Percutaneous autologous bone marrow transplantation for nonunion of the femur.

Percutaneous bone marrow injections were performed on 7 nonunions of the femur. There were 6 hypervascular nonunions and one avascular nonunion. Two nonunions presented with active infections. One other patient had a history of infection which had subsided. One nonunion received the injection twice. After the site of nonunion was curetted and the bone surface was scored, 150 ml of bone marrow aspirated from the iliac bone was injected. Complete union occurred in 4 patients within 9 months; all of them were uninfected hypervascular nonunions following intramedullary nail fixation. One nonunion with a bone defect united partially leaving a 1 x 1 cm defect. The two infected femoral nonunions failed to unite. The results show that percutaneous autologous bone marrow injection for femoral nonunions can be considered for uninfected hypervascular nonunions following intramedullary nail fixation. In these cases stimulation of healing processes of fracture leading to consolidation can be expected from bone marrow injection. However, femoral nonunion with an active infection and loss of fixation is considered to be a contraindication for this technique.     

Treatment of nonunions and osseous defects with bone graft and calcium sulfate

The treatment of long bone nonunions and fractures with osseous defects is challenging. The results of 26 patients with either a persistent long bone nonunion or an osseous defect after an open fracture were reviewed. Each patient was treated with debridement of devitalized tissue, open reduction and internal fixation, and bone grafting using a mixture of autogenous iliac crest bone graft and medical grade calcium sulfate. The current study evaluated the union rate and associated complications for treatment of these injuries using this protocol. Each nonunion was confirmed intraoperatively, and healing was determined clinically by the patients' return to full activities without pain and radiographically by the presence of bridging trabeculae. Complications included persistent nonunion (four patients), wound drainage (five patients), wound drainage and cellulitis (one patient) and cellulitis alone (one patient). Using this treatment protocol, 22 patients (85%) achieved healing after one surgery and an additional two patients (92%) achieved healing after a second surgery. Medical grade calcium sulfate increases the volume of graft material, facilitates bone formation, and is safe in the treatment of nonunions and fractures with osseous defects.     

Nonunion of the diaphysis of long bones

The treatment of diaphyseal nonunion of long bones is difficult and controversial. We retrospectively reviewed 113 patients with diaphyseal nonunion treated by various modalities, during 15 years at one institution. There were 36 cases of nonunion of the tibia, 23 nonunions of the femur, 21 nonunions of the humerus, 13 nonunions of the radius, 18 nonunions of the ulna and two nonunions of the clavicle. The minimum followup was 24 months (average, 40 months, range 2-15 years). The nonunions were classified as aseptic (84) and septic (29) and additionally classified as hypertrophic (61) and atrophic (52) in order to determine the treatment. The treatment was individualized based on the stability at the nonunion site, need for bone grafting, and control of infection. All fractures healed and every patient in the study regained functional use of the limb without pain or instability and functional range of movements that they had at the time of presentation with nonunion. Residual problems seen in some patients were joint stiffness, limb length discrepancy, and angular deformity. Twenty-six patients required repeat surgery using bone grafting because no satisfactory progress of fracture healing was seen in 4 months. Complications were related to the iliac crest donor site and persistent infection at the nonunion site.     

Open reduction and internal fixation of clavicular nonunions with allograft bone substitute

Background:

Biologic augmentation with allograft has shown equivalent healing rates to autograft in several nonunion models. No literature exists clearly demonstrating this in the clavicle. The purpose of this study was to evaluate the healing and complication rates of clavicle nonunions treated solely with open reduction and internal fixation (ORIF) and allograft.

Materials and Methods:

Nineteen clavicle nonunions treated with ORIF and allograft were evaluated retrospectively to assess healing rates and complications based on clinical symptoms and radiographic findings.

Results:

For the 19 patients included and treated with ORIF and allograft, clinical follow-up averaged 15 months. Seven patients were smokers. Although complete radiographic healing was achieved in only 68% of patients, clinical success occurred in 16 (84%) patients who demonstrated full range of motion and strength without pain. The three patients who did not demonstrate full radiographic healing were completely pain free. Five patients experienced complications (26%). Two underwent hardware removal due to persistent irritation after union. Three had a persistent painful nonunion. Each of these three patients was a smoker (P=0.08). Two proceeded to union after revision fixation. The other had hardware failure, which was removed, with a persistent nonunion and did not wish any further treatment.

