal
more reliably when immobilized
• Most fractures heal with the relatively limited stability provided by splint or
cast immobilization –[secondary]
• Rigid internal fixation, represents the opposite end of the stability spectrum
associated with fracture care – [primary] relatively unnatural, yet
successful, strategy.

10. • Irrespectively -improper technique can lead to an increased risk of nonunion
1. Improperly applied splint or cast, lipomatous extremity
2. Rigid fixation without bone to bone contact
It is often difficult to predict the fracture healing response to excessive
motion, as either abundant callus or a paucity of callus may result

11. PARREN ‘S THEORY of interfragmentary strain
S M/G
S-strain
M-motion
G-gap
It is defined as “the ratio of relative displacement of fracture ends versus initial fracture
gap width”.
It relates the tissue response to the local mechanical environment
Strain is the deformation of a material when a given force is applied.

12. • ε=d/G where ε-the inter-fragmentary strain, d-fracture ends displacement, & G–
gap between ends.
• ε=d/G≤2% >Bone formation
• ε=d/G≤10% >Fibrocartilage
• ε=d/G≤100% >Granulation tissue
• ε=d/G>100% >No tissue formation
• Disadvantages of the Theory:
1. Oversimplified theory
2. Only Longitudinal Strain is considered
3. Multidirectional principal strains are not even considered.

13. • Strain is the deformation of a material when a given force is applied.
• Normal strain is the change in length (Δ l) in comparison to original length
(l)when a given load is applied.
• Intact bone has a normal strain tolerance of 2% (before it fractures), whereas
granulation tissue has a strain tolerance of 100%.
• Bony bridging between the distal and proximal callus can only occur when local
strain (ie, deformation) is less than the forming woven bone can tolerate. Thus,
hard callus will not bridge a fracture gap when the movement between the
fracture ends is too great .
• Nature deals with this problem by expanding the volume of soft callus. This
results in a decrease in the local tissue strain to a level that allows bony bridging.
• This adaptive mechanism is not effective when the fracture gap has been
considerably narrowed so that most of the interfragmentary movement occurs at
the gap, producing a high-strain environment. Thus, overloading of the fracture
with too much interfragmentary movement later in the healing process is not
well tolerated

14. • Interfragmentary movement stimulates the formation of a callus and
accelerates healing . As the callus matures, it becomes stiffer, reducing the
interfragmentary movement sufficiently, so that bridging by hard bony
callus can occur.

15. • If the interfragmentary strain is excessive (instability), or the fracture gap is
too wide, bony bridging by hard callus is not obtained in spite of good callus
formation, and a hypertrophic nonunion develops [25].
• Callus formation requires some mechanical stimulation and will not take
place when the strain is too low. A low-strain environment will be produced
if the fixation device is too stiff, or if the fracture gap is too wide [22].
Delayed healing and nonunion will result.
• The same deforming force produces more strain at the site of a simple
fracture than at that of a multifragmentary fracture.

16. Biological environment
• The damaged bone has a reduced inherent capacity to form new bone and
the damaged soft tissues have a reduced ability to stimulate the reparative
process
• Whereas modern surgical techniques emphasize biologically friendly tissue
handling,

17.  Biological failure -The main causes are
i.Distraction at the fracture site
ii.Soft - tissue interposition
iii.Bone loss at the time of fracture
iv.Infection from an open fracture
v.Damage to blood supply of fracture fragments
vi.Pathological fracture

18. INFECTION
• The inflammatory process in response to infection may inhibit fracture
healing by causing excessive remodeling and osteolysis
• Loose nonvital bone fragments - sequestra
• Infection not only predisposes to nonunion, but makes nonunion repair
substantially more complex

19. Summary
• The involved bone and the specific location of the fracture within any given
bone influence the innate ability for fracture healing.
• The characteristics of the original injury,
• The patient’s ability (or inability) to generate a normal healing response to the
particular injury,
• The mechanical and biologic environment created by the chosen treatment
method,
• The presence or absence of associated infection
• Are among the factors that can influence the rate and the likelihood of
uncomplicated and timely fracture healing.

