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 1 9/24/2015 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 2 9/24/2015 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……. 3 9/24/2015 STRAIN 6‐9 MONTHS NON UNION Fx Healed? TIME 4 9/24/2015 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 5 9/24/2015 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 6 9/24/2015 14 weeks post op 7 9/24/2015 WHEN IN DOUBT..OR TO BUY TIME…….GET A CT 6 WEEKS post lag screw 8 9/24/2015 9 9/24/2015 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 10 9/24/2015 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??? 11 9/24/2015 ANALYSIS OF NON-UNION DEFORMITY • ANGULATION • MALROTATION CT EVALUATION • LEG LENGTH DESCREPANCY • TRANSLATION RELATIVE ALIGNMENT OF MEDULLARY CANALS A/P ANGULATION LATERAL ANGULATION 12 9/24/2015 OBLIQUE PLANE DEFORMITY MAGNITUDE & DIRECTION 48 38 53 30 OBLIQUE PLANE DEFORMITY MAGNITUDE & DIRECTION 48 38 53 30 TRUE PLANE OF DEFORMITY 13 9/24/2015 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 14 9/24/2015 DEFORMITY ANALYSIS IF THE CORA IS NOT AT THE SAME LEVEL AS THE APEX OF THE DEFORMITY…..YOU HAVE A TRANSLATIONAL DEFORMITY AS WELL 15 9/24/2015 PROBLEMS PROBLEMS With any translation……ALWAYS HAS TO BE A COMPENSATORY MAL ROTATION 16 9/24/2015 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 17 9/24/2015 Hypertrophic, translation, malrotation, angulation, LLD ANALYSIS OF INFECTION PREVIOUS TREATMENT NON‐OPERATIVE EXTERNAL FIXATION IM NAILING ORIF HOW TO R/O INFECTION??? 18 9/24/2015 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 19 9/24/2015 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 20 9/24/2015 ….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 21 9/24/2015 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% 22 9/24/2015 ESR RESULTS PPV……58% NPV…..80% WBC > 11,000 PPV……50% NPV…..70% PATH WBC’S >3 HPF PPV……40% NPV…..81% 23 9/24/2015 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% 24 9/24/2015 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 25 9/24/2015 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 26 9/24/2015 PRE-OP PROBLEM LIST BONE LOSS INFECTED DEFORMITY LEG LENGTH DESCREPANCY 27 9/24/2015 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, 28 9/24/2015 CONSTRUCT INSTABILITY 29 9/24/2015 30.