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Bone Non-Union & Defects For Postgraduate Orthopaedic Exams
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Bone Non-Union & Defects For Postgraduate Orthopaedic Exams
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Segment:0 .
Good evening, everyone. Welcome to the orthopedic Academy teaching session, which is also being streamed by our partners or through TV.
My name is Nikki Evans and I will be your host tonight. I am joined by Mr Karthik Iyengar and Ashok from ortho TV. Mr David Hughes will be joining us shortly as well. So this evening we will have a lecture on non-union and bone defects by Mr iyengar, followed by 3 MSC questions to check your understanding. These are anonymous. So please answer promptly and then we'll talk through the answers with you.
If you have any questions during the lecture, please write them in the chat box and we will ask Mr. Lyon jr. at the end of the MKZ. We will offer three vyver spaces this evening, so please put in the chat if you would like to take part and we'll select the first three candidates. The virus will not be recorded, and this is an excellent opportunity for you to practice answering your questions in a mock Viber format.
For those people that are interested, we do run several courses throughout the year, including our intensive mock vyver course and our two new courses, which are a case based discussion's course for orthopedic exams and basic sciences course, with all the details and booking can be found on our website. Orthopedic Academy echo UK this session will be recorded and will be available on our YouTube channel in the next few days.
So don't panic if you miss part of it or you want to revise it. Our invited speaker this evening is a consultant, orthopedic surgeon in the Northwest of the UK, and he's a member of the faculty of surgical trainers of Edinburgh and honorary senior clinical lecturer at the University of Liverpool and edgehill University. So it gives me great pleasure to introduce a dear colleague and friend, Mr. Karthik Iyengar. Hi, everyone.
My name is Karthik. I work in a place called Southport. Originally, I'm from India, so welcome to everyone here in the UK and across the world. So today I'm going to talk on non-union of practice and we'll talk a bit briefly on bone defects. It's an interesting topic. I like it.
It is the White people. I take my first survivor courses and let's take it from there. So the learning objectives will try to look at. Where they are, these will try to define what's a non union and try to look at the classifications. How do we evaluate non unions? What are the options of treatment algorithm?
I made my own brief one at which so then I will discuss some cases and then we can have a chat about it. And then I have put up a slide where you can have some reference articles if you want to look into it. So let's go to what is a traditional queries in a talk. So why, what is it not? That's what I want to know. Why does it happen?
What are the risk factors? How do you classify them and how do you when you have diagnosed now, how do you go about managing? So we will look into all of this. So these are a couple of cases I want you to think about while we go through the talk. We will discuss this in the end. The first one is the eight-year-old is the background history of diabetes, and she fell, which is a common fracture nowadays is a distal femur.
And you can see the fixation and obviously you can see the non union there. And so the thought process is, how do we manage this the same? This is a bit more complex as patients live longer. Now we are getting all of these complicated problems, but here there is a further complication the patient has a failure of implant infected, nonunion and therefore, what do we do? So we will have a chat later as to how we can process these conditions.
So looking at a definition, so when I asked my candidates, there is a couple of definitions they do, but these are the three which I found consistently that I think we should refer to. So the FDA in the USA has defined the non union as fracture, which is at least nine months old and has not shown any progression of feeling or three consecutive months radiologic clinically as a symptomatic fracture with no apparent potential to heal without it.
So the two words are important here. So it's a symptomatic fracture and it's unlikely to heal without surgical intervention. And other commonly used definition can be it's one which takes double the amount of what is normal for a fracture to heal. But if I ask you, OK, define what the definition the upper two are, the ones I'm looking for. All all, these have traditional risk factors.
These are quoted extensively. We all know about systemic factors, including co-morbidities. I'll come to that. And most important is when you're managing nonunion is looking at the local factors. What's the type of fracture of personality was compound open? What was the fixation adequate or not? When you manage?
Is there a bone defect? How do we address the bone defect? What's the bone critical bone defect? So we will look into it? Most importantly, don't forget the neurovascular structure and the soft tissue. This will all come as we assess the patient and have devised an algorithm. How do you manage these patients?
So so there are multiple of these are the five I want you to look into because these four are higher or higher order in forces or four, 7 and 8. It's not just good enough. Oh, that's the risk factors are diabetes, smoking, et cetera. I want you to understand why diabetes patients are at a high risk, why smoking is a well defined factor we need to look at microscopic level, biological level.
Why you can. So let me expand on video of this. So this is a diabetes. So if the person asks you across the table, ok? Diabetes is a risk factor, but please explain and highlight how this happens. So a traditionally patient with a diabetes, these are the mechanisms how it leads to risk of non union. You need to talk about age.
You need to talk about Ross. And most importantly, is that it initiates a process where patients are at a higher risk of osteoporosis. They have a lot of free radicals at the fracture site, which are not conducive to healing. In fact, they have significant amount of inflammation mediators. And as you all know, these all patients are at increased risk of infection.
So that adds to the spectrum of non-union. So there is a difference. I quoted bottom. If you look at the patients who are diabetics have 3 times the incidence, so that's the number you need to call. That's three times likely for having nonunion delayed union or one complication. In fact, it has a seven-fold increased risk of fold increase, the risk of hip fractures and more about 1.5 times in type 2 diabetes.
Let's look at smoking now. Same thing. Same mechanism, a similar mechanism, but the same structure I'm trying to illustrate here. Smoking predominant is the relation is vascular. Nicotine is a ways of contract constricted. It increases the local carbon monoxide levels. It counters the antioxidant properties of vitamins C and E. And this all leads to environment which is not conducive to bone healing.
It also affects the preliminary stages of fracture healing itself. So if I put a couple of references there those are, I would suggest take home. Read them. There are two systematic reviews. One is by Bridget scammell. You will know from Oxford and calisthenics. Characteristically, you are asked, OK, what is the risk of smoking related non union?
Should they be able to go this one or two of these papers say OK, twice more likely to have non unions 2 times more, especially in TVA and long bone fractures. Vitamin D is another component, and how that's what we need to learn. We need to understand vitamin D acts at all levels of fracture healing. That is the five levels, whether it's had the inflammatory stage, the metro stage formation of the soft colors, art galleries and even remotely.
And also vitamin D is important from wound healing point of view. So these are the three key factors and risk factors. I want you to understand a bit. Develop a bit more info on it when you are across the table in a wider situation. Let's look at the concepts. So there are a few theories and concepts as to why no unit happens.
I'm sure you guys already must have read about patents, theory and hold steady. But what? I'm going to focus on a couple. The theory of biology. So union is interplay between biology and mechanical stability for the fracture to heal. Both should work in tandem. If one of them is missing, this relationship is disturbed and hence this is the concept that one expects you to renewal theory of biology.
However, at the emphasis or level, this is the concept everyone keeps talking about a diamond concept is the concept of two people. So if you need to know two people in the world who have done extensive work on non-union is these two people. Gionet is Professor from Leeds and Professor calorie from Italy. They devised this concept as to look out for. What are the reasons that the fractures heal and why these elements are critical, critically important in fracture healing.
