Non Union (Pseudorthrosis)

Pseudorthrosis


All over the world 5% to 7% of all fractures have some problem in healing. Those that fail to unite are known as a fracture nonunion. Because there is persistent motion at the site of injury, a nonunion is usually associated with pain, deformity and inability to walk.

The healing process of bone is quite diferrent for bones in the body, In general, if a nonunion is still evident at 20 to 24 weeks post injury it will remain unhealed without surgical intervention,

When to call non union

  • Pain on movements
  • Developing a deformity

  • Fracture site is mobile

  • No radiological signs of callus formation from x-ray and CT scan

Types of Non Union

1. Hypertrophic non union


Hypertrophic nonunion usually results from insufficient fracture fixation. most of the hypertrophic nonunions simply require the rigid fixation of the nonunion site distraction by Illizarov apparatus.

The reasons why union occurs without treating the nonunion site only by fixation and distrction osteogenensis because hypertrophic nonunion tissue could serve as a reservoir of mesenchymal progenitor cells .Flow cytometry revealed that the adherent cells were consistently positive for mesenchymal stem cells. After These results demonstrated for the first time that hypertrophic nonunion tissue contains mesenchymal progenitor cells. (bone stem cells)

This suggests that hypertrophic nonunion tissue plays an important role during the healing process of hypertrophic nonunion by serving as a reservoir of mesenchymal cells that are capable of transforming into cartilage and bone forming cells.


2. Atropic union


Certain fractures are particularly prone for nonunion.

For example:


  • Fractures associated with major soft tissue disruption (such as an open fracture where the bone is exposed to the outside environment) compound injuries
  • Fractures associated with a high velocity and high energy mechanism like road traffic accident and war / blast injuries
  • Certain bones have their natural position in the body.For example lower portion of leg as it has poor blood circulation
  • Fractures in patients with metabolic disorders
  • Congenital Pseudarthrosis

Treatment 
Treatment is planned according to the type of non union and previous surgeries performed on the fractured bone. When designing a treatment plan for a fracture nonunion. In the broadest terms, the treatment plan should include a method of stimulating the local biology at the nonunion site or improving the mechanical stability or both.

Stability can be provided with the help of plates and screws, nails and external fixation devises eg. ilizarov 

  • Ilizarov method is the choice of treatment when stability and stimulation for union is needed. Russian literature on ilizarov claims 99.5% success rate.
  • Some common treatment methods of stimulating the local biology include: bone grafting stem cells bone substitues can be used

With proper treatment, even the most longstanding and disabling fracture nonunion can be healed and the patient’s quality of life can be greatly improved. Because of the complex nature of this area of orthopedics, choosing a surgeon with vast experience is very important factor in treating non union.

3. Hypertrophic Non Union

A case of gun shot injury causing scarring and shortening of thigh length and union was achieved by applying illizarov fixator.


Hypertrophic Non UnionHypertrophic Non UnionHypertrophic Non UnionHypertrophic Non UnionHypertrophic Non Union



















Medical history of Neil (Congenital Pseudarthrosis) - Undergone Bone Transport

NeilCongenital Pseudarthrosis

FIG A.

1. The child was diagnosed with congenital Pseudarthrosis (Type II) Right Tibia when he was 6 months old (April 2005) Now Aged 6 Years.


2. He was operated in February of 2007, the fibro ma was removed and bone grafting was done in reputed Medical College Hospital in New Delhi.

Note: The x ray (Fig. A) was taken before the operation.

3. The child had a trauma and sustained a fracture at the operated area at the age of 3 years December 2007 he was subsequently treated; the deformity was corrected by Fixation and implantation of lock in Titanium Plate.







Congenital Pseudarthrosis

FIG B.

4. This plate was removed after a period of one year March 2009.

5. The patent further sustained injury and fractured his leg 6 Months after the plate was removed (May 2009.

6. The child had been on a caste for a period of 11 months with no significant improvement.
The following three X-rays show his condition:












Congenital Pseudarthrosis Congenital Pseudarthrosis Congenital Pseudarthrosis

7. The child was then referred to Dr Amar Sarin who operated upon him and Ilizarove`s application was done for his pseudoarthrosis right tibia with corticotomy Bone Trasport with fibular osteotomy. Neil went through the series of operations successfully and all his operations were uneventful.
The following X-Rays Show his treatment from day one until his present condition:

X-Ray 1

Congenital Pseudarthrosis
This X ray was taken after his first operation on June 4th 2010


 








X-Ray 2

Congenital Pseudarthrosis
This X ray was taken 8 weeks after first operation bone transport is under way on August 8th 2010



 






Ultrasound

Ultrasound
This ultra sound was done after the docking was done

 

 

 

 

 

 

 

 

 


X-Ray 3

Neil X-Ray
This is the latest X ray showing the area after 16 weeks of docking being done.











Patient Testimonials

I was the first lady in India to get treated by the Ilizarov method for my non union in Tibia by Dr. Amar Sarin in 1993. I have no problem since then in my leg.

Satya SethiMrs. Satya Sethi
New Delhi