SLIDE 1
Avoiding the Nonunion
- Acute fxs
Avoiding the Nonunions in Tibias: Biologics, Reaming, Types of Rods - - PowerPoint PPT Presentation
Avoiding the Nonunions in Tibias: Biologics, Reaming, Types of Rods - - PowerPoint PPT Presentation
Avoiding the Nonunions in Tibias: Biologics, Reaming, Types of Rods and Plates I have the Answers 8 tips in 8 Minutes William Obremskey MD MPH MMHC Vanderbilt Orthopedic Trauma Avoiding the Nonunion Acute fxs 1. Biologics Acute Open
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- 1. Biologics – Acute Open Tibia Fxs
- BMP-2 - yes
- BMP-7 (OP-1) - no
- PRP - no
SLIDE 4
- 1. Biologics
- BMP-2 FDA approved for Acute Type 3 open
tibia fxs
– Type 3 fxs only – Decreased Bone graft and Non-unions
- 20% vs 2%
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- 2. Adjuvants
- PEMF
- U/S
- $700 million annually
- projected growth of 6%/yr
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- 2. Adjuvants
- U/S and PEMF – Fresh Fxs
- Meta-analaysis 13 studies – Acute fxs
– Hannemann, P.F.W., Mommers, E.H.H., Schots, J.P.M. et al. Arch Orthop Trauma Surg (2014) 134
- No decrease in Nonunions at 3,6,12 months
- May decrease time to radiographic union
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- 2. Adjuvants
- U/S – Nonunions not enough data
- PEMF – Nonunions
– Ebrahim S Et al. Low-intensity pulsed ultrasonography versus electrical stimulation for fracture healing: a systematic review and network meta-analysis. Can J Surg. 2014 Jun; 57(3):
- PEMF better at 3 months ONLY
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- 2. Adjuvants
- When do I use?
- U/S – Acute
– High risk patient in Cast – 55 yo F w/ DM smokes 2 ppd
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- 2. Adjuvants
- When do I use?
- U/S – Nonunion
– Hyper/oligotrophic – Subcutaneus bone
- Tibia
- Radius
- clavicle
– Simple fx
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- 2. Adjuvants
- When do I use?
- PEMF– Nonunion
– Hyper/oligotrophic – Any bone - femur – Any fx
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- 2. Adjuvants
- When do I use?
- PEMF– Nonunion
– Hyper/oligotrophic – Any bone - femur – Any fx
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- 3. Reaming
- Femurs – Do it
- Tibia
– SPRINT Study 1200 pts reamed vs unreamed – More “Events” in Unreamed – BUT – A broken bolt counted even of healed – Remove broken bolts then no difference
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- 3. Reaming
- Ream - Some
- 10 years ago
- Reamed up to 13 mm
– 12 mm Tibia IMNs
- Now
– 10 mm IMNs – Single pass 11 mm reamer – Place 10 mm IMN
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- 4. Reaming II
- SPRINT data - 3 Strikes
– Open Tibia Fx – Smoker – Reamed IMN
- Increased Nonunions
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- 5. Proximal Tibia fxs
- Use Supra patellar IMN
– Avoid malreducion
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- 6. Bicondylar Tibia plateau fxs
- Use 2 plates if medial side “unstable”
– Not enough stability
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- 6. Bicondylar Tibia plateau fxs
- Good bone – too much stability
- Use non-locking plate(s)
- Locking too Stiff and get medial nonunion
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- 7. Distal Tibia Pilon fxs
- Use Bi-columnar fixation
- Especially if Meta-diaphyseal extension
– Not rigid enough – Get junctional nonunion at diaphysis
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- 7. Distal Tibia Pilon fxs
- Use Bi-columnar fixation
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- 7. Distal Tibia Pilon fxs
- Use Bi-columnar fixation
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- 8. Tibia Defects
- If defect size (RABG) is < 2.5 cm
– Graft not needed
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- 8. Tibia Defects
- If defect size (RABG) is > 2.5 cm
– Graft Early (4-6 weeks) – Growth factors peak at 4 weeks
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- 8. Tibia Defects
- If defect size (RABG) is > 2.5 cm
– Graft Early (4-6 weeks) – Growth factors peak at 4 weeks
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- 8. Tibia Defects
- Autograft Better than Allograft and BMP-2
- pTOG study
– 80 % union vs 60% – Auto vs BMP-2
SLIDE 25
Avoiding the Nonunion
- 1. Biologics – BMP-2 ONLY Type 3 open tibia fxs
- 2. Adjuvants – U/S - Smokers w/ Tibia
- 3. Reaming
- 1. Femur – Yes
- 2. Tibia – a little
- 4. Reaming - Wary - open and smokers
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Avoiding the Nonunion
- 5) Proximal Tibia – SP IMN better reduce
- 6) Bicondylar
– Medial plate if unstable – not too stiff – non locking
- 7) Distal tibia pilon – bicolumnar fixation
– Esp if Metadiaphyseal extension
- 8) Defect > 2.5 cm