Conclusion:

ORIF with allograft bone substitute is an acceptable treatment alternative to iliac crest bone graft for clavicle nonunions. However, we did not demonstrate equivalent healing rates to published results utilizing autograft. Smokers were identified to have a trend toward higher failure rates with ORIF augmented with allograft and therefore these patients may be better served by augmenting fixation with autograft.

Level of Evidence:

IV; retrospective comparative study.     

A capsular-based vascularized distal radius graft for proximal pole scaphoid pseudarthrosis

PURPOSE: To evaluate the clinical results of the application of a capsular-based dorsal distal radius vascularized bone graft in scaphoid proximal pole nonunions. METHODS: Thirteen patients with symptomatic nonunion at the proximal pole of the scaphoid (10 with avascular necrosis) were treated and reviewed retrospectively. The vascularized bone graft was harvested from the distal aspect of the dorsal radius and was attached to a wide distally based strip of the dorsal wrist capsule. It was inserted press-fit into a dorsal trough across the nonunion site after scaphoid fixation with a Herbert screw. RESULTS: After a mean follow-up period of 19 months 10 of the 13 nonunions (8 of the 10 with avascular necrosis) achieved solid bone union. No complications other than the 3 persistent nonunions occurred. CONCLUSIONS: Results of the use of a capsular-based vascularized bone graft from the distal radius for proximal pole scaphoid nonunions compare favorably with the results of pedicled or free vascularized grafts. It is a simple technique that eliminates the need for dissection of small-caliber pedicle or microsurgical anastomoses. No donor site morbidity was observed. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Compression screw fixation without bone grafting for scaphoid fibrous nonunion

Purpose

Bone graft is often recommended as an adjuvant for treatment of scaphoid nonunions. However, recent literature has suggested that fibrous nonunion may be suited to treatment with rigid fixation without bone grafting. This work reported on outcomes of compression screw fixation for established scaphoid fibrous nonunions without bone graft.

Methods

Fourteen patients underwent surgical compression screw fixation without bone grafting of scaphoid fibrous nonunion between January 1, 2000, and December 31, 2012, with minimum follow-up until the time of clinical and radiographic healing. Fibrous nonunion of the scaphoid was defined as a scaphoid fracture with all of the following features: (1) persistent tenderness, (2) incomplete trabecular bridging on three X-ray views, (3) injury that had occurred at a minimum of 6 months prior to surgery, and (4) identification of fibrous union at the time of surgery. Outcomes were assessed with range of motion assessment, Disability of the Arm, Shoulder and Hand (DASH) scores, and plain radiographs.

Results

Twelve of the 14 patients healed successfully, while two patients required secondary vascularized bone grafting. Both unhealed patients sustained proximal pole fractures and had a duration of ≥1 year from injury to surgery. Average time to healing was 4.4 ± 2.0 months. Average flexion was 73 ± 22° and average extension was 66 ± 22° postoperatively. Average grip strength was 90 ± 25 lbs on the operative side. Mean postoperative pain score was 1.4 (range, 0 to 7). Mean postoperative DASH score was 10.2 (range, 0 to 52). Increasing age and an interval from injury to surgery of >1 year correlated with worse DASH and pain scores.

Conclusions

Patients with fibrous scaphoid nonunion demonstrated good results with rigid fixation without bone grafting. Increasing age and >1-year interval between injury and surgery resulted in lower self-assessed outcomes.

Level of Evidence

Therapeutic Level IV, retrospective case series     

“Revision of subtrochanteric femoral nonunions after intramedullary nailing with dynamic condylar screw”

Background

Nonunions of the subtrochanteric region of the femur after previous intramedullary nailing can be difficult to address. Implant failure and bone defects around the implant significantly complicate the therapy, and complex surgical procedures with implant removal, extensive debridement of the nonunion site, bone grafting and reosteosynthesis usually become necessary. The purpose of this study was to evaluate the records of a series of patients with subtrochanteric femoral nonunions who were treated with dynamic condylar screws (DCS) regarding their healing rate, subsequent revision surgeries and implant-related complications.

Methods

We conducted a retrospective chart review of patients with aseptic femoral subtrochanteric nonunions after failed intramedullary nailing. Nonunion treatment consisted of nail removal, debridement of the nonunion, and restoration of the neck shaft angle (CCD), followed by DCS plating. Supplemental bone grafting was performed in all atrophic nonunions. All patients were followed for at least six months after DCS plating.

