• LecturehallNon-unions- Etiology and Repair
  • Lecture Transcript
  • TAPE STARTS – [00:00]

    Dr. Christopher Bromley: I'd like to take the moment to introduce Dr. Bromley. He's the chair of foot and ankle surgery of Vassar Medical Center, and famous in his own mind. His wife keeps his ego in check, and I do send her pictures every now and then to show her that my name is in print. But she reminds I get to come home and just be her husband. So, at the end of the meeting, if there's a lot of applause or maybe a few autographs, you might believe me that I am famous. Okay. So, we have two talks to do. The first one is non-union's etiology and repair. This is a CME talk, and we have to make it last at least 23 minutes so that we can put it in the can and get new credit. The next talk will be an offloading diabetic foot TCC talk which we'll blow through in about five minutes, because we already have it in the can and we'll get you out of here early.

    As a reminder, we're scanning you here in the room at the end of the second talk. There was a session for question and answer which we could do at the end, anybody here who want to do question and answer or would you like to go home? Nobody wants to do question and answer? Alright. Great. So, perfect. Alright. Disclosure, this is CME presentation. There's no financial conflicts with this talk. I do consulting for a number of companies but none of them in this particular space. Objective today is to talk about the definition of non-union to understand the etiology, evaluation, classification, as Dr. Triple [phonetic] has said, is really great for boards, but it doesn't really matter much in reference to we just treat each one of them individually.

    Prevention is going to be key, and then treatment. We'll focus on stabilization and then all the biologic and regenerative things at our disposal. So, it would be remiss if we didn't spend a little bit of time since this is a residency meeting.


    Just reminding you about how sensitive bones are and understanding that this is obviously a living vital structure, understanding that there is a blood flow to the part of the foot or leg that we're treating, but there's also blood flow in the periosteum, and then the blood flow that was within the bone itself. The important of the osteoblasts and the osteoclasts, understanding the role of bone healing, and then understanding the different type of bone density and blood flow in each of the individuals. I said earlier, you need to know your anatomy. If you don't know your anatomy, you don't belong performing surgery.

    So, the definition of a non-union really is there's two definitions that you need to be aware of. One, for your boards, which is what we'll get to next, and the other one is the more important one, which is, what do know from Medicare? Non-union is a fracture that exists only when there had been serial radiographs. That's really important. So, if you're treating a non-union, take lots of x-rays, because the Medicare and the privates that are going to cover the things that you want to do, whether it's a bone simulator or a surgery, need to have serial x-rays, need to have good quality serial x-rays, so that you can document these. They want you to document that there's been a seasoned healing for three or more months.

    So, again, documenting when the patient comes in. When did this injury happen? We don't always see the patient on day one. When did this injury happen? Did you seek care with anybody else? Did you go to the ER? Did you have x-ray? Did you go to a doc-in-a-box? Where did you go? So, you want to document this, and have you got x-rays from those places? Even if they brought in the report, I always ask them to bring in a disk of whatever they have so that I can incorporate that into my PACS system so that I have that, and I can do a much better job. So, these serial radiographs have to include a minimum of two sets with multiple views of the fracture that are separated by – usually about 90 days.


    So, again, how you document and how you get a really good history, and what you do in your chart, will help you in reference to getting the treatment options you would like to have.

    So, in the literature, the sort of the Wikipedia definition of a non-union, is something that is nine months of elapsed time with no healing, progression over the last three months. A union is delayed and a fracture is seized to show any evidence of healing. Now, practically, this is a facture or an osteotomy or effusion that we performed that has no potential to heal. So, what happens to bone healing? There's a delayed union. There's been a failure for it to consolidate in the time that we would expect. They may end up with a pseudoarthrosis where we've got basically a false joint that's a fiber cartilage plug that are actually synovial tissue involved, and this leads to pain and instability.

    So, what happens in fracture healing? There is obviously whether it's an injury that we created in the operating room where we're trying to do effusion or an arthrodesis, what happens? Typically, they're much like in the wound healing. There are different phases of wound healing. There are different phases of bone healing. What typically happens after there's been a fracture is the body reacts. As you know, there's bleeding and there's a cocoon-like structure that will occur. And the body starts to heal via this callus formation. And the way I explain it to patients is it's about as durable as a spider web. And that analogy and that visualization that they have in their mind of the spider web, then they go, "Oh, I guess I shouldn't be walking on this or I should be more compliant."

