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Nonunions: Evaluation 10022 and Treatment 10022 CHAPTER 22 Nonunions: Evaluation 10022 and Treatment ......................................................... Mark R. Brinker, M.D. and Daniel P. O’Connor, Ph.D. a fracture that, in the opinion of the treating physician, s0010 INTRODUCTION shows slower progression to healing than anticipated and p0010 While fracture nonunions may represent a small percent- is at risk of nonunion without further intervention. age of the traumatologist’s case load, they can account for To understand the biological processes and clinical impli- p0070 a high percentage of a surgeon’s stress, anxiety, and frustra- cations of fracture nonunion, an understanding of the normal tion. Arrival of a fracture nonunion may be anticipated fracture healing process is required. The following section following a severe traumatic injury, such as an open fracture reviews the local biology of fracture healing, requirements with segmental bone loss, but may also appear following a for fracture union, and types of normal fracture repair. low-energy fracture that seemed destined to heal. p0020 Fracture nonunion is a chronic medical condition asso- FRACTURE REPAIR ciated with pain and functional and psychosocial disabil- s0030 180 ity. Because of the wide variation in patient responses Fracture repair is an astonishing process that involves p0080 to various stresses177 and the impact that may have on the spontaneous, structured regeneration of bony tissue and patient’s family (relationships, income, etc.), these cases restores mechanical stability. The process begins at the are often difficult to manage. moment of bony injury, initiating a proliferation of tissues p0030 Some 90 to 95 percent of all fractures heal without pro- that ultimately leads to healing. 87,245 blems. Nonunions are that small percentage of cases in The early biological response at the fracture site is an p0090 which the biological process of fracture repair cannot inflammatory response with bleeding and the formation overcome the local biology and mechanics of the bony injury. of a fracture hematoma. The repair response occurs rapidly in the presence of osteoprogenitor cells from the perios- teum and endosteum and hematopoietic cells that are s0020 DEFINITIONS capable of secreting growth factors. Following fracture ’ p0040 “ ” healing, bony remodeling progresses according to Wolff s A fracture is said to have gone on to nonunion when the 20,21,238,272,328 normal biologic healing processes cease to the extent that law. solid healing will not occur without further treatment The repair process, involving both intramembranous p0100 intervention. The definition is subjective, with criteria and enchondral bone formation, requires mechanical sta- that result in high interobserver variability. bility, an adequate blood supply, good bony contact, and p0050 The literature reveals a myriad of definitions of non- the appropriate endocrine and metabolic responses. The union. For the purposes of clinical investigations, the U.S. biological response is related to the type and extent of Food and Drug Administration (FDA) defines a non- injury and the type of treatment (Table 22-1). union as a fracture that is at least 9 months old and has not Healing via Callus s0040 shown any signs of healing for 3 consecutive months.125,307 209 Müller’s definition is failure of a (tibia) fracture to unite In the absence of rigid fixation (e.g., cast immobilization), p0110 after 8 months of nonoperative treatment. These two defi- stabilization of bony fragments occurs by periosteal and nitions are widely utilized, but their arbitrary use of a tem- endosteal callus formation. If the fracture site has an ade- poral limit is flawed.113 For example, several months of quate blood supply, callus formation proceeds and results observation should not be required to declare a tibial shaft in an increase in the cross-sectional area at the fracture fracture with 10 cm of segmental bone loss a nonunion. surface. This increased cross-sectional area enhances frac- Conversely, how does one define a fracture that continues ture stability. Fracture stability is also provided by the for- to consolidate but requires 12 months to heal?264 mation of fibrocartilage, which replaces granulation tissue p0060 We define nonunion as a fracture that, in the opinion at the fracture site. Enchondral bone formation, in which of the treating physician, has no possibility of healing bone replaces cartilage, occurs only after calcification of without further intervention. We define delayed union as the fibrocartilage. 