Results

Between 2002 and 2017, we identified 40 patients with a mean age of 65.4?years (range 34–91?years) who met the inclusion criteria. At a mean follow-up period of 26.3?months (range 6–173), 37 of the 40 (92.5%) nonunions healed successfully (secondary procedures included). The mean healing time of the 37 patients was 11.63?months (± 12.4?months). A total of 13 of the 40 (32.5%) patients needed a secondary revision surgery; one patient had a persistent nonunion, nine patients had persistent nonunions leading to hardware failure, two patients had deep infections requiring revision surgery, and one patient had a peri-implant fracture due to low-energy trauma four days after the index surgery.

Conclusions

The results indicate that revision surgery of subtrochanteric femoral nonunions after intramedullary nailing with dynamic condylar screws is a reliable treatment option overall. However, secondary revision surgery may be indicated before final healing of the nonunion.

     

Bone morphogenetic protein-2 compared to autologous iliac crest bone graft in the treatment of long bone nonunion

This retrospective study investigated the effect of recombinant human bone morphogenetic protein-2 (rhBMP-2) mixed with cancellous allograft on fracture healing compared to iliac crest autograft in the treatment of long bone nonunion. Eighty-nine patients with 93 established long bone nonunions treated between January 2002 and June 2004 at a single academic Level I trauma center were evaluated. Patients with clinical and radiographic evidence of failed fracture union underwent nonunion debridement, revision of fixation, and implantation at the nonunion site of either rhBMP-2 or the standard treatment autologous iliac crest bone graft. Union rate, operative time, estimated intraoperative blood loss, hospital length of stay, and postoperative infections were recorded. Nineteen nonunions received rhBMP-2 on a specialized carrier matrix (an absorbable collagen sponge) mixed with cancellous allograft, and 74 nonunions were treated with autologous iliac crest bone graft. There was no statistical difference in the rate of healing between treatment groups (68.4% vs 85.1%, respectively; P=.09). Incidence of postoperative infection was 16.2% after autologous iliac crest bone graft and 5.3% after rhBMP-2/absorbable collagen sponge (P=.22). Iliac crest autograft was associated with longer operative procedures (257.9±93.0 vs 168.9±86.5 minutes; P=.0007) and greater intraoperative blood loss (554.6±447.8 vs 331.6±357.2 mL; P=.01). These outcomes suggest that rhBMP-2 may provide a suitable alternative to autologous iliac bone graft, with the possible advantages of shorter operative time and reduced intraoperative blood loss, and may be considered as part of the orthopedic surgeon's treatment options.     

Healing of fracture nonunions treated with low-intensity pulsed ultrasound (LIPUS): A systematic review and meta-analysis

IntroductionBone fractures fail to heal and form nonunions in roughly 5% of cases, with little expectation of spontaneous healing thereafter. We present a systematic review and meta-analysis of published papers that describe nonunions treated with low-intensity pulsed ultrasound (LIPUS).MethodsArticles in PubMed, Ovid MEDLINE, CINAHL, AMED, EMBASE, Cochrane Library, and Scopus databases were searched, using an approach recommended by the Methodological Index for Non-Randomized Studies (MINORS), with a Level of Evidence rating by two reviewers independently. Studies are included here if they reported fractures older than 3 months, presented new data with a sample N ≥ 12, and reported fracture outcome (Heal/Fail).ResultsThirteen eligible papers reporting LIPUS treatment of 1441 nonunions were evaluated. The pooled estimate of effect size for heal rate was 82% (95% CI: 77–87%), for any anatomical site and fracture age of at least 3 months, with statistical heterogeneity detected across all primary studies (Q = 41.2 (df = 12), p < 0.001, Tau² = 0.006, I² = 71). With a stricter definition of nonunion as fracture age of at least 8 months duration, the pooled estimate of effect size was 84% (95% CI: 77%–91.6%; heterogeneity present: Q = 21 (df = 8), p < 0.001, Tau² = 0.007, I² = 62). Hypertrophic nonunions benefitted more than biologically inactive atrophic nonunions. An interval without surgery of <6 months prior to LIPUS was associated with a more favorable result. Stratification of nonunions by anatomical site revealed no statistically significant differences between upper and lower extremity long bone nonunions.ConclusionsLIPUS treatment can be an alternative to surgery for established nonunions. Given that no spontaneous healing of established nonunions is expected, and that it is challenging to test the efficacy of LIPUS for nonunion by randomized clinical trial, findings are compelling. LIPUS may be most useful in patients for whom surgery is high risk, including elderly patients at risk of delirium, or patients with dementia, extreme hypertension, extensive soft-tissue trauma, mechanical ventilation, metabolic acidosis, multiple organ failure, or coma. With an overall average success rate for LIPUS >80% this is comparable to the success of surgical treatment of non-infected nonunions.     