    So, what you have to do is take all that you learned in medical school and all the doctorese that you know in your head, and convert it into English.


    And convert it into things that patients can see. So, use that. You can steal that from me. As I said, it's basically as durable as a spider web, and that gets them to be a lot more – they're going to be able to protect that. People really want to get better but, if they have the information and you create it a priority for them, they'll be better patients.

    So, there are different stages of fracture healing, just like in wound healing. There's a hematoma formation, and you can see we have an injury, and we've got a hematoma, and this is that cocoon structure. And then, there's this inflammation and cellular proliferation phase. Now, we talked in the workshops that we did earlier in the weekend about why we don't use NSAIDs after surgery. We don't use NSAIDs because they reduce this inflammatory response. So, the same thing in fractures. If you want to minimize your risk of a delayed union or non-union, you want to stay away from NSAIDs because they are going to suppress. And the patients don't always know that. Aleve is an NSAID. So, you have to be very specific with your care instructions. Write it down. I say to my patients on my post-op instructions, after surgery, I say it for fracture care, "These are the things that you are not allowed to take. You may take acetaminophen. You make the following, but you are not allowed to take this."

    And I think I mentioned in the workshop, they have an anesthesiologist all the time who want to give Toradol every single case I do, and I have to remind them at the beginning of the case, please do not give my patient Toradol. It's a lovely medication but it's not going to help my effusion. Again, there's a consolidation after you have this neovascularization that occurs across the callus. And then, we start to have the osteoblasts put down bone. And then, hopefully, we get on to the remodeling phase which as we know, can take up to a year.

    So, what are the causes of non-union? In trauma cases which we'll get into or patients who have underlying metabolic disease or there's a poor vascularity, the incidence of small vessel disease because of diabetes is rampant in this country, and instability.


    It was the patient not immobilized properly. Did they not follow instructions? Universally, patients are very noncompliant. Did they end up with an infection with the soft tissue or the bone? And then, there are other causes such as poor surgery or poor management. So, this is a great slide if you want to take a picture of your phone. Please feel free to do it. This sums up what goes on in a cellular basis during the different phases of bone healing. So, you see obviously the body is responding with all of the different growth factors and the macrophages that are involved. And we have all of this reaction going on, very, very dynamic.

    It's controlled by your autonomic nervous system. So, if you have a patient who has neuropathy from alcohol or diabetes, these reactions are very, very reduced, and you're not going to have good healing to these patients, because this whole reaction is controlled by your autonomic nervous system, a whole another lecture we give on what happens in autonomic nervous system. So, as this proliferation progresses, you're going to get to that soft callus. Again, all these growth factors, and you have these progenitor cells. And then, eventually, the osteoblasts laid out.

    So, the factors of delayed non-union here, these are external factors such as a fracture gap, soft tissue damage, adverse events that may occur or multiple trauma, lack of good cortical position. As mentioned before in Dr. Triple's lecture, the osteoblastic jumping distance. Two bones in the same room will heal, maybe, maybe not. It depends on what bone it is, insufficient mechanical stability and infection.


    The internal factors, those are the patient's age and sex, comorbidities. Diabetes is obviously rampant, osteoporosis. I had a case about a year ago, we were doing a Lapidus procedure and it just didn't feel right to me when I went ahead and cut, started looking at her bone. I was able to take a K-wire and just pushed it in the bone without even driving it in. And I thought to myself, this doesn't look good. And I asked the resident to break and go look at her chart, nothing about osteoporosis.

    So, we made a decision not to do the Lapidus. And afterwards, I was talking to her and she's, "Oh yeah. I've had osteoporosis for years." And I said, "Well, I looked at your chart, you're not on any medication for osteoporosis and you didn't put that in your history." "No, I didn't think it was important. And I didn't react well to the osteoporosis medicine." So sometimes the patients forget that that's important to tell you, but it is a problem. Alcohol abuse, key, and obviously smoking. I mentioned it in our workshop on Friday that I don't operate on patients who smoke. Every now and then, we have trauma patients and we get them to stop smoking, smoking cessation program. Drugs, long-term use of steroids and NSAIDs, and also chemotherapy.

    So, the current strategy is to have biophysical enhancement. What happens, what can we do with the soft tissue, the ligaments, the tendons and the structures? What can we do to stimulate effusion with different hormones and growth factors? A lot of the surgery that we do now in the foot – every foot and ankle, we're using a lot of the biologics to stimulate that. We'll get into slides about how we use the amnion and chorion as wraps for different bones and we can inject it. I'll also use injectable, room temperature amniotic fluid, and some of the non-union cases which we'll get into.