20. Classification of Non-union:
Judet Muller Weber, Cech
Classification:
1. Hypertrophic Hypertrophic
2. Atrophic
Elephant foot
Non-union
Horse Hoof
Non-union
Oligotrophic
Non-union

21. • Atrophic:
Torsion
Wedge
Non-union
Comminuted
Non-union Gap
Non-union
Atrophic
Non-union

22. Dror Paley et at Classification:
A- Bone loss < 1cm B- Bone loss > 1cm
A1 A2.1 A2.2 B1 B2 B3
A1 - Lax
A2. - Stiff
A2.1 - No Deformity
A2.2 - With fixed
deformity
B1- Bone gap without shortening
B2- No Bone gap with shortening
B3- Bone gap with shortening

23. PSEUDOARTHROSIS
• Sub-classification of nonunion .
• Because of excessive and chronic motion, an actual synovial pseudocapsule
is formed, containing fluid much like an actual synovial joint .

24. DIAGNOSIS
• the diagnosis of a nonunion may be one of inclusion or exclusion
• In usual clinical practice, the information gathered from many modalities,
such as history, physical examination, radiographs, and other special tests is
used in concert to determine the presence or absence of fracture union

25. RADIOGRAPHY
• Plain radiographs are used ubiquitously in the evaluation
• circumferential bridging, as evidenced by bridging across four cortices on
orthogonal x-rays
• radiograph and fracture are coplanar.
• Serial Radiological Assessment is necessary.
• Stress radiograph gives the status of stability of the fixation.
• Scoring systems - Radiographic Union Score for Tibia Fractures (RUST)

27. • lack of union may be directly or indirectly evident.
• Direct-
Direct evidence is a fracture gap seen on a radiograph taken coplanar
with the fracture
• Indirect-
Progressively loosened or broken implants indicate persistent motion at
the fracture

30. • Ct scan- can be reformatted in high quality in any plane -to evaluate
potential absence of bridging bone
• Highly sensitive but less specific

31. • Nuclear imaging-(Tc-99m) bone scintigraphy can be used to help diagnose
nonunion yet non specific
• psseudoarthrosis where a cleft between two intense areas
• SPECT is used in evaluating vital and avital even infected nonunions

32. Non operative treatment
LIPUS

33. TREATMENT
OBJECTIVES
1. Healing of fracture
2. Correction of deformity
3. Mobilization of adjacent stiff joints
4. Complete eradication of infection
The common requirements to all successful
techniques are reduction and firm stabilization
with or without bone grafting

35. Timing of operative treatment
• Difficulty in establishing the optimal time to intervene surgically in the
treatment of a nonunion parallels the difficulty in the diagnosis of a
nonunion
• Once diagnosed can be interevened
• however, if a future nonunion can be accurately predicted at an early stage
then interevened early

36. Treatment of uninfected non union
1. First step to classify and decide on type
2. Soft tissue consideration-look for skin condition,neurovascular injury
Goals
• Good reduction
• Stable fixation
• Stimulation of bone healing

37. • The methodology-
1.Clinical examination to check for stiffness/ mobility.
2.Radiograph of the affected part to check for the following:
•Bone gap
•Shortening
•Nature of fragments whether transverse or oblique
•To locate the nonunion site whether it is near to joint or away
from the joint.

40. Reducing the fragments
• Fibrous tissue between the fragments-
If in good allignment-retain periosteum, callus and fibrous tissue stabilize
and graft
If displaced –using external fixator correct deformity, secondary plating or
nailing may be planned
Also ilozarov frame is used –to restore length,appose fragments and stabilize
till union
Plating if planned – scar tissue excisedmeduallry canal opened
Nailing is preferred for diaphyseal nonunion
But mataphyseal region plating will be the best option

41. Treatment of hypertrophic non union
• As its vital non union –increasing stability alone will achieve union
1. Intramedullary nailing> plating
2. Ilizarov-distraction alone gives result and deformities also can be corrected

43. Treatment of atrophic non union
• Avital ,hence the intervening fibrous tissue with avascular bony ends are
resected to get punctuate bleeding, bone grafting might me useful
• plate with compression and bone graft
• Nailing-reaming will additionally add bone graft at fracture site
• If ilizarov –
Initial compression and ditraction
corticotomy and bone transport are usually necessary

45. • Articular nonunions are relatively uncommon.
• A potential causative factor is inadequate compression of the articular fracture
gap leading to prolonged exposure of the fracture surfaces to synovial fluid.
• These nonunions are therefore commonly oligotrophic and amenable to
compression techniques.
• As with any articular fracture, the goals of articular nonunion treatment include
• restoration of articular congruity,
• recreation of proper limb alignment,
• maximization of joint function,
• minimization of pain.
• When these goals cannot be accomplished with non- union repair, joint
arthroplasty becomes a relatively attractive option, resection arthroplasty or
arthrodesis become considerations.
Metaphyseal articular non union