Butterfly fragments in diaphyseal tibial fractures heal unpredictably: Should we be adopting other strategies for these high risk fractures?

IntroductionThe natural history of diaphyseal tibial butterfly fragments is poorly documented. Numerous studies have analyzed risk factors for nonunions in the tibial shaft with known factors including Gustilo classification, ASA class, and cortical contact. However, the healing potential and ideal management of nonsegmental butterfly fragments in this setting remains unknown. The aim of this study was to determine the nonunion rate of diaphyseal tibial fractures with a butterfly fragment.MethodsA performed a retrospective review of patients at a single academic Level 1 Trauma Center from 2000-2020 who underwent intramedullary nailing of tibial shaft fractures. Those with non-segmental butterfly fragments (OTA/AO: 42-B) and minimum 12 month follow up were included. Morphologic measurements of butterfly fragments were performed to measure location, size, and displacement, and mRust scores at final follow up were calculated. Outcome measures were surgery to promote union, and mRust scores.ResultsA total of 99 patients were included with 21 patients requiring revision surgery to promote union. Thirty six patients had open fractures and 77% of patients were male with a mean age of 34 (range: 12-80). Average follow up was 19 months (3 months – 12 years). The most common location of the butterfly fragment was the anterior cortex (42%), with a mean length of 7.8cm (SD: 3.3) and width of 1.8cm (SD: 0.5cm). At final follow-up 37% of fractures had persistent lucency without callus at the site of the butterfly while only 31% of fractures had remodeled cortex. Average time to complete healing was 13.3 months. Open fractures with butterfly fragments were more likely to go on to nonunion than closed (44% vs 9.2%, p=<0.001). The length of the butterfly fragment was not different between the union and nonunion groups (7.7 vs 7.5, P=0.42).ConclusionsOpen tibial shaft fractures with a butterfly fragment have a high risk of nonunion. Further research may seek to determine if adjunct treatment of butterfly fragments (ie inter-fragmentary compression) in the acute setting could improve healing rates.     

Anterior-inferior plate fixation of middle-third fractures and nonunions of the clavicle

OBJECTIVE: Results of surgical treatment for clavicle injuries using standard approaches have shown relatively high complication rates including loss of fixation, persistent nonunion, implant related problems, and the need for subsequent surgeries are common. The purpose of this study is to evaluate the clinical results of patients treated for clavicle fractures and painful clavicular nonunions with anterior-inferior plating using a 3.5 mm plate. DESIGN: Consecutive clinical series. SETTING: 3 tertiary care academic trauma centers (Level 1 and 2). PATIENTS: Eighty consecutive patients with a middle-third fracture or painful nonunion of the clavicle. INTERVENTION: Open reduction and internal fixation using an anterior-inferior plating technique with a precontoured 3.5 mm plate and lag screw(s). Nonunions received autologous bone grafts. MAIN OUTCOME MEASUREMENTS: Patients were evaluated using physical and radiographic examination, the American Shoulder and Elbow Surgeons Shoulder Assessment (ASES), and the Short Form-36 (SF-36) outcomes questionnaire. RESULTS: Fifty-eight patients had sufficient records and follow-up of at least 24 months (mean 49 months). Clinical and radiographic union was present at a mean of 9.5 weeks for patients treated for acute fracture and 10.5 weeks those treated for nonunion. Complications included 1 failure of fixation, 1 nonunion, and 3 infections. Two patients underwent implant removal for bothersome hardware. Shoulder motion was good or excellent in all patients except those with neurologic injury. Functional results (ASES and SF-36) were good or excellent for the vast majority of patients, except those with neurologic injury. CONCLUSIONS: Anterior-inferior plating of acute middle-third fractures of the clavicle and clavicular nonunions using a plate and lag screws typically results in early healing, few complications and an excellent return of function. Advantages of this technique include stable bony fixation with instrumentation directed away from potentially dangerous infraclavicular structures and a minimal incidence of implant prominence problems.     

