Nonunions : Diagnosis, Evaluation and Management

350 Pages·2017·12.63 MB·English

by  Agarwal

Animesh Agarwal
Editor
Nonunions
Diagnosis,
Evaluation and
Management
123
Nonunions
Animesh Agarwal, MD
Editor
Nonunions
Diagnosis, Evaluation
and Management
123
Editor
AnimeshAgarwal, MD
Division of Orthopedic Traumatology,
Departmentof Orthopedics
University of Texas HealthScience
Center
SanAntonio, TX
USA
ISBN978-1-4939-7176-3 ISBN978-1-4939-7178-7 (eBook)
DOI 10.1007/978-1-4939-7178-7
LibraryofCongressControlNumber:2017940364
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We must find time to stop and thank the people who make a
difference in our lives.
—John F. Kennedy
First and foremost, I would like to thank my parents, Jagdish
and Kusum, for being extraordinary role models, as well for
their hard work and dedication to parenthood. They
have supported me throughout my life, both personally and
professionally.Iamforevergrateful.Theycontinuetoamazeme
now as grandparents.
To the most delightful, caring, and resilient children I could
haveeverhad.ThankyouPriya,Deven,andTrevorforbeingso
understanding when I am on call or working late. You remind
me what is most important in life every time I look at you. The
three of you have been and continue to be my inspiration.
I want to thank those who have supported me professionally.
I am lucky to have trained at an institution with many “giants”
of orthopedics, and even more fortunate to have joined them as
a faculty member. They have always treated me as an equal,
despite having been my attendings. So thank you to Drs. James
Heckman, Charles Rockwood, and Fred Corley, who all
believed in me and gave me a chance. Thank you to those
that trained me during my orthopedic trauma fellowship, Drs.
Attila Poka, Robert Ostrum, and Brian Davison for making that
year of training educational, fun, and unforgettable.
Last but not least, I would be remiss if I did not thank my two
research mentors, Drs. Kyriacos Athanasiou and Mauli
Agrawal. They were instrumental in fueling my curiosity,
teaching me to write scientifically, and steering me towards
orthopedics. I wouldn’t be where I am today without their
encouragement and guidance so early in my career.
Animesh Agarwal, MD
Boerne, TX, USA
February 2017
Foreword
It is an honour to be invited to write the foreword to this important contri-
bution to the orthopedic surgical literature. This textbook is an extension
of the robust fracture information and knowledge base originally created in
the Department of Orthopedics at the Health Science Center in San Antonio
byRockwoodandGreeninthe1970s.Despitemanysubstantialadvancesin
primary fracture care over the last several decades, our ability to enhance
fracture healing has not improved very much; thus, delayed unions and
nonunions remain a common clinical challenge. Furthermore, as patients
develop greater expectations for very good or even perfect results after
injury,theyarelesswillingtoacceptincompletefracturehealingasthefinal
outcome. Today’s patient wants to be able to return to high-level perfor-
mance following injury and not be sidelined because of a failure offracture
healing. Therefore, when fracture healing does not occur, it is incumbent
upon the surgeon to identify the cause and develop an effective solution to
restorefunctioninatimelymanner.Thetextbookisaveryusefulresourceto
that end.
Dr. Agarwal has compiled a very comprehensive overview of the causes
of and the effective treatments for virtually all of the common nonunion
patterns.Hiscontributingauthorsareauthoritativeandrecognizedexpertsin
theirrespectivefields,andthetreatmentsforspecificnonunionsarepresented
in a very comprehensive, well-illustrated, and user-friendly way.
This textbook clearly advances our understanding of the evaluation and
treatment of fracture nonunions, and it will be a very useful guide to the