46. Metaphyseal articular non union
• Most difficult
• The small articular fragment are porotic and displaced
• The joint is stiff secondary to adhesions ,muscle contracture and
malalignment
• Pseudoarthrosis as the neighbouring joint is stiff
• Treatment- stiff joint to be mobilized in OT
joint is opened and capsulectomy
arthrolysis-releasing adhesons and synovium
loose fragments and bodies removed
adjacent muscles are also released

48. • Treatment of synovial pseudoarthrosis-follows methodology of atrophic non
union,
debridement of the pseudoarthrosis, opening of the medullary canal, and
enhancement of stability, typically with compression at the nonunion site
• Treatment of oligotrophic non union- where its intermediate
vascularityusually manifest minimal radiographic healing reac- tion
(callus),
combination of biologic and mechanical method

49. Soft tissue management with non
unions
• The soft tissues about nonunions are compromised by the original injury or
subsequent surgeries
• If operative treatment is planned, it may be necessary to acquire soft tissue
coverage with local, rotational, or free tissue flaps prior to successful
nonunion repair
• Most important with infected non union after 3 to 4 debridements and
infection controlled  flaps planned
• Another successful strategy is primary shortening during nonunion repair,
followed by secondary lengthening after union
• ilizarov is used extensively in the management

51. Operative techniques
• Exchange nailing,
• Nail dynamization,
• Plate osteosynthesis,
• Ilizarov circular external fixation, and external bone stimulation for a mid-
diaphyseal tibial nonunion
Planned with consideration of the integrity of the soft tissue envelope, the
degree of bone loss, and coexisting conditions
Nonunion in the face of associated infection makes repair with plates less, and
external fixation more attractive

52. Plates and screws
• Nonunion repair with plate and screw constructs is applicable to most anatomic
locations ,repair of diaphyseal as well as end segment nonunions
Advantages
• Ability to address angular, rotational, and translational deformities,
• With minor technical modifications the ability to manage periprosthetic
nonunions
• Powerful method that can be used successfully for any class of nonunion (i.e.,
atrophic or hypertrophic)

53. • Disadvantages
Cannot be used with soft tissue compromise
Infection
As it’s a load bearing device cannot weight bear early

56. I M NAILING
• Three forms: primary nailing of a nonunion in the absence of a pre-existing
nail, exchange nailing, and dynamization.
• Most applicable to diaphyseal nonunions
Primary nailing.

57. EXCHANGE NAILING
• Where deficiencies of the pre-existing nail can be overcome with a new,
larger reamed nail
• Deficiencies include lack of rotational and stability with undersized nail
• The reaming associated with an exchange nailing procedure can deposit
small amounts of local bone graft and can stimulate an inflammatory
response
• When considering exchange nailing for the tibia, an associated fibular
osteotomy to allow fracture compression during repair has been considered
an integral part of the procedure
• Cannot be used in bone loss and angular deformities

59. Dynamization.
• Practice of removing interlocking screws at one end of a nail to allow axial
shortening with weight bearing
• Usually just a few millimeters

60. External Fixation for Nonunion
Treatment
• Relative paucity of soft tissue trauma
• Correction of deformities
• In failed plate fixation
• Fine tune correction and the potential for early weight bearing.
• Oppurtunity to address soft tissue coverage
• Computer-guided treatment with the Taylor Spatial Frame is a recent
advance , six axes of deformity can simultaneously and accurately be
corrected

61. Ilizarov
• Stiff nonunions have inherent biologic activity and therefore usually do not
require a bone graft and respond favorably to closed external fixation
methods that utilize compression, distraction, or a combination of both
• Before distraction, a short period of compression, typically 7 to 14 days, may
be helpful to “prime” the site for the osteogenic process
• Treatment of mobile nonunions with ring fixators usually requires opening
the nonunion site to surgically convert the nonviable atrophic nonunion to
fresh viable bone ends,
• Perform a corticotomy of the involved bone at a site surrounded by healthy
soft tissues followed by transport of the intercalary segment to eventually
achieve healing by compression at the nonunion and regenerate formation at
the corticotomy site

63. problems
• Pin site infection
• Costly
• Cumbersome

64. Arthroplasty for Nonunion Treatment
• There are limited circumstances that make total joint arthroplasty or
hemiarthroplasty a viable option.
• Minimum requirement is nonunion in a periarticular location , that can
accommodate the bone resection.
• In the elderly, especially with associated joint arthrosis, which may be in the
form of pre-existing arthritis, post-traumatic arthritis, joint destruction from
prior implants, or osteonecrosis, arthroplasty is preferred.
• Physiologically younger patients, arthroplasty becomes less advantageous
because of limited longevity of the implants.
• Active infection at the site of nonunion is a contraindication to arthroplasty.