    Obviously, this is a very difficult patient to manage. They have lost the biophysical window. We've got huge, huge risk of below-knee amputation here. And sometimes, poor vascularity can be coming from the surgeon. If you're not aware of the neurovascular anatomy and you're not doing a good surgical dissection, you can do a wonderful plate and screw, but you may ruin the patient's opportunity to heal by your surgical technique. It can be just intrinsically unstable. These are very difficult fractures. This is going to require open reduction and internal fixation. This is obviously something that would not be amenable to close reduction. Infections, these happen. This case went particularly well, but if you look at this and you look at it honestly and you take serial x-rays and from different angles, you would look at this bone and see that although this was a lovely plate and screw combination, you can see the bone is disappearing.

    So, you have to be able to differentiate pain, swelling. Look at the blood work and determine whether or not the patient may have an infection that's destabilizing and will lead you to a surgical problem and non-union. Again, risk factors for non-union. Open facture is very, very high risk, high energy fractures with trauma, excessive soft tissue damage and bone loss and infection. These are all part of the biophysical things that we have to deal with that – will put us at risk for non-union.

    This is my favorite patient. You can see she's obviously immobilized, but we're helping her healing with the cigarettes and systemic risk. Malnutrition is a big issue. We have lots of people because of the type of diet and lifestyle that people live.


    They may be malnourished if they're low in protein. They don't have good diet. They don't have good social situation. They're really at risk. Obviously, smoking, I can't say that enough, NSAIDs are a big problem. And then obviously, the diabetes, alcohol abuse. I've got a patient now who's got a nasty Charcot from alcohol-induced. And then, there's this good old-fashioned patient noncompliance. Rule of thumb in my practice is you do exactly what we agree that you're going to do or you go see somebody else.

    I've been doing this for 30 years, and if you're not going to be compliant, we'll find somebody else for you to see. One of the ways that I do that is if I have somebody who's noncompliant, I look at the patient dead in the eye, and I say, "You have a very complex condition. It is far beyond what I can do, and you're going to need to see a specialist. And I'm going to give you the name of three people that you could go see, and today is no charge. And we're going to get a copy of your medical records on the way out, because it's beyond me. It's just so much more than I can handle." And we give them a nice bon voyage. You do have to medically legally see them for 30 days if they come back, but that's one way to get rid of the patient who's noncompliant.

    Alright. Classification for the board questions. Obviously, site makes a difference. Whether it's diaphyseal or metaphyseal, extraarticular or intraarticular, Dr. Triple's lecture on epiphyseal injury, it was really great. And then, really based on callus formation, is it hypertrophic? You can see here it got a big hypertrophic with lots of callus. Is it atrophic? Is it narrowing down, not a lot going on, very impaired healing? Or is it oligotrophic where it's got callus and it's mal-aligned? And then, of course, there's the infection, the classification systems that you're maybe familiar with from your studies. There's the [indecipherable] [00:15:55] classification which really focuses and very easy to remember.


    It's either a lesson one sonometer or more than one sonometer. It's the As and Bs. And then Weber classification is vascular and avascular. And then, there's the Judith Weber classification which does basically avascular which is atrophic, and then the hypervascular which is the hypertrophic. So, these are the three classifications that really they ask you on the board.

    When we get down to discussing what's happening, the delayed union, non-union in pseudoarthrosis, again, the definitions, we've already touched on. Delayed union is usually between that four- to six-month window whether it's effusion or a fracture. Again, delayed unions are typically healed by mobilization and strict compliance. I think it's important to think at this point, what are you doing for the patient nutritionally? What are you doing for them metabolically? Can they get into a bone simulator? If we get into a non-union situation where it's greater than nine months old and we've had serial x-rays for 90 days with no improvement, typically in that situation, we get into the bone simulators which we'll talk about coming up. Those are very helpful. Those patients who don't respond to bone simulators, we talk about we use whole food supplements like Astrof [phonetic] and PMG. We also talked to the patients about injecting their non-unions in the office whether we have access to room temperature, 1 cc amniotic fluid. If you can do a percutaneous injection of the biologics right into the non-union, anybody here who does Lapidus like me, they do happen to, in spite your best efforts, that's a great save move.