If you look at it, it has got all the four components. It's got three biological components and one features suggestive of mechanical stability. So the biology, and if you can look at the figure on the right stem cells, these are essential for osteogenic matrix. Organic matrix is important for vascular conduction and growth for factors which are important for us to induction. So remember, these are the three key criterias which we use while we are talking about bone grafts as well, isn't it?
So therefore, these three key factor biological elements, but supported by the importance of mechanical stability, that's what it comes with fixation. But the biological three factors are important for fracture healing. The significance of this. What they feel as they develop this concept is for a fracture to heal. You need to have all of this working in tandem.
The efficiency of one other or a combination of other leaves and it's a risk factor for nonunion. Let me show you for the other one. So though the biologic concept of diamond transfer was initiated in about, say, 2008 or so. This has been rightly emphasized now with the Pentagon regenerative concept, what it described to say is, I think, why vascular supply is key.
So apart from the four elements of the diamond, the element that has been included now is vascularization, because that's the key element where the blood supply, all the elements that are required to achieve healing are initiated. So here this Pentagon concept is the current concept that we need to. Diamond is good, but Pentagon is a step further than the. Looking at classifications, so these are the two classification I would like you to put across the table.
Everybody is aware of Weber and check, but non-union scoring system is the hot topic. So let's talk about the traditional one. So this is a traditional classification we all describe. However, we are talking about hypertrophy and profit here. This was discovered and developed by surgeons Weber from Switzerland and Zach from Prague.
They looked at x-rays, and this is basically radiological classification, looking at the biology and of the bone. So if you can see on the left hypertrophy and the right is atrophy, how is this relevant? Classically hypertrophic non-unionised show a lot of bone formation. However, the key problem here is mechanical established. Hence, you can fix the mechanical instability the fracture should go on to heal.
However, on the atrophic side, the element that is missing is biology. There, mechanical stabilization won't help, so you need to include induced bone formation for achieving the healing. So why do we need a new scoring system? We traditionally widely used Weber and said I put roughly I prove it very easy to describe what, as with any classifications, there were factors which needed to be improved on the old Weber and set classification are necessary for you to communicate across, and therefore this had to be strengthened.
So this concept of new classification came into Vo in about 2008 2009, around that time and also again by two people. Professor gionet is and calgary, and they have emphasized the three key elements that the data require. So one is the bone, the soft tissue, and third. Third is the patient factors. So let's look at this. So this is a busy side, but this is what I could get.
Very good article. Please refer to it so they bark and give marks or score each element that patient are assisted this week. This includes clinical examination, imaging factors, patient, the general Excel is sick rates, et cetera and also what is the scoring of the patient and X-rays on website classification. All of these are scored and you come to a number when you come to a number.
They are again reclassified into four groups and one slide I would like you guys to take home. Is this because this makes your algorithm and management quite straightforward and understanding? So if after the new scoring system, a patient scores the scores between 0 to 20 five, it's a straightforward non-union similar to the hypertrophic one. And if you improve the mechanical stability by revisiting the fixation, the fracture should go on to unite.
Second one is the middle one where both. Biology and mechanics at ford, these patients are scoring between 26 to 50, so in along with improving the mechanical stability, you have to induce biological stimulation. This could be due to various modalities. You can use pulse electric pulse electronic magnetic field. You can use extracorporeal shock therapy or the traditional biotechnologies like BNP growth factors, et cetera, et cetera.
When you come to the third group, that's where it becomes a bit more complicated. These patients have both mechanical and biological insufficiency. But along with this, predominantly these patients tend to have infection with this. They have a problem of bone defect as well. So you have to manage multiple things. Yeah, you have to manage the patient or to manage the fracture.
But along with this, you have to manage the infection. And then after you are taken or resected the part of infected bone, you need to start understanding how you are going to organize the bone effectively. So there are various methods where you can apply to achieve the bone defect mechanism. You can have bone transport, transport mechanism, mass killings.
Well, well talked about. And the newer one, which I think is being talked about, is the RCA system. Rima irrigated and aspirated works well in femur, not much in tibia. And the traditional biologics, which are the scaffolds, growth factors and et cetera, coming to the fourth one. If a patient is scoring seven more than 70 five, the patient is course type C in that they have significant co-morbidities.
Patients condition local and generally very poor. Shanghai the default defect is so large that trying to undertake what we could undertake in the third group is literally not going to work. So probably they are. The candidates for amputation are to resist or consider a complete resection and use of mega prosthesis. After your diagnosis or classified, how do we assess the radiological union?
So this is the first article, which was by Bandari atoll, where they established a scoring system to evaluate union across tibial fractures after internal fixation. So they scored. They again had a point for scoring to assess three dimensional healing. So if you look at bone as a three dimensional concept, it has got four vortices.
So if you see no in any of the four Cortez's that you get one point each. So you can have a minimum of 4 and a maximum of 16. If you look at the second figure, there is some calcium see, but you can still see the fracture line. So this code to. If there is a breach in callus, this, but the fracture lines slightly still visible again, is this a similar score?
If you have a fracture which has seen with bridge angles, no fracture lines in that, that is 3. So you count and multiply with all the four participants and look at whether the fracture is healing. I have recently look, this is being applied to humoral fractures. This is being applied to femur fracture. Article got published last week. Please have a look.
So they people have started to extrapolate the rest classification score, fracture scoring, union scale into other fractures, humerus femur. And probably this will come more and more popular. How do you assess patients apart from your traditional ways of looking or assessing a patient of look, feel and move? Looking for scars, sinuses, bleeding for pain, obviously for testing mobility, always check for joints about because above and below, because this has an effect on management of the neurovascular.
Don't forget, but these are the three percentages that you can put and the sensitivity and specificity of each of these factors. You can look at inability to bear where there is the significant clinical way of judging by taking in history and tenderness on palpation. With about 35% to 40% imaging, I can give a whole talk on imaging for fracture healing and non union. But I made it concise as to what are the traditional modalities of these.
All the modality modalities have their own place in evolution of non-union plane. The communist one, the first one. It gives you the whole character of the fracture story fracture journey that is good. You can know what was the type of injury you can know. How was the pattern of injury? You can. You can look at the healing effort, callus formation, previous implants, how they were.
However, more and more and more CT is being used to evaluate bridging callus, especially you can apply maybe extension of the rust classification. It is useful in looking at patients who have hardware near intractable fractures, looking at rotational deformities and limb and discrepancy because this is common with infected bone. You get that MRI has got that punch hole, but it is.
It's use more around joint replacement bed and cintiq roughly is significant in that you can look at CTE using glucose looks at the metabolism that is going on around the nonunion and fracture site, and apparently it is useful in knowing the level of deception when you want to go in. So if you do a PET scan, you look at the metabolic activity and know where the activity is dead, where there is none and probably can mark your level of resection rather than under dissection of the fractures.
So this is a ladder, which I keep in mind when I have been given an X-ray or something to debate. So far, classified defined define non-union confirmed why it is non-union and describe the X-ray or the pathology, then decide more. Mostly, I would suggest, is to know whether it's in fact you're a non-infected one. Apply your analysis criteria, then you have an algorithm.
