PROBLEMS OF FRACTURE REPAIR

G. Volpin, A.Gorsky Dept Orthop. Surgery, Nahariya Hospital ISRAEL

Fracture repair

Repair of a fractured bone by formation of new bone through proliferation of periosteal and endosteal cells

Fracture repair
Bone heals more rapidly than cartilage because its blood supply is more plentiful and there is rapid activation and turnover of bone cell types

FRACTURE REPAIR PROBLEMS

Repair of a fracture is a progressive process: Inflammation Repair ( callus) Remodeling

FRACTURE REPAIR - PROBLEMS

Repair of a fracture is a progressive process ( X-RAY ): Fracture Union Consolidation Bone remodeling ( up to 7 years)

UNION
It may be clinically complete but on X-ray -still incomplete repair. X-ray show the fracture line still clearly visible, with fluffy callus around it. Repair is therefore still incomplete It is not safe to subject the unprotected bone to stress.

CONSOLIDATION
This is a condition with complete clinical and X-ray repair; the calcified callus is ossified. X-ray show the fracture line to be almost obliterated and crossed by bone trabeculae, with well- defined callus around it. Further protection is unnecessary.

REMODELLING
Continuous process of alternating bone resorption and formation The medullar cavity is reformed. Eventually, and especially in children, the bone reassumes something like its normal shape.

FRACTURE REPAIR PROBLEMS

Sometimes the normal process of fracture repair is disturbed and the bone fails to unite. 5% of 2 millions fractures that occur per year become nonunion (100 000 per year )
Heppenstall R.B.: Fracture treatment and Healing. Philadelphia, WB Saunders, 1986

Fracture repairproblems
Fracture Healing Delayed Union Nonunion UNION Pseudoarthrosis
5% ( Heppenstal R.B. )

DELAYED UNION If the normal time of fracture repair is unduly prolonged, the term delayed union is used.

DELAYED UNION

Time of unionPerkins timetable

Spiral fracture in the upper limp for union 3 weeks, for consolidation multiply by 2 ( 3 X 2= 6 weeks ) For transverse fracture multiply again by 2 ( 3 x 2x 2= 12 weeks)

Time of unionPerkins timetable

A spiral fracture of lower limb 6 weeks. Transverse fracture multiple again by 2 ( 6 x 2= 12 weeks )

Time of union
A more sophisticated formula is as follows: Spiral fracture in the upper limb takes 6-8 weeks to consolidate; the lower limb needs twice as long (12-16 weeks ). Add 25% if the fracture is not spiral or if it involves the femur.

DELAYED UNION
DELAYED UNION?

NONUNION?

NONUNION
1. A minimum of 9 months has elapsed since injury and the fracture shows no visible progressive sign of healing for 3 months
FDA panel 1986

NONUNION
2. Sclerosis develops around the bone ends and medullar canal. 3. The bone ends are joined by fibrous tissue- formation of pseudoarthrosis.

NONUNION
4. Failure to show any progressive radiographic appearance for at least 3 months after the period of time when fracture union would be have occurred

NONUNION- Classification
NONUNION STRONTIUM 85 uptake RICH Blood Supply POOR

Hypervascular

Avascular

NON UNION

NONUNIONHypervascular type

Elephant foot

Horse hoof

Oligotrophic

NONUNION
Hypervascular or hypertrophic: Are rich in callus and have rich blood supply in the end of bones. They result from insecure fixation or premature weight bearing in a reduced fracture. Failed enchondral ossification & type II collagen predominates.

NONUNION
Oligotrophic (Hypotrophic): Callus is absent. They typically occur after major displacement of fracture, distraction of fragment.

NONUNIONavascular type

Torsion wedge

Comminuted

Defect

Atrophic

NONUNION
Avascular or atrophic:
Ends of the fragments have become osteoporotic and atrophic. The nonunion is inert and incapable of biologic reaction. There is poor blood supply to the ends of the fragments. These are typically seen in tibial fracture treated by plate & screws. These are usually final result when intermediate fragments are missing .

NONUNION
Comminuted nonunions:
There are characterized by the presence of one or more intermediate fragments. Typically these nonunions result in the breakage of any plate used for stabilization

NONUNION
Defect nonunion:
These are characterized by the loss of a fragment of the diaphysis. The ends of the fragments are viable, but there is no union across the defect. The ends of fragments atrophic. Occurs after open fracture, sequestration in osteomyelitis and resection of bone.

Causes of nonunion
1. The injury: a. Soft tissue loss b. Bone loss c. Intact adjacent bone ( forearm or leg ) d. Soft tissue interposition

Causes of nonunion
2. The bone: a. b. c. d. Poor blood supply Poor hematoma Infection Pathological lesion

Causes of nonunion
3. The surgeon: a. b. c. d. Distraction Poor splintage Poor fixation Impatience

Causes of nonunion
4. The patient: a. b. c. d. Age Poor medical condition Smoking Drugs ( Steroids, NSAID, Ciprofloxacilin )

Causes of nonunion
Age Nutritional level Vascular injury Hormones Smoking Medical condition Nerve function NSAID Infection

Biological

Factor

Mechanical
Soft tissue Stability Location Bone loss Distraction

Causes of nonunion
FACTOR

GENERAL

LOCAL

CAUSES OF NONUNION
General factor ( most important): Diabetus mellitus ( collagen formation injured ). Smoking ( depression of osteoblastic function & vasoconstriction ). Nutrition ( level of albumin & transferin ).