Treatment of allograft nonunions with recombinant human bone morphogenetic proteins (rhBMP)

Fractures and nonunions are the main complications associated with bone allografts. Although the osteogenic role of recombinant human bone morphogenetic proteins (rhBMPs) has been demonstrated in experimental models and human tibial nonunions, the results are unknown for allograft nonunions. In this study, the efficacy of rhBMPs was evaluated in nonunions of femoral allografts. The results of six allograft nonunions in five patients who underwent resection of malignant bone tumours and allograft bone transplantation were analysed one to five years following application of rhBMPs at the nonunion site. There were two osteoarticular allografts and three intercalary allografts. Of three intercalary allografts, one demonstrated nonunion at both ends. Four patients received adjuvant chemotherapy and three had additional radiation therapy. There were two allograft fracture nonunions and four nonunions at the allograft-host junction. Two allograft fracture nonunions and one nonunion at the allograft-host junction were treated with 12 mg of rhBMP-2. The remaining three nonunions were treated with 7 mg of rhBMP-7 (Osigraft). The outcome and radiological evidence of healing were evaluated at a minimal follow-up of twelve months. There was neither healing of allograft fractures nor union of allograft-host junction. There was elongation or enlargement of the callus from the host. One patient continued to develop resorption of the allograft, which led to allograft fracture. Two patients who were treated with rhBMP-7 and corticocancellous allografts developed sterile drainage. There was no tumour recurrence with the use of rhBMPs after a mean follow-up of 39+/-25 months. rhBMP's alone were not sufficient to achieve healing in allograft nonunions and fractures following wide resection including periosteum and soft tissues.     

Osteogenic protein-1 (bone morphogenic protein-7) combined with various adjuncts in the treatment of humeral diaphyseal nonunions

A prospective study was conducted to determine the efficacy of using recombinant BMP-7 (rhOP-1) as an adjuvant in the treatment of diaphyseal humeral nonunions. Twenty-three consecutive patients with atrophic humeral diaphyseal nonunions were treated at seven separate institutions. All nonunions were fixed with either a compression plate or an intramedullary nail in conjunction with various bone grafting techniques. Recombinant OP-1 was delivered to the fracture site in a Type I collagen carrier at the time of fixation. All fractures went on to eventual union. There were no serious complications and no adverse reactions to the rhOP-I implant. Our study suggests that rhOP-1 may be a safe and effective adjuvant for the treatment of humeral diaphyseal nonunions.     

Osteogenic Protein-1 Overcomes Inhibition of Fracture Healing in the Diabetic Rat: A Pilot Study

Type I diabetes mellitus inhibits fracture healing and leads to an increase in complications. As a pilot study, we used a closed fracture model in the diabetic rat to address the question of whether osteogenic protein-1 (OP-1) in a collagen carrier can overcome this inhibition by increasing the area of the newly mineralized callus and femoral torque to failure compared with diabetic animals with fractures treated without OP-1. Diabetes was created in 54 rats by injection of streptozotocin. After 2 weeks, a closed femur fracture was created using a drop-weight impaction device. Each fracture site was immediately opened and treated with or without 25 μg OP-1 in a collagen carrier. Animals were euthanized after 2 or 4 weeks. Fracture healing was assessed by callus area from high-resolution radiographs, callus strength from torsional failure testing, and undecalcified histologic analysis. The area of newly mineralized callus was greater in diabetic animals treated with 25 μg OP-1/carrier compared with diabetic animals with untreated fractures and with fractures treated with carrier alone. This increase in callus area did not translate into an equivalent increase in torque to failure. Osteogenic protein-1 showed some evidence of overcoming the inhibition of fracture healing in the diabetic rat.     

OP-1 Augments Glucocorticoid-inhibited Fracture Healing in a Rat Fracture Model

Glucocorticoids inhibit bone remodeling and fracture healing. We sought to determine whether osteogenic protein 1 (OP-1) can overcome this inhibition in a closed fracture model in the rat. Time-released prednisolone or placebo pellets were implanted subcutaneously; closed femoral fractures were created 2 weeks later in rats. Fractures received sham, OP-1 and collagen, or collagen-only implants. Femurs were harvested at 3, 10, 21, 28, and 42 days postfracture. Fractures were examined radiographically for amount of hard callus; mechanically for torque and stiffness (also expressed as a percentage of the contralateral intact femur); and histomorphometrically for amount of cartilaginous and noncartilaginous soft callus, hard callus, and total callus. Glucocorticoid administration inhibited fracture healing. The application of a devitalized Type I collagen matrix mitigated the inhibitory effects of prednisolone on fracture healing However, further increases in indices of fracture healing were observed when OP-1 was added to the collagen matrix compared with collagen alone. OP-1 and collagen was more effective than collagen alone.