And obviously, if you have a bone defect coming into the lower level three, then you will know what other options that you need to talk about. You anticipate what are the questions that is going to? So this is one other key element that I think you need to keep in mind. So poly therapy is when you combine all the fundamental principle, which we have in our armoury, including the which involve the diamond and said we need to get your scaffold factors, you need to get growth practice, you need to get osteoporosis.
And all these, including the mechanical steroids called therapy, usually traditionally used in the third group between the 51.75 scoring on tenodesis. Let me talk briefly on bone defects, I have not put many slides of it. The key here element I wanted to learn when I was reading about is the concept of critical bone defect. So, you know, you have a bone defect if you have infected non union or non infected one.
But how do you classify that which which bone defects should? You may be autologous bone graft, which do you need some larger techniques or vascular supplies or not? So this is a definition commonly asked. Critical bone defect. So what's the critical bone defect? It's a defect where, you know, after resection or after nonunion that you are left with a gap.
And if you leave it as that, it's not going to heal. So the definition is passed. However, I found out any gap nonunion that is more than 2.5 centimeters is called a critical bone defect. So if you have a patient who has a nonunion, whether in fact your non-infected and the gap is more than 2.5 than surgical intervention is required. I looked at a bit more to look at traumatic bone defect classification.
This is a new one that has come back. Very nice. Classification is given makes things very clear. So if you look at the incomplete defects, these are less than 2 centimeters. They are unique cortical or by particular losses. And as we go onto defects, which are less than 2 centimeters with some deformity and obliquity of the fracture site, they are D2 too.
But the critical one that is difficult to treat. The treatments where the critical bone defects is more than 2 to 2.5 centimeter, you can have some which are less than four major when they are between centimeters and massive defects, which are more than eights. Why do we need to do that? Because you can plan the management accordingly. If it is a massive defect more than centimeters then probably you need this osteogenesis.
If you have a defect, which is 2 to 4 centimeters, maybe you can get away with mass or if you vascularized. So this is important first to establish whether the defect is critical or not, and if it is critical. Start thinking whether you need to do something else about it. So that's an algorithm. Again, I keep coming back to our algorithm. We find nonunion, establish whether it's in fact you or not.
In fact, you decide whether you have a bone defect, which is critical or not. And depending whether it's critical or not, you can do traditional bone grafting or if you are, it is critical, then you need some more instruments in your material. So again, challenge. In fact, your bone graft is a different topic altogether significant challenges, including diagnosis, knowing the organism's imaging strategies completely different, different spectrum of this.
Again, I come back to this side learn biology for the fracture to heal, not to go into nonunion. Need to have two concepts. One is the biology. Second is the stability. So if you need the biology, you need the three elements of that or the induction or conduction and also modalities there. So let's go back to our patient.
So this is I know her. She's 80 diabetic, had this fracture. And you can see from the fracture fixation, it is insufficient. You can see there is a virus angulation at the fracture site. The proximal screws are backing out. This is insufficient. However, the critical factor I can see from the X-ray itself, it has neither the callus formation and the fracture site, nor is the implant stable.
So therefore, this probably comes in the second level of tenodesis 25 and 50, where both biology support and stability support. So how do you go about this? Confirmed there is no infection and then see what we did. So we have restored the mechanical stability with the locking plate and see we have used dual plating because that used a three dimensional stability at the fracture site.
We have included the whole of the collateral, but we are supported the stem at the top and obviously we added bone graft and she has recovered very well, fully independently mobile. And that probably should have been the first choice of treatment. So let's look at this one. This is a complex one. These are the X-rays I got from my friend, and I should thank him for it.
So this is a lady who's 74, had a fracture nearly a couple of years back. The first trigger is the one where they plated it, but she ended up in an emergency situation with the fracture on the first. So obviously, you can see now that she has a broken plate classical non union with a wound infection. So this is in fact you nonunion prosthetic distal to the stem. But when you try to go in and recheck that bone part, you are left with a big void.
So this void is significant. So how do you feel that? So the coming through the feeling of this, you can see that this is a two stage procedure. Where had you have excised the infected bone, temporarily stabilized with cushioning sort of picture and significant amount of antibiotic related, similar antibiotic loaded human gives a significantly good illusion of antibiotics at the local level controls the infection.
Luckily, the infected organism was strep. Therefore, it worked very well. So that's the X-ray few weeks down the line. You can see there is some concern, some orientation of the fracture site, and this is the second stage. So this is a custom built, custom made prosthesis not available. I know at all centers, but these are difficult fractures who treat.
So you got a custom-made prosthesis with a proximal stamp where extension, where you can have the stem fitting in the custom made plant itself. And then there is a flange on the outside just supporting the stem on the outside distally. We managed to save the femoral condyle, but these are complex injuries, difficult to treat. But these what I'm trying to say is a way of creating, understanding and applying that for you.
So if you are asking the people, OK, tell me your paper, so this is a mnemonic I. This is what they're paid, so to speak up. So this is a general information. If you guys need to say you are put on a spot, OK, tell me about a recent paper. So this is the way I go into learning this, so this can be your template. Classically, if you look at it, this says the learning resources.
But believe me, if you Google or PubMed both gallery and journalism, you will get most of that because that you need to on non-union. There are a couple of articles I squeezed in there because I did masters in nuclear medicine, and therefore I published a couple of them. Please have a look at it. And if you need any, please let me know. I can send it across.
And probably that's where I will. Thank you. All right. Thank you. Thank you, Karthik, that was excellent, very useful talk, and I'm sure that everybody that's listening will have learnt something, you know, and some good tips for the exam as well as for your practice.
So I've noticed there's a couple of questions which I've written down. So what I'm going to do now is I'm going to launch the MSCI. Q so there's just 3 and 6 questions. It's anonymous. So if you just answer them as soon as you can. And then we'll talk through the answers and then we'll move on to the questions. Shall we take it on.
So one percent, so let's look at the first one. If you look at the first one, this is what I put it up on, my definitions key is slide, isn't it? Definition of non-union FD is a fracture which has taken at least nine months or with no signs of radiological progression of healing or a symptomatic fracture with no apparent potential to heal or fracture, which has taken twice.
So the first one is incorrect. Good 70% Nearly 70% have answered correctly. That's a good number. So let's look at smoking and nonunion, correct? You got the key element that I pointed out that smoking remember twice two. So twice then that the more likely to develop nonunion TBA and twice the number of in any fracture.
So if you are asked for that, remember to right, that's good. Let's of. Right, so and USS Cole, yeah, they come into the second group, remember where I suggested that you need mechanical and biological, so you that you revisit your mechanical stability and then you have to enhance, Uh, biology, isn't it? So what can you do? You can do the pulse electric magnetic field.
Yes 69 antibiotic therapy has no role in the classification system of any USS mega processes, as you said. For patients who are more than 75 in any uses for in their patients who have significant co-morbidities, type C host. And masterly is required for the group three, where they're scoring between 50 to 75.
