How to Work up a Nonunion and Potential Infection How to Work up A

9/24/2015

PRE OPERATIVE PLANNING How to work up a Nonunion and Potential Infection

If you could order ONE x-ray study for a the pre-op planning of a tibial nonunion ….it would be??? CT scan to determine if its hypertrophic vs atrophic MRI to elucidate infection status…infected nonunion??? Long alignment film PET / CT to determine infection AND biologic status of nonunion 4 cone down views of tibia, A/P, lateral, and 2 oblique views

NON UNION CHARACTERIZATION DETERMINE TRUE PLANE OF DEFORMITY • METHODOLOGY OF CORRECTION OSTEOTOMY POSSIBLE? WITH REASONABLE EXPOSURE • LEVEL OF DEFORMITY LOCATION OF DEFORMITY LEVEL OF OSTEOTOMY • BIOLOGY OF NON‐UNION HYPERTROPHIC vs ATROPHIC

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ANALYSIS OF NONUNION BIOLOGY OF NONUNION • HYPERTROPHIC • ATROPHIC • SEPTIC

BIOMECHANICAL CHARACTERIZATION EVALUATE “STABILITY” OF CONSTRUCT • MOTION ARTIFACT • BROKEN..LOOSE SCREWS • OSTEOLYSIS • CALLOUS…NO CALLOUS??? • PRIMARY FRACTURE LINE ORIENTATION CT EVALUATION…..helps in this regard

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OTA MINI SYMPOSIA 2014 Managing Nonunion: Theory and Practice

Moderator: Christopher G. Moran, FRCS Faculty: Pierre Guy, MD; R. Malcolm Smith, MD John J. Wixted, MD

STRESS / STRAIN

COMMINUTED FRACTURES NEVER FORM A COMMINUTED NONUNION???? AS FRACTURES HEAL…. A DELAYED HEALING SEGMENT SEES MORE STRAIN….THUS CHANGES THE HEALING CURVE FOR THAT SEGMENT REDUCING STRAIN …….ALLOW SEGMENT TO HEAL…….

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STRAIN

6‐9 MONTHS

NON UNION Fx Healed?

TIME

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HEALING POTENTIAL 6‐9 MONTHS

NON UNION Fx Healed?

TIME

STRAIN

6‐9 MONTHS HEALING POTENTIAL NON UNION Fx Healed?

TIME

UNION Strain

6‐9 MONTHS

Decrease strain ( add stability)

TIME

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UNION

HEALING POTENTIAL 6‐9 MONTHS

Augment healing potential ( add graft)

TIME

UNION

STRAIN

HEALING 6‐9 MONTHS POTENTIAL UNION Fx Healing?

TIME

CRUSH INJURY WITH COMPROMISED TISSUE DISTAL 1/3 TIBIA

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14 weeks post op

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WHEN IN DOUBT..OR TO BUY TIME…….GET A CT

6 WEEKS post lag screw

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PRINCIPLES OF Rx HYPERTROPHIC NON-UNION MECHANICAL STABILIZATION “BIOLOGIC” SURGICAL APPROACH LIMITED NEED FOR BONE GRAFT ADJUVANTS

PRINCIPLES OF Rx ATROPHIC NON-UNION MECHANICAL STABILIZATION

PLUS

PRINCIPLES OF Rx ATROPHIC NON-UNION PROVIDE BIOLOGIC STIMULUS

SMALL DEFECTS• BMAC GRAFT + DBM • INDUCTIVE FACTORS (BMP’s, PDGF, PRP, DBM) LARGE DEFECTS• AUTOGRAFT –RIA, ILIAC CREST • VASCULARIZED TRANSPLANT • BONE TRANSPORT

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UNION

STRAIN

HEALING 6‐9 MONTHS POTENTIAL UNION Fx Healing?

TIME

ANALYSIS OF NON-UNION

PREVIOUS TREATMENT • NON‐OPERATIVE • EXTERNAL FIXATION • IM NAILING • ORIF (must R/O infection)

DEFORMITY CHARACTERIZATION DETERMINE MAXIMAL DEFORMITY • METHODOLOGY OF CORRECTION • ACUTE vs GRADUAL CORRECTION NERVE INJURY > 15O ACUTE CORRECTION UNLESS SHORTENING AT SAME TIME • CANAL MALALIGNMENT IM NAILING POSSIBLE? REVISION PLATING???

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ANALYSIS OF NON-UNION DEFORMITY • ANGULATION • MALROTATION CT EVALUATION • LEG LENGTH DESCREPANCY • TRANSLATION RELATIVE ALIGNMENT OF MEDULLARY CANALS

A/P ANGULATION

LATERAL ANGULATION

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OBLIQUE PLANE DEFORMITY

MAGNITUDE & DIRECTION 48 38

OBLIQUE PLANE DEFORMITY

MAGNITUDE & DIRECTION 48 38

TRUE PLANE OF DEFORMITY

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DEFORMITY ANALYSIS MECHANICAL AXIS DEVIATION • FRONTAL PLANE DEFORMITIES • LEVEL DETERMINED BY INTERSECTION OF MECHANICAL AXIS FEMUR / TIBIA

DEFORMITY ANALYSIS CORA • CENTER OF ROTATION AND ANGULATION… INTERSECTION OF ANATOMIC AXIS INTERSECTION OF MECHANICAL AXIS

RELATIONSHIP OF ANGULATION TO TRANSLATION

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DEFORMITY ANALYSIS

IF THE CORA IS NOT AT THE SAME LEVEL AS THE APEX OF THE DEFORMITY…..YOU HAVE A TRANSLATIONAL DEFORMITY AS WELL

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PROBLEMS

With any translation……ALWAYS HAS TO BE A COMPENSATORY MAL ROTATION

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1” block to level pelvis

PROBLEMS

• Malrotation 20 degrees

Problems

• Leg length 1in. • Translation 100% • Angulation 20 degrees • Mechanical axis deviation lateral • Malrotation 20 degrees • Hypertrophic • Infection

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Hypertrophic, translation, malrotation, angulation, LLD

ANALYSIS OF INFECTION

PREVIOUS TREATMENT NON‐OPERATIVE EXTERNAL FIXATION IM NAILING ORIF HOW TO R/O INFECTION???