65. Amputation for Nonunion Treatment
• Amputation as definitive treatment for nonunions is often dictated by
associated comorbid conditions and by patient preference rather than a
technical inability to eventually achieve union.
• Psychological and psychosocial factors specific to each individual patient are
important to recognize, discuss, and consider before pursuing shared
decision making for amputation

67. Arthrodesis for Nonunion Treatment
• Arthrodesis is sometimes indicated for the management of peri- articular
nonunions.
• The choice of arthrodesis is typically one of last resort
• Nonreconstructable periarticular nonunions without good arthroplasty
options that can accommodate bone defects (e.g., ankle),
• Young patients who are likely to have poor long term success with
arthroplasty, and infected periarticular nonunions, are typical indications
for arthrodesis

68. Fragment Excision and Resection
Arthroplasty for Nonunion Treatment
• Avulsion fractures of the base of the fifth metatarsal, fractures of the medial
malleolus, the inferior pole of the patella, the greater trochanter of the
femur, the ulnar styloid, the olecranon,and the greater tuberosity of the
humerus

69. Osteotomy for Nonunion Treatment
• Osteotomy related to the treatment of nonunions usually serves the purpose
to realign the nonunion directly or to allow secondary axial shortening of an
adjacent bone
• The ultimate goal of osteotomy is to allow compression at the nonunion site
to promote healing
• Prototypical reallignment osteotomy is the Pauwels osteotomy for a femoral
neck nonunion
• Fibular osteotomy or partial excision is performed
• The level of fibular excision has been suggested to be at a site other than
that of the nonunion

70. synostosis for Nonunion Treatment
• The lower leg > forearm, by virtue of having paired bones, are amenable to
synostosis techniques

71. ADJUNCTS TO OPERATIVE
NONUNION REPAIR
• Autologous > allografts
• Properties
• Osteogenic a source of vital bone cells
• Osteoinductive recruitment of local mesenchymal cells
• Osteoconductive scaffold for ingrowth of new bone
• The ideal graft substitute for nonunion treatment would be inexpensive, of
unlimited supply, easy to prepare and handle, easy to implant, without
adverse reactions, and 100% efficacious.
• But none have all

72. Autogenous graft
• Standard graft substance used in the repair of atrophic nonunions, some
oligotrophic nonunions, and some pseudoarthroses .
• Cancellous autogenous bone graft supplies osteogenic and osteoconductive
materials .
• Recent data also indicate that various growth factors and BMPs are present
in autologous bone graft .
• It has been estimated that the limit of defect length that can be filled using
iliac crest bone graft (ICBG) is 5 to 7 cm .
• Limiations-limited quantities that can be harvested, variable quality, and
donor site morbidity.

73. ICBG-iliac crest bone graft
• The anterior iliac crest is the most common site .
• A number of techniques are available.
• Trap door in the crest , from the inner table , or from the outer table.
• Structural graft is available in the form of a tricortical wedge from the crest.
• Most commom complications are pain,infection,lateral femoral cutaneous
nerve symptoms ,abdominal herniation etc.

74. Other sites
• Distal femur
• Proximal tibia
• Distal tibia
• Proximal humerus
• Olecranon

75. Reamer–Irrigator–Aspirator
• Autogenous graft can also be harvested using the reamer– irrigator–
aspirator (RIA) (Synthes)
• Typically 60 to 80 cm of graft can be harvested

76. Vascularized Grafts
• Vascularized grafts are most commonly used to treat segmental defects.
• They are advantageous in this situation as they provide a live bone graft
that also has structural properties.
• The fibula is the most commonly harvested bone although other sites such
as the iliac crest and rib have been used.