So, Uh, less than, Uh, 0 to 25. Stability hypertrophic, predominantly union. So to improve the stability, biology is already there. 26 to 50, we need improved stability or better stability and improve your. Improve the biology, which you can do with multiple levels and then pulsed electric magnetic and the third one where you have a defect infected, non-union.
And fourth is where it's more than so someone put it on the chat. They wanted to a new SS score against four groups. Easy for groups divided into four groups. How do you get to a score with score is the slide before. So there are three days. This is a busy slide. But each of the elements, which are risk factors or predictors of nonunion are given a score.
In the end, all these are calculated and you come to work for no. So when you come to a core number, you have a patient say, OK, the patient has a score of anywhere between 0 to 25. So this patient traditionally have. Biology is good, but they have mechanical instability. So if you establish stability, then they are going to go to see patients who are scoring between 26, six to 50 have probably both a problem.
So therefore, you integrate the mechanical stability but enhance biology by various models. You can use pulsed electromagnetic field. You can use short wave short wave. Corporal shockwave therapy, you can use biologics, anything that is possible when you come to the third group, which are scoring between 51 to 75. These are more complex, my more complex.
These are probably patients who have infections. These are patients who will develop a bone defect and therefore you are now landed of a problem of infection plus bone defects. So you have to address all this. So how do you address this? Obviously, you need stability, but you need to organize things to heal by getting a bone defect healed up.
So there are various techniques for this. So techniques can be masculine or induce membrane technique, which they have quoted nearly 80% healing of non unions. Remember, even with all these techniques, nearly 20% of non unions don't go on to. Uh, then you have the newer modality for our AI system. Well, describing literature again from prof and leads, please have a look at it.
And all this is called, so you have to get the three key biological elements of healing that includes osteogenesis or induction and/or conduction. So that's why this all therapy jointly called as therapy. And obviously, the patient is scoring more than 75. It comes into the last group where the force itself has is in host C group, significant comorbidities where any reconstructive surgery is going to be more detrimental than conceding a salvage procedure.
So did you all guys get that? I'll stop sharing. OK, Mohammed, I hope that helped. Muhammad had another question, I wasn't sure whether it was a question Mohammed or whether it was a statement. You've written why dual plating, distal femur, LCP and bone graft would have done the job.
Yes, the thought process is that both at the distal and proximal. Slap broke into the Liverpool concept is if you have a support country, non-union, you know, traditional use and need to do And knowledge, but they end up nearly 20% end up in no need. Liverpool has a low threshold, you'll. Why?
because play team, you can give you a good angular stability, maybe in one play, but you know, subsequently the proximal fragment always tends to flex up. So if you have fixed it laterally, that is therefore they just put a neutralizing sort of picture so that you get integrated in for the similar concept, maybe in the distal femur as well. See, remember that still a fragment in distal femur flexes, isn't it, because the hamstring gets stuck as it has there, so the gastric pulls it down, so you get a lateral AP line stability with your lateral plating.
But if you want to do it in the AP, in the operatively, probably your plate, you may get away with a single bit, but that. Encompasses everything you come out of it and, you know, it's going to be stable. That's great, thanks, Karthik. It's one of those I want to go to bed and don't call me operations, so you know, and then I've got a question from Norman Norman as asked, what is the definition of delayed union?
So delayed union is a B fracture, which has taken. Longer than the traditional amount of time that it is required to heal and is at a risk of not being so delayed, you then can be anything, say, for example, people are three to four months. So if it is taking and you are checking at 6 to six months, still not healing. But it's not at the time where it is becoming a non union.
Probably it may end up in healing in the next one. So that is delayed. So traditionally longer than normally, it takes a fracture to heal, but not as long as a nonunion nonunion is a fracture where it won't heal. It's unlikely to heal without intervention that could be intervention surgically or by non surgical like pulse electric, et cetera, et cetera.
Right, thank you, I hope that answers your question. Norman and Muhammad's got another question. What's the role of Elizabeth in nonunion? Is it a good device to address the non unions? Yes, very well established before the muscolare and newer techniques of AIA. But there is a limitation may be on how much length you can achieve. Maybe it is good to say draw palace article it says about 8 to 5 to 15 centimeter.
However, remember all the destruction osteogenesis L0 have long reapplication. They are aware that frame for ages lot of inside problems, so therefore patients compliance is also difficult. But believe me, a is of external fixator in fixator the marvelous way of trying to heal, especially defect and infect you and non-infected defect unions. We use that traditional India Royal Liverpool has a very good laser unit and it requires a dedicated unit, a dedicated team, patient compliance.
And remember, they do well with tibial fractures, not in femur. Femur is a no no for Lazaro because lots of complications. Thank thanks, Celtic, and I got a question from Mohammed, a different Muhammad, would you consider an email and plate rather than dual plating? Yes, but remember if you are using two modalities of techniques, so I am nearly taking your industrial supply off.
Lating is taking your very austere breaths for supply. I know there are fractures nowadays where they're advocating retrograde daily and a stabilizing place. Yes, you can. You need to get stabilization, whichever way. So if you are going down, you open the fracture site itself. Little waiting, you have done you put simply put, an interior. You are there, aren't you?
Otherwise, you go ahead with a different construct, different element. And remember that I am Neal. They had put Hatfield, isn't it? So once, but maybe use set a different technique which works well in your hand? I think that's the way forward. Thank you. OK, one more question, and then we'll move on to vivus, so again, it's Mohammed.
What's the protocol in the UK to treat infected non-union? It's a big subject, so all the regions have a dedicated recon unit, so that's where most of these patients do get. So is a difficult. So if you are in trouble, if you have scored so and your system is to no non specialty clinic went to. So if you have a patient, you have fixed it six months, nine months down the line, you scoring 25 50, then you are heading for a nonunion.
Seek early advice from them. You can communicate with them. Listen, I have this and they are very good at dealing with this because they have a system in place. So obviously when they are seen in their clinic, they have a non-union clinics, you know, Royal Liverpool as well established non-union. Like every Friday, go there you see a spectrum of patients. They have a system of assessment, they have a system of imaging, they have a system of getting the organisms.
It requires MDT meeting. The microbiologists are involved. First They have various organisms. Some require more medical input because they are diabetic, unstable diabetes, et cetera so you need an MDT approach. You need a little recon unit. You need someone who does this regularly need MDT input. You need to have a team of physiotherapists and rehab specialists to look after because pin sites and looking after the fray is key element.
Thanks, Celtic. Yeah, I think I'm not sure where you work, Mohammed, but I certainly work in a DDR and an infected non unions for us or, you know, infected joint replacements. Everything seems to be a lot more centralized in the UK. So if you have any kind of problem, there's usually a regional center that you can refer to or at least discuss the cases with and send over the radiographs and things.
So for anyone that's doing the parks exam, the key thing to say in these questions is mdc-t approach regional centre, and that will tick marks off for you. And it shows that you're safe for the purposes of, well, if you're working in the UK, yes, but for the purposes of the exam, it's important that you say those things. OK, that's great. So we finish the questions.