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INFECTED NONUNION?? HOW TO MAKE DIAGNOSIS PRE –OP • POTENTIAL STAGED RECONSTRUCTION

The workup for a “suspected” infected non-union should routinely include

Indium labeled WBC scan Intra‐op path (WBC per HPF) Gallium subtraction bone scan MRI with and without contrast PET / CT to determine infection AND biologic status of nonunion WBC, WSR, CRP WBC, WSR,CRP, intra‐op path

PRE –OP STUDIES SPECIFIC FOR INFECTION? RADIOGRAPHIC STUDIES • PLAIN FILMS • CT SCANS • MRI • NUCLEAR MEDICINE BONE SCAN WBC / INDIUM LABELED GALLIUM

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GALLIUM SCAN ? BONE SCAN

INDIUM SCAN

MRI…..SENSITIVE……. …BUT NOT SPECIFIC FOR INFECTION

PRE – OP - INTRA –OP STUDIES LABORATORY STUDIES • WBC • WSR • CRP PATHOLOGY • SINUS TRACT CULTURE • INTRA‐OP GRAM STAIN • INTRA‐OP BIOPSY

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….WHAT SHOULD I ORDER?

WHAT TESTS MAKE THE MOST SENSE…………

PERI-OPERATIVE DIAGNOSIS OF INFECTION IN NONUNIONS / ACUTE Fx PRE OP BLOOD WORK • WBC • CRP • ESR COMBINED INDIUM WBC / BONE SCAN INTRA OP gm STAIN INTRA OP DEEP CULTURES TORNETTA et. al….AAOS 2011

WHAT DO THE RESULTS MEAN?

PPV…POSITIVE PREDICTIVE VALUE • PROBABILITY THAT THE pt. HAS THE INFECTION COMPARED TO ALL THE PTS THAT ARE INFECTED

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WHAT DO THE RESULTS MEAN?

NPV…NEGATIVE PREDICTIVE VALUE . PROBABILITY THAT THE pt. DOES NOT HAVE INFECTION ….. COMPARED TO THE ALL PTS THAT ARE NOT INFECTED

WBC SCAN RESULTS

PPV……50% NPV…..72%

CRP RESULTS

PPV……54% NPV…..75%

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ESR RESULTS

PPV……58% NPV…..80%

WBC > 11,000

PPV……50% NPV…..70%

PATH WBC’S >3 HPF

PPV……40% NPV…..81%

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RESULTS

NO SINGLE TEST WAS INDEPENTLY ACCURATE…….. COMBINATION OF RISK FACTORS USED TO CALCULATE OVERT INFECTION RISK

RESULTS RISK FACTORS . ELEVATED WBC, ESR, CRP, AND + SCAN . FOR 0,1,2,3 RISK FACTORS BEING + PPV…O‐22%, 1‐36%, 2‐57%, 3‐83%

RESULTS

ELIMINATED NUCLEAR SCANS WBC, ESR, AND CRP PPV….O‐25%, 1‐27%. 2‐58%, 3‐100%

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RECOMMEND

SIMPLE BLOOD TEST ‘s ‐ CRP, ESR, WBC’’s ‐ INTRA‐OPERATIVE WBC/HPF

Stucken C, Olszewski DC, Creevy WR, Murakami AM, Tornetta P. Preoperative Diagnosis Of Infection In Patients With Nonunions. J Bone Joint Surg Am. 2013 Aug 7;95(15):1409‐12

FACTORS AFFECTING BONE HEALING

PHYSIOLOGIC  STEROIDS  DIABETES  HYPERVITAMINOSIS A & D  CASTRATION  ANEMIA  RADIATION  Ca++ METABOLISM

BRINKER et.al

FACTORS AFFECTING BONE HEALING PHYSIOLOGIC SMOKING!!!!! • NICOTINE….DIRECT TOXIN TO OSTEOBLASTS • INHIBIT COLLAGEN SYNTHESIS • DECREASE OXYGEN CARRYING CAPACITY • PERIPHERAL VASCULAR EFFECT

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MAKE PROBLEM LIST

CHARACTERIZE NONUNION TYPE • BIOLOGIC • BIO‐MECHANICAL DETERMINE DEFORMITY PARAMETERS EVALUATE POTENTIAL INFECTION STATUS METABOLIC QUALIFIERS

Infected distal nonunion with LLD, malrotation, deformity, mechanical axis deviation

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PRE-OP PROBLEM LIST

BONE LOSS INFECTED DEFORMITY LEG LENGTH DESCREPANCY

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WHEN TREATING A NON UNION……..IT’S PROBABLY BETTER NOT TO SCREW UP IF YOU DON’T HAVE TO……. Vert Mooney….Chair U.T. Southwest 1987

Busch Stadium,

PMD007379-1.0

Busch Stadium,

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CONSTRUCT INSTABILITY

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