77. Bone Graft substitutes and
Other Modifiers of Bone Healing
1. Recombinant Proteins
2. Demineralized Bone Matrix
3. Bone Marrow Aspirate
4. Platelet-Rich Plasma
5. Allograft and Ceramics

78. BMP’s
• Extremely costly
• Recombinant human osteogenic protein-1 (rhOP-1), also known as BMP-7
shows good results either alone are adjunt to auto graft only approved for
special cases in USA
• BMP-2 and freeze dried cancellous allograft in the management of
diaphyseal tibial shaft fractures with segmental defects. While approved by
the US FDA only for the treatment of acute open tibia fractures, spinal
fusions and oral facial bone augmentatio

79. • Demineralized Bone Matrix -DBM contains type I collagen and
noncollagenous proteins including osteoinductive growth factors
• Bone Marrow Aspirate -contain osteoprogenitor cells and has osteogenic and
osteoinductive properties
• Platelet-Rich Plasma -promote osteoblast proliferation and differentiation.
How- ever, to date no clinical evidence exists
• Allograft and Ceramics -primarily osteoconductive and function best as graft
extenders or carriers

80. Managing segmental Bone Loss
• acute bone loss or be related to established nonunions
• very challenging problem
• Options available are
1. Autogenous bone grafting
2. Free vascularized fibular bone grafts,
3. Fibula stud grafts
4. Bone transport using ilizarov

84. Autogenous Bone Grafting Using the
Masquelet Technique
• primary shortening followed by lengthening is favored
• the area of segmental loss is filled with a PMMA cement.
• At 4 to 6 weeks, when an osteogenic membrane has been formed around the
cement, the membrane is surgically reopened, the cement is removed, and
generous cancellous grafting is carried out
• Recorticalization generally occurs slowly but usually by 3 to 6 months.
conjunction with internal stabilization
• In his original article, Masquelet reported successful use of this two-stage
technique in 35 cases with defects ranging from 4 to 25 cm in length

86. Ilizarov Techniques
• Typically involves simple compression or distraction or some combination of
compression and distraction at the nonunion site , This is considered a
monofocal Ilizarov technique.
• When bone defects are present, corticotomy at an adjacent site followed by
distraction osteogenesis through the corticotomy (bone transport) and
eventual compression at the nonunion site is a bifocal (distraction-
compression) Ilizarov method for management of bone defects.
• Two-level lengthening with compression at the nonunion site is considered
trifocal bone transport.

89. • In the Ilizarov approach, vascularity is increased by corticotomy and appli-
cation of a circular external fixator
• Ilizarov method allows simultaneous treatment of all components,
• The sequence of correction of complex deformities, include
shorteningrotationangulationtranslation
• Ilizarov frame careful preoperative evaluation of deformities allows
assembly of the proper frame

90. Lengthening over nail
• Limb lengthening using Ilizarov external fixation is safe, but the
consolidation phase tends to take too long.
• A method that can safely reduce the time spent in external fixation would
help increase patient tolerance and comfort
• And reduce external fixation duration in limb lengthening.

93. Management of Infected Nonunions
• One of the greatest problems in orthopaedics as we are dealing with both 1)non union and 2)
infection
• Problems associated with long standing non union(by gustilo)
1. Most cases,multiple surgeries result in scarring and cicatrization and environment around
becomes avascular
2. Sinus tract indicating sequestrum
3. Osteomyelitis established-hence deliniation will be difficult for normal bone-bone scan an
MRI useful
4. Joint stiffness
5. Drug resistsant organisms
6. Limb length discrepency
7. Deformities
8. Infected gap non union

94. Classification
• Rosen et al in ao manual
1. Infected non draining nonunion
Quiesent
Active
1. Infected draining nonunion

95. Principles of treatment
• Healing occurs when decreased bacterial activty,stable fixation,surrounding
environment
1. Eradication of infection by radical debridemrnt and local antibiotic beads
or rods
2. Achievement of a vascular or viable environment around
3. Fracture stability
4. Adequate soft tissue coverage
5. Early and massive bone grafting and repeated if necessary
6. Early joint mobilization
7. Correction of deformity

96. Treatment
• Radical debridementstabilization skin cover
Step 1-radical debridement
To achieve vascular environment around,excision of sinus and dead and infected tissue till
active bleeding noted
Implant forms a biofilm and becomes difficult to prevent infection,although implant can be
retained for stability ,once union is obvious implant removal becomes a must.
Bone is resected till punctuate bleeding occurs.
Once debridement give stability by external fixator.
Reaming can be done to clear intramedullry infection
Thorough wash to be given,local antibiotic wash is adviced in some studies
Debridement may be repeated