I am going to stop the recording and we'll move on to the vivas.
It's
Segment:0 .
Good evening, everyone. Welcome to the orthopedic Academy teaching session, which is also being streamed by our partners or through TV.
My name is Nikki Evans and I will be your host tonight. I am joined by Mr Karthik Iyengar and Ashok from ortho TV. Mr David Hughes will be joining us shortly as well. So this evening we will have a lecture on non-union and bone defects by Mr iyengar, followed by 3 MSC questions to check your understanding. These are anonymous. So please answer promptly and then we'll talk through the answers with you.
If you have any questions during the lecture, please write them in the chat box and we will ask Mr. Lyon jr. at the end of the MKZ. We will offer three vyver spaces this evening, so please put in the chat if you would like to take part and we'll select the first three candidates. The virus will not be recorded, and this is an excellent opportunity for you to practice answering your questions in a mock Viber format.
For those people that are interested, we do run several courses throughout the year, including our intensive mock vyver course and our two new courses, which are a case based discussion's course for orthopedic exams and basic sciences course, with all the details and booking can be found on our website. Orthopedic Academy echo UK this session will be recorded and will be available on our YouTube channel in the next few days.
So don't panic if you miss part of it or you want to revise it. Our invited speaker this evening is a consultant, orthopedic surgeon in the Northwest of the UK, and he's a member of the faculty of surgical trainers of Edinburgh and honorary senior clinical lecturer at the University of Liverpool and edgehill University. So it gives me great pleasure to introduce a dear colleague and friend, Mr. Karthik Iyengar. Hi, everyone.
My name is Karthik. I work in a place called Southport. Originally, I'm from India, so welcome to everyone here in the UK and across the world. So today I'm going to talk on non-union of practice and we'll talk a bit briefly on bone defects. It's an interesting topic. I like it.
It is the White people. I take my first survivor courses and let's take it from there. So the learning objectives will try to look at. Where they are, these will try to define what's a non union and try to look at the classifications. How do we evaluate non unions? What are the options of treatment algorithm?
I made my own brief one at which so then I will discuss some cases and then we can have a chat about it. And then I have put up a slide where you can have some reference articles if you want to look into it. So let's go to what is a traditional queries in a talk. So why, what is it not? That's what I want to know. Why does it happen?
What are the risk factors? How do you classify them and how do you when you have diagnosed now, how do you go about managing? So we will look into all of this. So these are a couple of cases I want you to think about while we go through the talk. We will discuss this in the end. The first one is the eight-year-old is the background history of diabetes, and she fell, which is a common fracture nowadays is a distal femur.
And you can see the fixation and obviously you can see the non union there. And so the thought process is, how do we manage this the same? This is a bit more complex as patients live longer. Now we are getting all of these complicated problems, but here there is a further complication the patient has a failure of implant infected, nonunion and therefore, what do we do? So we will have a chat later as to how we can process these conditions.
So looking at a definition, so when I asked my candidates, there is a couple of definitions they do, but these are the three which I found consistently that I think we should refer to. So the FDA in the USA has defined the non union as fracture, which is at least nine months old and has not shown any progression of feeling or three consecutive months radiologic clinically as a symptomatic fracture with no apparent potential to heal without it.
So the two words are important here. So it's a symptomatic fracture and it's unlikely to heal without surgical intervention. And other commonly used definition can be it's one which takes double the amount of what is normal for a fracture to heal. But if I ask you, OK, define what the definition the upper two are, the ones I'm looking for. All all, these have traditional risk factors.
These are quoted extensively. We all know about systemic factors, including co-morbidities. I'll come to that. And most important is when you're managing nonunion is looking at the local factors. What's the type of fracture of personality was compound open? What was the fixation adequate or not? When you manage?
Is there a bone defect? How do we address the bone defect? What's the bone critical bone defect? So we will look into it? Most importantly, don't forget the neurovascular structure and the soft tissue. This will all come as we assess the patient and have devised an algorithm. How do you manage these patients?
So so there are multiple of these are the five I want you to look into because these four are higher or higher order in forces or four, 7 and 8. It's not just good enough. Oh, that's the risk factors are diabetes, smoking, et cetera. I want you to understand why diabetes patients are at a high risk, why smoking is a well defined factor we need to look at microscopic level, biological level.
Why you can. So let me expand on video of this. So this is a diabetes. So if the person asks you across the table, ok? Diabetes is a risk factor, but please explain and highlight how this happens. So a traditionally patient with a diabetes, these are the mechanisms how it leads to risk of non union. You need to talk about age.
You need to talk about Ross. And most importantly, is that it initiates a process where patients are at a higher risk of osteoporosis. They have a lot of free radicals at the fracture site, which are not conducive to healing. In fact, they have significant amount of inflammation mediators. And as you all know, these all patients are at increased risk of infection.
So that adds to the spectrum of non-union. So there is a difference. I quoted bottom. If you look at the patients who are diabetics have 3 times the incidence, so that's the number you need to call. That's three times likely for having nonunion delayed union or one complication. In fact, it has a seven-fold increased risk of fold increase, the risk of hip fractures and more about 1.5 times in type 2 diabetes.
Let's look at smoking now. Same thing. Same mechanism, a similar mechanism, but the same structure I'm trying to illustrate here. Smoking predominant is the relation is vascular. Nicotine is a ways of contract constricted. It increases the local carbon monoxide levels. It counters the antioxidant properties of vitamins C and E. And this all leads to environment which is not conducive to bone healing.
It also affects the preliminary stages of fracture healing itself. So if I put a couple of references there those are, I would suggest take home. Read them. There are two systematic reviews. One is by Bridget scammell. You will know from Oxford and calisthenics. Characteristically, you are asked, OK, what is the risk of smoking related non union?
Should they be able to go this one or two of these papers say OK, twice more likely to have non unions 2 times more, especially in TVA and long bone fractures. Vitamin D is another component, and how that's what we need to learn. We need to understand vitamin D acts at all levels of fracture healing. That is the five levels, whether it's had the inflammatory stage, the metro stage formation of the soft colors, art galleries and even remotely.
And also vitamin D is important from wound healing point of view. So these are the three key factors and risk factors. I want you to understand a bit. Develop a bit more info on it when you are across the table in a wider situation. Let's look at the concepts. So there are a few theories and concepts as to why no unit happens.
I'm sure you guys already must have read about patents, theory and hold steady. But what? I'm going to focus on a couple. The theory of biology. So union is interplay between biology and mechanical stability for the fracture to heal. Both should work in tandem. If one of them is missing, this relationship is disturbed and hence this is the concept that one expects you to renewal theory of biology.
However, at the emphasis or level, this is the concept everyone keeps talking about a diamond concept is the concept of two people. So if you need to know two people in the world who have done extensive work on non-union is these two people. Gionet is Professor from Leeds and Professor calorie from Italy. They devised this concept as to look out for. What are the reasons that the fractures heal and why these elements are critical, critically important in fracture healing.