CAUSES OF NONUNION
Local Factors: Position of fragments ( distraction ) Status of soft tissue, bone Vascular status Fixation of fracture ( inadequate ) Open fracture Infection

Biochemistry of fracture healing

Step Collagen type

Mesenchymal Chondroid Chondroid-osteoid Osteogenic

I, II(III,V) II, IX I, II, X I

Growth factors of bone

1. Bone morphogenic protein 2. Transforming Growth FactorBeta 3. Insulin-Like Growth factor II 4. Platelet- Derived Growth Factor

Growth factors of bone

1. Bone Morphogenic Protein- BMP Osteoinductive; induced metaplasia of mesenchymal cells into osteoblastBMP stimulates bone formation

Growth factors of bone

2. Transforming Growth Factor- Beta ( TGF-b):

Regulates cartilage and bone formation in fracture callus. Also induced osteoblast to synthesize collagen.

Growth factors of bone

3. Insulin- Like Growth factor II ( IGF-II ):

Stimulates type I collagen, cellular proliferation, cartilage matrix synthesis, and bone formation.

Growth factors of bone

4. Platelet- Derived Growth Factor ( PDGF ):

Released from platelet, attract inflamatory cells to the fracture site (chemotaxic ).

Endocrine Effect on Fracture Healing

Hormone Cortisone Calcitonin TH/PTH Growth hormone Effect Mechanism Decreased callus proliferation Unknown Bone remodeling Increase of callus volume

+? + +

Principles of treatment
Fracture healing Delayed Union Nonunion UNION Pseudoarthrosis

malunion

Principles of treatment
Prophylactic:
Treatment of general factors Treatment of medical condition Stable fixation of fracture Minimal invasive fixation Treatment of soft tissue injury Aseptic & atraumatic surgery Time of immobilization

Delayed Union Treatment

Is the signal to continue treatment of the fracture until consolidation is complete. If union is delayed for more than 6 months and is no sign of callus formation, internal fixation and bone grafting are indicated.

Nonunion- treatment
Old patient & symptomless nonunion in non- weight bearing limp-

Treatment??? No treatment???

NonunionConservative treatment
Functional bracing( hypertrophic ) Electrical and electromagnetic stimulation stimulation Low- intensity ultrasound Weight bearing Injection of Bone Morphogenic protein in nonunion

Nonunionoperative treatment
Hypervascular or hyperthrophic: Rigid fixation of the fragments. If angulatory deformity is not present, these nonunions do not have to be opened. Compression - distraction osteogenesis by Ilizarov E.F.

Nonunionoperative treatment
Oligotrophic : Stable fixation Bone grafting for healing ( ? )

Nonunionoperative treatment
Avascular or atrophic:
Open decortication ; Bone grafting Stable fixation Resection of nonunion & bone transport for filling of the large defect Prosthesis replacement

BONE GRAFTS

Bone cells within the graft may survive the transplantation procedure and synthesize new bone. This can only occur in case of fresh autograft

NONUNION- TRATMENT

NONUNION- TRATMENT

BONE GRAFTING- types

1. Autograft: 2. Allograft: Cancellous Cortical Fresh Fresh- frozen

3. Demineralized bone matrix 4. Bone marrow 5. Ceramics

BONE GRAFTING 1. Osteoinduction 2. Osteoconduction 3. Osteogenic cells 4. Structural integrity

BONE GRAFTING 1. Osteoinduction:

Ability of a graft to induce stem cells & osteoprogenitor cells to differentiate to osteoblasts. It may occur with Auto & Allografts. Mediated by polypeptides as BMP. Inactive- by radiation+ autoclaing

2. Osteoconduction:

Support attachment of new osteoblasts &osteoprogenitor cells and form of new blood vessels

The partially or completely replacing of the graft by the host is named INCORPORATION

BONE GRAFTINGStages of graft healing

STAGES 1 2 3 4 5 inflammation Osteoblast differentiation Osteoinduction Osteoconduction Remodeling ACTIVITY
Chemotaxis stimulated by necrotic debris

From precursor Osteoblast/osteoclas t function New bone forming over scaffold

Process continues for years

NONUNIONTREATMENT

3 Y.O. CHILD WITH NONUNION OF TIBIA

2,5 MONTHS LATER

NON UNION

NON UNION

NONUNIONTREATMENT

NONUNIONTREATMENT

NONUNION- TREATMENT

NONUNION- TREATMENT

BONE GRAFTS SUBSTITUTES

BONE GRAFTS SUBSTITUTES

Allografts
Allogro- deminerelized bone matrix (DBM) Dyanagraft- DBM & polymer

Ceramic based: Osteoset - Calcium sulfates tab (left) Aloomatrix- Calcium sulfates tab + DBM (right)

Hydroxyapetite based: Proosteon- hydroxyapetite in either a particulate Or a block, form by chenically treated sea corals.

MALUNION
When the fragments join in an unsatisfactory position, such as: unacceptable angulation, rotation or shortening, the fracture is then considered as MALUNITED.

MALUNION
FRACTURE

UNION in unsatisfactory position

MALUNION

MALUNION
CAUSES: Failure of proper & adequate reducion of fracture fragment Gradual collapse of comminuted or osteoporotic bone Failure to maintain reduction during healing process

MALUNION
Long- term effect: May cause asymmetrical loading of the joints above or below, Followed by gradual development of secondary osteoarthritis.

MALUNION

Classification:
1. Shortening ( with overlap ) 2. Angulation 3. Rotation deformity

MALUNION- shortening

MALUNIONangulation

MALUNION- treatment
Prophylactic:

Most important Fractures should be reduced as near to as possible.

anatomical alignment

MALUNION- treatment
Long bones Angulation of more than 15 degrees or marked rotation deformity, may need correction by remanipulation, or by osteotomy and internal fixation

MALUNION- treatment
In the lower limb shortening of more than 2.5 cm is not acceptable and a limb correction procedure may be indicated.

MALUNION- treatment
In children: Angular deformities near the bone ends will usually remodel with time: Rotational deformities will not.

REMODELING PROCESS

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