1 Browner, 978-1-4160-2220-6 10022 2 SECTION 1 Section Title INSTABILITY Table 22-1 s0090 t0010 Type of Fracture Healing Based Mechanical instability, excessive motion at the fracture site, p0150 on Type of Stabilization can follow internal or external fixation. Factors producing mechanical instability include inadequate fixation (implants Type of Stabilization Predominant Type of Healing too small or too few), distraction of the fracture surfaces Cast (closed treatment) Periosteal bridging callus and (hardware is as capable of holding bone apart as holding interfragmentary enchondral bone together), bone loss, and poor bone quality (i.e., poor ossification purchase) (Fig. 22-1). If an adequate blood supply exists, Compression plate Primary cortical healing (cutting excessive motion at the fracture site results in abundant cone-type remodeling) callus formation, widening of the fracture line, failure of Intramedullary nail Early: periosteal bridging callus fibrocartilage to mineralize, and ultimately failure to unite. Late: medullary callus External fixator Depends on extent of rigidity INADEQUATE VASCULARITY s0100 Less rigid: periosteal bridging callus Loss of blood supply to the fracture surfaces may arise p0160 More rigid: primary cortical healing because of the severity of the injury or because of surgical Inadequate immobilization dissection. Several studies have shown a relationship With adequate blood Hypertrophic nonunion (failed between the extent of soft tissue injury and the rate of frac- 50,62,124 supply enchondral ossification) ture nonunion. Open fractures and high-energy Without adequate blood Atrophic nonunion closed injuries may strip soft tissues, damage the periosteal supply blood supply, and disrupt the nutrient vessels, impairing Inadequate reduction with Oligotrophic nonunion the endosteal blood supply. displacement at the Injury of certain vessels, such as the posterior tibial artery, p0170 fracture site may also increase risk of nonunion.34 Vascularity may also be compromised by excess stripping of the periosteum as well as damage to bone and the soft tissues during open reduction and hardware insertion. Whatever the cause, s0050 Direct Bone (Osteonal) Healing inadequate vascularity results in necrotic bone at the ends of the fracture fragments. These necrotic surfaces inhibit p0120 Direct osteonal healing occurs without formation of exter- fracture healing and often result in fracture nonunion. nal callus and is characterized by gradual disappearance of the fracture line. This process requires an adequate blood POOR BONE CONTACT s0110 supply and absolute rigidity at the fracture site, most com- monly accomplished via compression plating. In areas of Poor bone-to-bone contact at the fracture site may result p0180 direct bone-to-bone contact, fracture repair resembles from soft tissue interposition, malposition or malalign- cutting-cone type remodeling. In areas where small gaps ment of the fracture fragments, bone loss, and distraction exist between fracture fragments, “gap healing” occurs via of the fracture fragments (see Fig. 22-1). Whatever the appositional bone formation. cause, poor bone-to-bone contact compromises mechani- cal stability and creates a defect. The probability of fracture s0060 Indirect Bone Healing union decreases as defects increase in size. The threshold value for rapid bridging of cortical defects via direct osteo- p0130 Indirect bone healing occurs in fractures that have been nal healing, the so-called osteoblastic jumping distance, is stabilized with less than absolute rigidity, including intra- approximately 1 mm in rabbits291 but varies from species medullary nail fixation, tension band wire techniques, to species. Larger cortical defects may also heal, but at a cerclage wiring, external fixation, and plate-and-screw much slower rate and bridge via woven bone. The “critical fixation (applied suboptimally). Indirect healing involves defect” represents the distance between fracture surfaces coupled bone resorption and bone formation at the frac- that will not be bridged by bone without intervention. ture site. Healing occurs via a combination of external The critical defect size depends on a variety of injury- callus formation and enchondral ossification. related factors and varies considerably among species. Other Contributing Factors s0120 s0070 ETIOLOGY OF NONUNIONS In addition to mechanical instability, inadequate vascular- p0190 s0080 Predisposing Factors—Instability, ity, and poor bone contact, other factors may contribute Inadequate Vascularity, Poor Contact to development of nonunion (Table 22-2). These factors, p0140 The most basic requirements for fracture healing include however, are not direct causes of nonunion per se. (1) mechanical stability, (2) an adequate blood supply INFECTION (i.e., bone vascularity), and (3) bone-to-bone contact. s0130 The absence of one or more of these factors predisposes Infection in the zone of fracture increases the risk of non- p0200 the
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