If you look at it, it has got all the four components. It's got three biological components and one features suggestive of mechanical stability. So the biology, and if you can look at the figure on the right stem cells, these are essential for osteogenic matrix. Organic matrix is important for vascular conduction and growth for factors which are important for us to induction. So remember, these are the three key criterias which we use while we are talking about bone grafts as well, isn't it?
So therefore, these three key factor biological elements, but supported by the importance of mechanical stability, that's what it comes with fixation. But the biological three factors are important for fracture healing. The significance of this. What they feel as they develop this concept is for a fracture to heal. You need to have all of this working in tandem.
The efficiency of one other or a combination of other leaves and it's a risk factor for nonunion. Let me show you for the other one. So though the biologic concept of diamond transfer was initiated in about, say, 2008 or so. This has been rightly emphasized now with the Pentagon regenerative concept, what it described to say is, I think, why vascular supply is key.
So apart from the four elements of the diamond, the element that has been included now is vascularization, because that's the key element where the blood supply, all the elements that are required to achieve healing are initiated. So here this Pentagon concept is the current concept that we need to. Diamond is good, but Pentagon is a step further than the. Looking at classifications, so these are the two classification I would like you to put across the table.
Everybody is aware of Weber and check, but non-union scoring system is the hot topic. So let's talk about the traditional one. So this is a traditional classification we all describe. However, we are talking about hypertrophy and profit here. This was discovered and developed by surgeons Weber from Switzerland and Zach from Prague.
They looked at x-rays, and this is basically radiological classification, looking at the biology and of the bone. So if you can see on the left hypertrophy and the right is atrophy, how is this relevant? Classically hypertrophic non-unionised show a lot of bone formation. However, the key problem here is mechanical established. Hence, you can fix the mechanical instability the fracture should go on to heal.
However, on the atrophic side, the element that is missing is biology. There, mechanical stabilization won't help, so you need to include induced bone formation for achieving the healing. So why do we need a new scoring system? We traditionally widely used Weber and said I put roughly I prove it very easy to describe what, as with any classifications, there were factors which needed to be improved on the old Weber and set classification are necessary for you to communicate across, and therefore this had to be strengthened.
So this concept of new classification came into Vo in about 2008 2009, around that time and also again by two people. Professor gionet is and calgary, and they have emphasized the three key elements that the data require. So one is the bone, the soft tissue, and third. Third is the patient factors. So let's look at this. So this is a busy side, but this is what I could get.
Very good article. Please refer to it so they bark and give marks or score each element that patient are assisted this week. This includes clinical examination, imaging factors, patient, the general Excel is sick rates, et cetera and also what is the scoring of the patient and X-rays on website classification. All of these are scored and you come to a number when you come to a number.
They are again reclassified into four groups and one slide I would like you guys to take home. Is this because this makes your algorithm and management quite straightforward and understanding? So if after the new scoring system, a patient scores the scores between 0 to 20 five, it's a straightforward non-union similar to the hypertrophic one. And if you improve the mechanical stability by revisiting the fixation, the fracture should go on to unite.
Second one is the middle one where both. Biology and mechanics at ford, these patients are scoring between 26 to 50, so in along with improving the mechanical stability, you have to induce biological stimulation. This could be due to various modalities. You can use pulse electric pulse electronic magnetic field. You can use extracorporeal shock therapy or the traditional biotechnologies like BNP growth factors, et cetera, et cetera.
When you come to the third group, that's where it becomes a bit more complicated. These patients have both mechanical and biological insufficiency. But along with this, predominantly these patients tend to have infection with this. They have a problem of bone defect as well. So you have to manage multiple things. Yeah, you have to manage the patient or to manage the fracture.
But along with this, you have to manage the infection. And then after you are taken or resected the part of infected bone, you need to start understanding how you are going to organize the bone effectively. So there are various methods where you can apply to achieve the bone defect mechanism. You can have bone transport, transport mechanism, mass killings.
Well, well talked about. And the newer one, which I think is being talked about, is the RCA system. Rima irrigated and aspirated works well in femur, not much in tibia. And the traditional biologics, which are the scaffolds, growth factors and et cetera, coming to the fourth one. If a patient is scoring seven more than 70 five, the patient is course type C in that they have significant co-morbidities.
Patients condition local and generally very poor. Shanghai the default defect is so large that trying to undertake what we could undertake in the third group is literally not going to work. So probably they are. The candidates for amputation are to resist or consider a complete resection and use of mega prosthesis. After your diagnosis or classified, how do we assess the radiological union?
So this is the first article, which was by Bandari atoll, where they established a scoring system to evaluate union across tibial fractures after internal fixation. So they scored. They again had a point for scoring to assess three dimensional healing. So if you look at bone as a three dimensional concept, it has got four vortices.
So if you see no in any of the four Cortez's that you get one point each. So you can have a minimum of 4 and a maximum of 16. If you look at the second figure, there is some calcium see, but you can still see the fracture line. So this code to. If there is a breach in callus, this, but the fracture lines slightly still visible again, is this a similar score?
If you have a fracture which has seen with bridge angles, no fracture lines in that, that is 3. So you count and multiply with all the four participants and look at whether the fracture is healing. I have recently look, this is being applied to humoral fractures. This is being applied to femur fracture. Article got published last week. Please have a look.
So they people have started to extrapolate the rest classification score, fracture scoring, union scale into other fractures, humerus femur. And probably this will come more and more popular. How do you assess patients apart from your traditional ways of looking or assessing a patient of look, feel and move? Looking for scars, sinuses, bleeding for pain, obviously for testing mobility, always check for joints about because above and below, because this has an effect on management of the neurovascular.
Don't forget, but these are the three percentages that you can put and the sensitivity and specificity of each of these factors. You can look at inability to bear where there is the significant clinical way of judging by taking in history and tenderness on palpation. With about 35% to 40% imaging, I can give a whole talk on imaging for fracture healing and non union. But I made it concise as to what are the traditional modalities of these.
All the modality modalities have their own place in evolution of non-union plane. The communist one, the first one. It gives you the whole character of the fracture story fracture journey that is good. You can know what was the type of injury you can know. How was the pattern of injury? You can. You can look at the healing effort, callus formation, previous implants, how they were.
However, more and more and more CT is being used to evaluate bridging callus, especially you can apply maybe extension of the rust classification. It is useful in looking at patients who have hardware near intractable fractures, looking at rotational deformities and limb and discrepancy because this is common with infected bone. You get that MRI has got that punch hole, but it is.
It's use more around joint replacement bed and cintiq roughly is significant in that you can look at CTE using glucose looks at the metabolism that is going on around the nonunion and fracture site, and apparently it is useful in knowing the level of deception when you want to go in. So if you do a PET scan, you look at the metabolic activity and know where the activity is dead, where there is none and probably can mark your level of resection rather than under dissection of the fractures.
So this is a ladder, which I keep in mind when I have been given an X-ray or something to debate. So far, classified defined define non-union confirmed why it is non-union and describe the X-ray or the pathology, then decide more. Mostly, I would suggest, is to know whether it's in fact you're a non-infected one. Apply your analysis criteria, then you have an algorithm.