    I had a gentleman who came to me with a one year old distal fibular non-union. We did bone simulator for a while, weren't really making progress. He paid out of pocket. We charge about $600 for a cc of amniotic fluid. It basically covers our cost, and we did it right in the office, ultrasound-guided, and he did really well.


    And so, there are ways to get ahead of and do cutting-edge stuff. Pseudoarthrosis again end stage of a non-union, very, very unstable. This typically need to be resected, crafted and fixed. Non-union, again, signs to remember, patients who have persistent pain in the area ruling out on infection, non-physiologic motion, progressive deformity. You can see you got loss of fixation here versus any aseptic non-union failed implants. It does happen.

    Radiologic evaluation, again standard look is to do serial x-rays, remembering what I said at the top of the talk, if the patient has been to other places, get a good history. Get the x-rays from the beginning. Oblique films, very, very helpful, looking at something particularly in the foot with an oblique view is very helpful compared to the stray AP or DP views. False positives remain at risk. Serial x-rays, we've talked. There's a rule of bone scan in reference to determine the blood flow. I think MRI as I mentioned in the previous lecture, very, very helpful, and then CT if you've got hardware in there and you don't want to have artifact.

    Just a note on the MRI side, a lot of places now have stronger 1.5 magnets. If you have a hardware case and you want an MR, if you go to a 0.31 magnet which are the smaller magnets, you have less artifact. So, a bigger, more powerful MRI is not always helpful. You can do just the imaging that you want with a 0.31 magnet and stay away from the 1.5. Some of the big teaching institutions now have the 3.0 magnets which are really, really super powerful, which give you all artifact and they can't see anything.


    So, if you do an MRI in a case like this where you've got hardware, make sure it's not the 1.5 magnet. Make sure it's the older one.

    Again, just looking at classifications, a hypertrophic non-union in this situation, the hypertrophic is good because that usually means you've got blood flow, but the civility is usually poor. So, the treatment in this case would be stabilize and try to correct the deformity. In atrophic non-union, these are the ones where we don't have a lot of blood flow and we've got poor stability. So, these are the cases where we typically have to get in there, much like a wound. When a wound is stalled and not healing, why do we debride it? We debride it because we want to stimulate the healing process, and we want to get rid of the bioburden and get rid of the necrotic stuff. So, in this case, we've got to get in here, get this cleaned out, and get that metatarsal out to length, and use a nice plate with a bone graft to give us a chance to heal.

    Obviously, if it's an older complicated diabetic patient, you may elect to not do anything at all. I mean, they can live with this if they're not in pain and you could elect to take it out. Not that that's a perfect option, but you have to member, smoking diabetics don't get hardware with the bone grafts. That doesn't work. And surgical management, again, you've got to cure the infection. If they've got a problem and it's infected, you got to clear that up before anything else. You got to fix the underlying deformity, be able to provide stability either with an internal implantation or ex-fix. George Vito [phonetic] did a great job yesterday talking and showing his ex-fix cases. And then, remembering that you have biologics. Most of us have biologics at our disposal in the office and in the operating room. I'm not a huge PRP fan. I think if the blood was going to heal me in this arm, if you took it out, span it in a nice effusion and put it in this arm, it's not going to do a lot.


    But I do like having application for allografts and then also the biologics have been very helpful in our repair. What are the benefits of bone graft? Obviously, if it's an autograft, preferably, we're taking it from that calcaneus as opposed of the iliac crest, because those of you who the iliac grafts, it really hurts worse than the thing we're trying to fix in the foot. The reason they're helpful is because they're osteogenic, because they're going to provide you with a vital bone cells you need. They're osteo-inductive. They're key recruitment of mesenchymal cells and they're osteo-conductive, and we get that nice scaffold ingrown for bone. We have obviously access to allografts now. There are lots of different things out there. I think I like to mix, if I'm using an allograft, I would like to mix in the PRP or some of the patient's own blood products. It has been very helpful to stimulate the whole cascade of healing.

    There are lots of different companies now that will give you access to aspiration of calcaneals themselves which are extremely also conductive. You don't have to take a big piece of that calcaneus out or create a new problem. They're very effective, lots of great companies out there. A downside to them is they tend to be costly, but they're very easy to learn how to use. From a nonoperative management side, we have electromagnetic options. These are direct current devices. They can be put over the dressing or over the cast. There's also these are post-electromagnetic field devices that are typically worn and are effective. An alternative to that is ultrasound. These are mechanical energy that forms a low frequency that typically the 30-watt centimeter, this is going to again stimulate the bone, remembering the Wolff's law that we talked about in the last lecture.


