Fracture nonunion, bone defect bone grafting

Fracture nonunion and bone defects are often caused by improper treatment of fractures or infections after fractures. The commonly used treatment method is bone transplantation, but there are a series of pathological changes (such as fracture end hardening, bone marrow cavity closure, skin defect, soft tissue scar, poor blood supply, etc.) due to non-union of the fracture and bone defect. Treatment is more difficult. Treatment has been more difficult if there have been multiple surgeries or extensive recurrent infections. Treating diseases: fractures do not heal Indication Fractures do not heal, bone defects. Contraindications 1. The general situation of the wounded is not good, or the concomitant shock, must first rescue, until the shock is stable, the general situation can be improved before surgery. 2. If there is a life-threatening head, chest or abdominal cavity and other important organ damage, it must be treated first. The treatment of the fracture should be relegated to the secondary position. Temporary external fixation can be performed first, and the fracture should be treated after the condition is stable, or non-surgical treatment can be used. . 3. There are more than 8 to 12 hours of open wounds in the fracture. Preoperative preparation 1. Fracture non-healing: patients with bone defects, most of them stay in bed for a long time, repeated surgery, repeated infections, poor general condition, should be improved before surgery; and should be under the guidance of functional exercise to improve heart and lung function To enhance endurance to surgery; at the same time improve muscle strength, joint function and osteoporosis decalcification. 2. In the past, patients with a history of infection should be treated with antibiotics before surgery to prevent recurrence of infection. 3. Limbs that are shortened due to bone defects, especially the lower limbs, should be pulled for 1 to 2 weeks to restore the length of the limb. Surgical procedure 1. Position should be selected according to the location of the medical history and the location of the bone. 2. The incision and the fracture end are exposed in the lesion site, and the incision with sufficient exposure and small lesion is selected, and the length should be determined according to the length of the graft bone. The exposure of the fracture end should be carried out from the muscle space as much as possible to reduce bleeding; and pay attention to protect the blood vessels and nerves around the incision, and be careful not to damage. The exposed end of the fracture can meet the placement of the hardened end and the placement and fixation of the graft plate, and try to retain the adhesion of the surrounding muscles and bones. The exfoliation of the periosteum should be minimized so that the exposed bone surface is similar to the area of the graft plate. The periosteum and the soft tissue and the recipient bone are preserved as much as possible to preserve good blood supply and osteogenesis. 3. The main purpose of soft tissue and fracture end treatment is to create a blood-rich environment. Soft tissue scars should be removed completely until normal tissue. The hardened bone at the fracture end is removed with a wire saw or a bone knife until most of the section is a normal blood-rich cortical bone (generally hardened cortical bone is hard, ivory, thickened, and without blood). Then, the closed marrow cavity is manually drilled or drilled by a small circular chisel. 4. Repositioning and bone transplantation If the bone graft is planned for internal fixation, the cortical bone that is in contact with the graft bone at both ends of the fracture should be leveled so that the graft bone and the receiving bone are tightly joined. At this point, the surgical procedure before the bone graft has been completed, and it is feasible to reset and bone graft. In order to promote the osteogenesis of the endosteum, a small piece of cancellous bone can be inserted into the medullary cavity. Then, the ends of the fracture were clamped by a rongeur, and the assistant was pulled down to perform the reduction, and the other end of the medullary bone was inserted into the contralateral medullary cavity. In addition to attention to the alignment of the fracture surface during the reduction, special attention should be paid to the alignment of the axis to avoid the formation of rotational deformities. After the reduction, there should be a person to maintain the position of the limb, so as to avoid the displacement of the fracture end and break the bone graft in the medullary cavity. The cortical bone plate waiting to be transplanted is placed on the bone surface that has been flattened to receive the bone (the length of the bone plate should generally be 5 times the diameter of the receiving bone, and the contact between the two ends and the bone receiving surface is ensured to be more than 3 cm). In the upper limbs, the fracture surface should be aligned as much as possible. After the bone defect is eliminated, the length of the limb should be restored in the lower limbs. The bone and the cortical bone plate of the transplanted bone are fixed together with a fracture fixator and fixed with 4 to 6 screws. Finally, a large number of small pieces and small strips of cancellous bone are filled around the bone defect gap and the bone graft to eliminate all voids. For bone defects less than 6cm, osteoporosis at the fracture end, and fractures close to the joint do not heal. After resection of the hardened bone end, when the fracture end is too short, double bone graft should be performed for internal fixation. After the fracture end is finished, a helper bone plate is placed on the side of the receiving bone and temporarily fixed with a short screw to maintain the alignment. The other graft plate was placed on the opposite side, and the two sides of the graft plate and the receiving bone were fixed together with long screws. Then, unscrew the short screws and replace them with long screws. In this way, the receiving bone can be firmly clamped by the bone graft plates on both sides and firmly fixed. Finally, a large amount of cancellous bone is used to fill the bone defect area. For bone defects over 6 cm, it is best to use a vascular graft with a blood vessel. Because the shape of the upper end of the humerus is similar to that of the lower end of the humerus and the lower end of the humerus, if there is a defect of the lower end of the humerus or a defect of the lower end of the humerus, the upper end of the humerus can be used for the whole bone and half joint transplantation, which not only repairs the bone defect but also restores the joint function. There are few soft tissues around the lower end of the humerus, and the blood supply is poor. When the bone is transplanted due to non-union and bone defect, it is easy to fail. Repeated bone graft failure can lead to increased bone defects and autologous bone supply depletion. At this time, the ipsilateral iliac bone island graft with blood vessels can be used. The method is the same as that of vascularized iliac bone graft, except that only one end of the iliac and vein is cut off. The appropriate length of the tibia is transplanted into the humeral defect area and the procedure can be completed in one operation. If the ipsilateral humeral shift is used, the operation must be completed twice. After the first operation, the proximal end of the humerus was sawn and the upper end of the humerus and the humerus were cut into a plane, and the distal end of the limb was moved inward to make the ankle and ankle fit closely. The screws are fixed and the gap in the upper part of the tibia is filled with a large amount of cancellous bone. After the bone graft is healed, the second operation is performed. The distal side of the humerus was exposed. After the distal radius of the humerus was treated, the length of the iliac bone graft was predetermined (about the length of the tibia defect plus the length of the tibia overlap). The distal end of the humerus was sawn and the distal part of the limb was moved outward. The end is embedded in the medullary cavity, and the tibia is filled with a large amount of cancellous bone. In this way, after the bone graft is healed, the tendon and the tibia are integrated, which increases the strength. 5. Suture and loosen the tourniquet to completely stop bleeding. Loosen the fracture fixator while the person is holding the limb position, and then suture it layer by layer.