And obviously, if you have a bone defect coming into the lower level three, then you will know what other options that you need to talk about. You anticipate what are the questions that is going to? So this is one other key element that I think you need to keep in mind. So poly therapy is when you combine all the fundamental principle, which we have in our armoury, including the which involve the diamond and said we need to get your scaffold factors, you need to get growth practice, you need to get osteoporosis.
And all these, including the mechanical steroids called therapy, usually traditionally used in the third group between the 51.75 scoring on tenodesis. Let me talk briefly on bone defects, I have not put many slides of it. The key here element I wanted to learn when I was reading about is the concept of critical bone defect. So, you know, you have a bone defect if you have infected non union or non infected one.
But how do you classify that which which bone defects should? You may be autologous bone graft, which do you need some larger techniques or vascular supplies or not? So this is a definition commonly asked. Critical bone defect. So what's the critical bone defect? It's a defect where, you know, after resection or after nonunion that you are left with a gap.
And if you leave it as that, it's not going to heal. So the definition is passed. However, I found out any gap nonunion that is more than 2.5 centimeters is called a critical bone defect. So if you have a patient who has a nonunion, whether in fact your non-infected and the gap is more than 2.5 than surgical intervention is required. I looked at a bit more to look at traumatic bone defect classification.
This is a new one that has come back. Very nice. Classification is given makes things very clear. So if you look at the incomplete defects, these are less than 2 centimeters. They are unique cortical or by particular losses. And as we go onto defects, which are less than 2 centimeters with some deformity and obliquity of the fracture site, they are D2 too.
But the critical one that is difficult to treat. The treatments where the critical bone defects is more than 2 to 2.5 centimeter, you can have some which are less than four major when they are between centimeters and massive defects, which are more than eights. Why do we need to do that? Because you can plan the management accordingly. If it is a massive defect more than centimeters then probably you need this osteogenesis.
If you have a defect, which is 2 to 4 centimeters, maybe you can get away with mass or if you vascularized. So this is important first to establish whether the defect is critical or not, and if it is critical. Start thinking whether you need to do something else about it. So that's an algorithm. Again, I keep coming back to our algorithm. We find nonunion, establish whether it's in fact you or not.
In fact, you decide whether you have a bone defect, which is critical or not. And depending whether it's critical or not, you can do traditional bone grafting or if you are, it is critical, then you need some more instruments in your material. So again, challenge. In fact, your bone graft is a different topic altogether significant challenges, including diagnosis, knowing the organism's imaging strategies completely different, different spectrum of this.
Again, I come back to this side learn biology for the fracture to heal, not to go into nonunion. Need to have two concepts. One is the biology. Second is the stability. So if you need the biology, you need the three elements of that or the induction or conduction and also modalities there. So let's go back to our patient.
So this is I know her. She's 80 diabetic, had this fracture. And you can see from the fracture fixation, it is insufficient. You can see there is a virus angulation at the fracture site. The proximal screws are backing out. This is insufficient. However, the critical factor I can see from the X-ray itself, it has neither the callus formation and the fracture site, nor is the implant stable.
So therefore, this probably comes in the second level of tenodesis 25 and 50, where both biology support and stability support. So how do you go about this? Confirmed there is no infection and then see what we did. So we have restored the mechanical stability with the locking plate and see we have used dual plating because that used a three dimensional stability at the fracture site.
We have included the whole of the collateral, but we are supported the stem at the top and obviously we added bone graft and she has recovered very well, fully independently mobile. And that probably should have been the first choice of treatment. So let's look at this one. This is a complex one. These are the X-rays I got from my friend, and I should thank him for it.
So this is a lady who's 74, had a fracture nearly a couple of years back. The first trigger is the one where they plated it, but she ended up in an emergency situation with the fracture on the first. So obviously, you can see now that she has a broken plate classical non union with a wound infection. So this is in fact you nonunion prosthetic distal to the stem. But when you try to go in and recheck that bone part, you are left with a big void.
So this void is significant. So how do you feel that? So the coming through the feeling of this, you can see that this is a two stage procedure. Where had you have excised the infected bone, temporarily stabilized with cushioning sort of picture and significant amount of antibiotic related, similar antibiotic loaded human gives a significantly good illusion of antibiotics at the local level controls the infection.
Luckily, the infected organism was strep. Therefore, it worked very well. So that's the X-ray few weeks down the line. You can see there is some concern, some orientation of the fracture site, and this is the second stage. So this is a custom built, custom made prosthesis not available. I know at all centers, but these are difficult fractures who treat.
So you got a custom-made prosthesis with a proximal stamp where extension, where you can have the stem fitting in the custom made plant itself. And then there is a flange on the outside just supporting the stem on the outside distally. We managed to save the femoral condyle, but these are complex injuries, difficult to treat. But these what I'm trying to say is a way of creating, understanding and applying that for you.
So if you are asking the people, OK, tell me your paper, so this is a mnemonic I. This is what they're paid, so to speak up. So this is a general information. If you guys need to say you are put on a spot, OK, tell me about a recent paper. So this is the way I go into learning this, so this can be your template. Classically, if you look at it, this says the learning resources.
But believe me, if you Google or PubMed both gallery and journalism, you will get most of that because that you need to on non-union. There are a couple of articles I squeezed in there because I did masters in nuclear medicine, and therefore I published a couple of them. Please have a look at it. And if you need any, please let me know. I can send it across.
And probably that's where I will. Thank you. All right. Thank you. Thank you, Karthik, that was excellent, very useful talk, and I'm sure that everybody that's listening will have learnt something, you know, and some good tips for the exam as well as for your practice.
So I've noticed there's a couple of questions which I've written down. So what I'm going to do now is I'm going to launch the MSCI. Q so there's just 3 and 6 questions. It's anonymous. So if you just answer them as soon as you can. And then we'll talk through the answers and then we'll move on to the questions. Shall we take it on.
So one percent, so let's look at the first one. If you look at the first one, this is what I put it up on, my definitions key is slide, isn't it? Definition of non-union FD is a fracture which has taken at least nine months or with no signs of radiological progression of healing or a symptomatic fracture with no apparent potential to heal or fracture, which has taken twice.
So the first one is incorrect. Good 70% Nearly 70% have answered correctly. That's a good number. So let's look at smoking and nonunion, correct? You got the key element that I pointed out that smoking remember twice two. So twice then that the more likely to develop nonunion TBA and twice the number of in any fracture.
So if you are asked for that, remember to right, that's good. Let's of. Right, so and USS Cole, yeah, they come into the second group, remember where I suggested that you need mechanical and biological, so you that you revisit your mechanical stability and then you have to enhance, Uh, biology, isn't it? So what can you do? You can do the pulse electric magnetic field.
Yes 69 antibiotic therapy has no role in the classification system of any USS mega processes, as you said. For patients who are more than 75 in any uses for in their patients who have significant co-morbidities, type C host. And masterly is required for the group three, where they're scoring between 50 to 75.