surgeon who must find an effective means to restore function when the
normal fracture healing process has failed.
Manchester, VT, USA James D. Heckman, MD
March 2017
vii
Preface
Aninvestmentinknowledgepaysthebestinterest.
—BenjaminFranklin
Nonunions have been a challenging aspect for orthopedic trauma surgeons.
The literature is scarce with recommendations for many of these problems.
Theprinciplesofnonunionmanagementhavebeentraditionallybasedonthe
type of nonunion and its aetiology, whether it is a mechanical or biological
one. As orthopedic care has advanced with newer implants—such as locked
plating—old problems have been alleviated, but new issues have arisen as
well. Although patient factors and injury factors contribute significantly to
the development of nonunions, iatrogenic causes are not infrequent. Ortho-
paedictraumacarestillrequiresattentiontodetailandthebasicprinciplesof
fracture management tohelpprevent thesurgeon’scontributiontononunion
development.
Over thelast twentyyears of mypractice, nonunions havealwaysbeen a
difficult problem to assess. New patient issues such as vitamin D deficiency
havecometolight.Infectionalltoooftenaccompaniesnonunionsandmustbe
evaluated. This text was designed to provide a single reference for the basic
principlesofnonuniondiagnosis,evaluation,andmanagement.Althoughnot
everysingletreatmentoptioncanbecoveredforeverysingleanatomicalarea
andtypeofnonunion,wehopethatthistextisuseful,notonlyformanaging
these difficult problems but also in preventing nonunions from occurring by
avoidingsurgical causes and mitigating patient risk factors.
The contributors to this text were selected based on their interest and
expertise in this subject. Nonunion management is unique in that it is rarely
taught; rather, surgeons have learned over the years through their own per-
sonal experience, oftentimes by trial and error. Learning a new subject,
technique, or gaining new knowledge requires the desire to be more
well-informed.ToquotethegreatWoodyAllen,“Eightypercentofsuccessis
showing up”. The contributors have certainly shown up. If you are reading
this preface, we hope that you have taken a step towards “showing up”, and
thus being successful in the management of these difficult and challenging
cases.
Boerne, TX, USA Animesh Agarwal, MD
ix
Contents
1 Principles of Nonunions . .... .... .... .... .... ..... .... 1
Animesh Agarwal
2 Fracture Healing.. ..... .... .... .... .... .... ..... .... 45
Saam Morshed and Anthony Ding
3 Clavicle Nonunions ..... .... .... .... .... .... ..... .... 75
Laura A. Schemitsch, Emil H. Schemitsch
and Michael D. McKee
4 Proximal Humerus Nonunions .... .... .... .... ..... .... 95
Ethan S. Lea and Philip R. Wolinsky
5 Supracondylar Humeral Nonunions.... .... .... ..... .... 115
Joseph Borrelli, Jr.
6 Nonunions of the Forearm ... .... .... .... .... ..... .... 125
Fred G. Corley and Ben S. Francisco
7 Nonunions of the Wrist and Hand. .... .... .... ..... .... 143
Matthew Lyons, Ahmad Fashandi and Aaron M. Freilich
8 Acetabular and Pelvic Nonunions.. .... .... .... ..... .... 183
Kyle F. Dickson
9 Proximal Femur Nonunions .. .... .... .... .... ..... .... 207
Roman A. Hayda
10 Femoral Shaft Nonunions.... .... .... .... .... ..... .... 227
Gil R. Ortega and Brian P. Cunningham
11 Distal Femoral Nonunions.... .... .... .... .... ..... .... 243
Animesh Agarwal
12 Nonunions of the Tibial Plateau and Proximal
Tibial Metaphysis . ..... .... .... .... .... .... ..... .... 275
Thomas F. Higgins
13 Tibial Nonunions.. ..... .... .... .... .... .... ..... .... 287
Samuel E. Galle and David P. Zamorano
14 Distal Tibia and Ankle Nonunions. .... .... .... ..... .... 309
Kevin J. Pugh
xi
xii Contents
15 Special Techniques for Nonunions Associated
with Traumatic Bone Loss ... .... .... .... .... ..... .... 323
Mark A. Lee and Michael P. Leslie
Index ... .... .... .... ..... .... .... .... .... .... ..... .... 339