99. After debridement
• Local antibiotic delivery use antibiotic beads or antibiotic coated nail if
necessary
• Beads have greater surface area than a spacer
• Bioabsorbable bone substitutes that can be impregnated with antibiotics are
osteoconductive, may promote bone healing, and do not necessarily require a
second stage procedure for removal.
• Wound is closed or secondary coverage procedures planned
• culture-specific parenteral antibiotics to be continued
• Continue for 6-8 weeks when infection is minimal and coverage is ideal go for
definitive fixation

103. Ilizarov
• Although infected non- unions
frequently have been successfully
treated without débridement, some
authors recommend open
débridement to remove necrotic and
infected segments, followed by bone
• Monofocal compression also is used
for infected hypertrophic nonunions
with deformity
• For atrophic nonunions with disuse
infection or sequestered bone, open
resection of the infected segment is
performed and bifocal compression is
used

104. • Wu et al reported success with one-stage surgical treatment of infected nonunion
of the distal tibia. Twenty- two consecutive patients were successfully managed
to union with a protocol of implant removal, intra- and extramedullary
debridement, cancellous autograft with antibiotics (vancomycin and
gentamycin), and stabilization with an Ilizarov fixator.

109. • Conclusively every surgeon has a preferred line of
management individualizing it to every patient the
local environment,the general conditions of the
patient,economy and technical expertise

110. Management of soft Tissue Compromise
Associated with Nonunion
• When soft tissues are poor or deficient and free tissue transfer is not
possible, primary shortening with an IM rod followed by full weight bearing
and an elevated shoe is preferred. Once healing has occurred, the limb can
be relengthened if the patient desires with either an internal skeletal
distraction nail or the Ilizarov technique

114. NONUNION OF SPECIFIC BONES
TIBIA
• Medial malloelus-closed treatmentnon union
1. resection of the distal fragment of the medial malleolus
2. sliding graft
3. bone graft of medial malleolar nonunion
•

115. Femoral neck
• vascular insuficiency, inaccurate reduction, and loss of fixation
• free vascularized fibular bone grafting in nonunions of femoral neck
fractures in patients younger than 50 years old ,highly demanding
1. Osteosynthesis
2. Subtrochanteric osteotomy
3. Prosthetic replacement
4. Total hip arthroplasty;
5. Arthrodesis .

116. osteotomy
1. displacement osteotomy (McMurray)-made just proximal to the lesser tro-
chanter
2. angulation osteotomy (Schanz)-made through or just distal to the lesser
trochanter
• mechanical advantages of an osteotomy are that the line of weight bearing is
shifted medially and that the shearing force at the nonunion is decreased
because the fracture surface has become more horizonta 1

117. Clavicle
• Nonunion of clavicular fractures is rare
• Despite the lateral clavicular fracture being the most likely to become a non-
union, it is the midshaft clavicular fracture that is the most common
fracture site for nonunion secondary to its higher incidence
• most successful is rigid internal fixation, such as plates and screws and bone
grafting

118. Humerus
• Proximal humerus-plating or arthroplasty
• Humeral shaft-10%-. Gaps may result from distraction, overriding, so tissue
interposition, or loss of bone. Comminuted fractures may have a disrupted
blood supply or+if with plates and screws and bone grafting
• Medial epicondyle-goes to fibrous union if conservatively treated
If ulnar neuritis anterior transposition of ulnar nerve
• Lateral epicondyle-Disability from nonunion in the condylar area usually is
caused by nonunion of the lateral condyle cubitus valgus deformity, and
instability of the elbow OPEN REDUCTION INTERNAL FIXATION
WITH BONE GRAFTING OF THE HUMERAL CONDYLE

120. Scaphoid non union
• Herbert screw with bone grafting
• Four Corner Fusion;
• Proximal Row Carpectomy;
• vascularized bone-grafting pedicled on 1,2 intercompartmental
supraretinacular artery

121. References
• J. M. Leow et al, The radiographic union scale in tibial
(RUST) fractures ,Bone Joint Res 2016;5:116–121.
• Paley D, Herzenberg JE, Paremain G, Bhave A. Femoral lengthening over an
intramedullary nail: A matched-case comparison with Ilizarov femoral
lengthening. J Bone Joint Surg Am. 1997;79:1464–80.

122. THANK YOU