So, Uh, less than, Uh, 0 to 25. Stability hypertrophic, predominantly union. So to improve the stability, biology is already there. 26 to 50, we need improved stability or better stability and improve your. Improve the biology, which you can do with multiple levels and then pulsed electric magnetic and the third one where you have a defect infected, non-union.
And fourth is where it's more than so someone put it on the chat. They wanted to a new SS score against four groups. Easy for groups divided into four groups. How do you get to a score with score is the slide before. So there are three days. This is a busy slide. But each of the elements, which are risk factors or predictors of nonunion are given a score.
In the end, all these are calculated and you come to work for no. So when you come to a core number, you have a patient say, OK, the patient has a score of anywhere between 0 to 25. So this patient traditionally have. Biology is good, but they have mechanical instability. So if you establish stability, then they are going to go to see patients who are scoring between 26, six to 50 have probably both a problem.
So therefore, you integrate the mechanical stability but enhance biology by various models. You can use pulsed electromagnetic field. You can use short wave short wave. Corporal shockwave therapy, you can use biologics, anything that is possible when you come to the third group, which are scoring between 51 to 75. These are more complex, my more complex.
These are probably patients who have infections. These are patients who will develop a bone defect and therefore you are now landed of a problem of infection plus bone defects. So you have to address all this. So how do you address this? Obviously, you need stability, but you need to organize things to heal by getting a bone defect healed up.
So there are various techniques for this. So techniques can be masculine or induce membrane technique, which they have quoted nearly 80% healing of non unions. Remember, even with all these techniques, nearly 20% of non unions don't go on to. Uh, then you have the newer modality for our AI system. Well, describing literature again from prof and leads, please have a look at it.
And all this is called, so you have to get the three key biological elements of healing that includes osteogenesis or induction and/or conduction. So that's why this all therapy jointly called as therapy. And obviously, the patient is scoring more than 75. It comes into the last group where the force itself has is in host C group, significant comorbidities where any reconstructive surgery is going to be more detrimental than conceding a salvage procedure.
So did you all guys get that? I'll stop sharing. OK, Mohammed, I hope that helped. Muhammad had another question, I wasn't sure whether it was a question Mohammed or whether it was a statement. You've written why dual plating, distal femur, LCP and bone graft would have done the job.
Yes, the thought process is that both at the distal and proximal. Slap broke into the Liverpool concept is if you have a support country, non-union, you know, traditional use and need to do And knowledge, but they end up nearly 20% end up in no need. Liverpool has a low threshold, you'll. Why?
because play team, you can give you a good angular stability, maybe in one play, but you know, subsequently the proximal fragment always tends to flex up. So if you have fixed it laterally, that is therefore they just put a neutralizing sort of picture so that you get integrated in for the similar concept, maybe in the distal femur as well. See, remember that still a fragment in distal femur flexes, isn't it, because the hamstring gets stuck as it has there, so the gastric pulls it down, so you get a lateral AP line stability with your lateral plating.
But if you want to do it in the AP, in the operatively, probably your plate, you may get away with a single bit, but that. Encompasses everything you come out of it and, you know, it's going to be stable. That's great, thanks, Karthik. It's one of those I want to go to bed and don't call me operations, so you know, and then I've got a question from Norman Norman as asked, what is the definition of delayed union?
So delayed union is a B fracture, which has taken. Longer than the traditional amount of time that it is required to heal and is at a risk of not being so delayed, you then can be anything, say, for example, people are three to four months. So if it is taking and you are checking at 6 to six months, still not healing. But it's not at the time where it is becoming a non union.
Probably it may end up in healing in the next one. So that is delayed. So traditionally longer than normally, it takes a fracture to heal, but not as long as a nonunion nonunion is a fracture where it won't heal. It's unlikely to heal without intervention that could be intervention surgically or by non surgical like pulse electric, et cetera, et cetera.
Right, thank you, I hope that answers your question. Norman and Muhammad's got another question. What's the role of Elizabeth in nonunion? Is it a good device to address the non unions? Yes, very well established before the muscolare and newer techniques of AIA. But there is a limitation may be on how much length you can achieve. Maybe it is good to say draw palace article it says about 8 to 5 to 15 centimeter.
However, remember all the destruction osteogenesis L0 have long reapplication. They are aware that frame for ages lot of inside problems, so therefore patients compliance is also difficult. But believe me, a is of external fixator in fixator the marvelous way of trying to heal, especially defect and infect you and non-infected defect unions. We use that traditional India Royal Liverpool has a very good laser unit and it requires a dedicated unit, a dedicated team, patient compliance.
And remember, they do well with tibial fractures, not in femur. Femur is a no no for Lazaro because lots of complications. Thank thanks, Celtic, and I got a question from Mohammed, a different Muhammad, would you consider an email and plate rather than dual plating? Yes, but remember if you are using two modalities of techniques, so I am nearly taking your industrial supply off.
Lating is taking your very austere breaths for supply. I know there are fractures nowadays where they're advocating retrograde daily and a stabilizing place. Yes, you can. You need to get stabilization, whichever way. So if you are going down, you open the fracture site itself. Little waiting, you have done you put simply put, an interior. You are there, aren't you?
Otherwise, you go ahead with a different construct, different element. And remember that I am Neal. They had put Hatfield, isn't it? So once, but maybe use set a different technique which works well in your hand? I think that's the way forward. Thank you. OK, one more question, and then we'll move on to vivus, so again, it's Mohammed.
What's the protocol in the UK to treat infected non-union? It's a big subject, so all the regions have a dedicated recon unit, so that's where most of these patients do get. So is a difficult. So if you are in trouble, if you have scored so and your system is to no non specialty clinic went to. So if you have a patient, you have fixed it six months, nine months down the line, you scoring 25 50, then you are heading for a nonunion.
Seek early advice from them. You can communicate with them. Listen, I have this and they are very good at dealing with this because they have a system in place. So obviously when they are seen in their clinic, they have a non-union clinics, you know, Royal Liverpool as well established non-union. Like every Friday, go there you see a spectrum of patients. They have a system of assessment, they have a system of imaging, they have a system of getting the organisms.
It requires MDT meeting. The microbiologists are involved. First They have various organisms. Some require more medical input because they are diabetic, unstable diabetes, et cetera so you need an MDT approach. You need a little recon unit. You need someone who does this regularly need MDT input. You need to have a team of physiotherapists and rehab specialists to look after because pin sites and looking after the fray is key element.
Thanks, Celtic. Yeah, I think I'm not sure where you work, Mohammed, but I certainly work in a DDR and an infected non unions for us or, you know, infected joint replacements. Everything seems to be a lot more centralized in the UK. So if you have any kind of problem, there's usually a regional center that you can refer to or at least discuss the cases with and send over the radiographs and things.
So for anyone that's doing the parks exam, the key thing to say in these questions is mdc-t approach regional centre, and that will tick marks off for you. And it shows that you're safe for the purposes of, well, if you're working in the UK, yes, but for the purposes of the exam, it's important that you say those things. OK, that's great. So we finish the questions.
I am going to stop the recording and we'll move on to the vivas.
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