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 Tibia Fxs • BMP-2 - yes • BMP-7 (OP-1) - no • PRP - no

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%

2. Adjuvants • PEMF • U/S • $700 million annually • projected growth of 6%/yr

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

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

2. Adjuvants • When do I use? • U/S – Acute – High risk patient in Cast – 55 yo F w/ DM smokes 2 ppd

2. Adjuvants • When do I use? • U/S – Nonunion – Hyper/oligotrophic – Subcutaneus bone • Tibia • Radius • clavicle – Simple fx

2. Adjuvants • When do I use? • PEMF– Nonunion – Hyper/oligotrophic – Any bone - femur – Any fx

2. Adjuvants • When do I use? • PEMF– Nonunion – Hyper/oligotrophic – Any bone - femur – Any fx

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

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

4. Reaming II • SPRINT data - 3 Strikes – Open Tibia Fx – Smoker – Reamed IMN • Increased Nonunions

5. Proximal Tibia fxs • Use Supra patellar IMN – Avoid malreducion

6. Bicondylar Tibia plateau fxs • Use 2 plates if medial side “unstable” – Not enough stability

6. Bicondylar Tibia plateau fxs • Good bone – too much stability • Use non-locking plate(s) • Locking too Stiff and get medial nonunion

7. Distal Tibia Pilon fxs • Use Bi-columnar fixation • Especially if Meta-diaphyseal extension – Not rigid enough – Get junctional nonunion at diaphysis

7. Distal Tibia Pilon fxs • Use Bi-columnar fixation

7. Distal Tibia Pilon fxs • Use Bi-columnar fixation

8. Tibia Defects • If defect size (RABG) is < 2.5 cm – Graft not needed

8. Tibia Defects • If defect size (RABG) is > 2.5 cm – Graft Early (4-6 weeks) – Growth factors peak at 4 weeks

8. Tibia Defects • If defect size (RABG) is > 2.5 cm – Graft Early (4-6 weeks) – Growth factors peak at 4 weeks

8. Tibia Defects • Autograft Better than Allograft and BMP-2 • pTOG study – 80 % union vs 60% – Auto vs BMP-2

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

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 – Graft early – 4-6 weeks – Use autograft