    Bone forms in reaction to pressure, so we're using the electromagnetic current or the ultrasound wavelength to stimulate the healing center which is very effective. The downside to these is again with Medicare, you typically have to wait out. So, you've got 90 days of no healing. I do have patients who have opted to rent the devices, and most of these companies will work with you if you have somebody who really doesn't want to wait, but you can get this device rented, and it's very effective. Again, the key is prevention. You don't want to work with what you have, biologic fixation, and make sure that you save what you can. Bring in all the different colleagues that you need to make sure you can try to save this leg to prevent the non-union.

    Just some cases from overall, when you look at patients who've gone on to non-union, the biggest problem that we have in non-union is recognizing that you have a delayed union. Nobody wants a problem, but problems happen. And if happens, don't do the [indecipherable] [00:25:05] thing, you stick your head in the sand. Well, maybe to look better the next time they come in, "Oh, I'll see you in four weeks." If you think that you have a non-union, the sooner you get on it, the better your chances of it not becoming a non-union. If it's delayed, if you think – don't look at this wishfully thinking that something is really not happening. If you line up your x-rays and you're taking good serial x-rays, and you don't see something happening, then you need to be proactive. Talk about nutrition. Is the patient compliant? Talk about how important it is. And if you think this is happening, start the process to get your bone simulators approved so you can get out in front of this.

    Again, this is from Ken Zoris [phonetic] and Medizino's [phonetic] lecture. That is a very good textbook talking about the treatment of non-unions. They're showing you the difference between attempted subtalar joint effusion with fixation.


    It's showing you a plain x-ray and also showing you what CT can show you and be very helpful. They talk about in their article the role of chronic regional pain or what we call RSD. Again, remembering that a lot of these patients, well, the symptoms will be very similar. It's hot. It's swollen. It's painful. Again, the chronic regional pain is your autonomic nervous system being out of whack, and that's what bone healing needs, is an autonomic nervous system to be functioning properly. So, you've got a patient. I think I mentioned it in the workshop the other lady I had a lady who come in. She had a Lisfranc's fracture dislocation. She had fallen for five weeks ago, obese, her both knees. And she was concerned about what I was going to do to fix their Lisfranc's fracture.

    I was concerned about the fact that her left leg was swollen, cold from the knee to the foot. And she had pulses but she obviously had a nice case of RSD, chronic regional pain. And of course, we sent her out for ultrasound, ruled out DVT right away. And then, we sent her to neurology, and we'll get that chronic regional pain situation under control before we embark on fixing her Lisfranc's fracture.

    Here's another example. Now, what do I do? Obviously, this was a nice attempt at effusion. This is not going to get better with a bone simulator. Again, in this particular non-union, you've got to take all this hardware out. Nature is helping you already. The screw is coming out through the top. You got to take all these out. You will resect. Get down to nice cleaning bleeding bone. Put a nice allograft in there, and augment it with your biologics and re-stabilize it, and make sure you evaluate the patient nutritionally. What's going on with their blood sugar? And then, you start over.

    So, the key to non-union is prevention. The most common cause of non-union is failure to diagnose and treat a delayed union. As I said to you, look at your x-rays.


    If you think that the bone is slow to heal, you want to make sure you get on top of it early, careful and honest evaluation of your own x-rays. If you're not sure, ask a friend. Ask a colleague. Bring your x-rays in. Talk to the radiologist at your hospital. If you're a new practitioner and you're a solo practitioner, and you don't have an associate to ask, bring it in. Bring your x-rays in. Talk to your radiologist. Ask them for additional studies so that you can stay on top of this.

    In summary, the definition, delayed unions and non-unions, and the natural course for fracture is really important to understand. The causes and disturbance of bone healing really comes down to blood flow, instability and the risk of infection. The principles of treatment we talked about, again, stabilization, enhance the biology using the regenerative tools, and then making sure that you've ruled out and treated underlying infection. How to prevent delayed unions, non-unions? Again, from the beginning, making sure that you've got biologic fixation. You've made sure that you've taken care of your soft tissue. And then, overall, a take-home message today, is early recognition of a delayed union.

    Be honest with yourself. If you're not sure, ask for help so that you can get ahead of this and make sure that this doesn't happen to you.

    TAPE ENDS [00:29:19]