Treatment of chronic nonunion of a sternal fracture with bone morphogenetic protein

Chronic nonunion of sternal fractures, up until now, has been treated by osteosynthetic plating with or without autologous bone grafting. A new technique is described involving the use of bone morphogenic protein to stimulate bone growth at the fracture site, thereby eliminating the need for bone grafting.     

Vascularized bone graft for scaphoid nonunion

The management of recalcitrant nonunion of the scaphoid can be frustrating. Recent understanding of the vascular anatomy of the distal radius has helped in the management of these problems. Vascularized bone grafting for scaphoid nonunion has improved the union rates. Consequently, familiarity with this procedure is an important tool for any surgeon who treats scaphoid nonunion. Although there are numerous publications discussing both the vascular anatomy of the distal radius and the scaphoid, little is written about the surgical technique. This study reviews the literature on scaphoid nonunion and outlines the authors' experience with this procedure.     

Human bone morphogenetic protein allografting for reconstruction of femoral nonunion

A composite inductive allograft consisting of an allogeneic, autolysed, antigen-free cortical bone carrier lyophilized with partially purified human bone morphogenetic protein was implanted in 30 consecutive femoral reconstructions that resulted from failure of fracture healing. There were 24 atrophic shortened femoral nonunions, four equal length femoral nonunions, and two femoral malunions. There were 10 men and 20 women with an average age of 47 years (range, 28-75 years). Allogeneic, autolysed antigen-free cortical bone was used as a structural alloimplant and as a delivery system for partially purified human bone morphogenetic protein. The composite implant of human bone morphogenetic protein/allogeneic, autolysed antigen-free cortical bone was used in conjunction with one-stage lengthening of the extremity, restoration of mechanical axis and rotational alignment. In 26 of 30 femurs, the human bone morphogenetic protein/allogeneic autolysed antigen-free cortical bone consisted of an allogeneic cortical bone implant incorporated into a one-stage lengthening of atrophic femoral nonunion. In four patients with equal length femoral nonunions, the human bone morphogenetic protein/allogeneic, autolysed antigen-free implant was placed as an medical femoral shaft onlay graft. Internal remodeling of the implant occurred within 8 to 12 weeks after implantation. Lengthening defects greater than 2 cm were supplemented with intercalary autogeneic bone graft. Twenty-four femurs healed at an average of 6 months at an average followup of 55 months. Four of six plate fatigue failures were salvaged with repeat plating. Two patients were lost to followup. The human bone morphogenetic protein/allogeneic, autolysed antigen-free bone allograft is an excellent structural and delivery system that induces host bone formation and implant remodeling allowing salvage of difficult femoral nonunions.     

Treatment of scaphoid nonunion using volar biconcave cancellous bone grafting.

We report the results of 28 patients with scaphoid nonunion treated with curettage and biconcave cancellous bone grafting from the distal radius using a volar approach and pin fixation. This study consisted of 28 patients (24 males and 4 females). The mean age at surgery was 28 years. The mean interval from injury to surgery was 22 months. The mean follow-up period was 20 months. By Russe classification, there were 6 distal third nonunions, 19 middle third nonunions and 3 proximal third nonunions. We reviewed final function and radiographic appearance. Bony union was achieved in all cases. Pins were removed at a mean of 7 weeks after surgery. Post-activity pain resolved in all cases. Mean wrist extension was 79 degrees and mean flexion 77 degrees. Mean grip strength was 35.8 kgf. The mean postoperative radio-lunate angle was 4.9 degrees (-21-28.8) compared to -5.9 degrees (-37.5-17.5) preoperatively. No complications were encountered. Our procedure is straightforward and not technically demanding. An STT arthrotomy is not necessary and the technique allows for concurrent correction of carpal instability. Bony union was achieved in all cases with no complications.     

逆行筋膜蒂桡骨茎突骨瓣移植及BMP复合物植入治疗腕舟骨骨不连

目的 探讨治疗腕舟骨阵旧性骨折骨不连的手术方法。方法 对11例腕舟骨陈旧性骨折骨不连,采用筋膜蒂逆行桡骨突骨瓣移植及骨形态发生蛋白（bone morphogenetic protein,BMP)与纤维蛋白（fibrin sealant,FS)复合物植入的手术方法治疗。结果 术后随访4－24个月,腕部疼痛及无力症状均消失。11例在术后3－6个月内,X线片示骨折已全部骨性愈合。结论 带筋膜蒂的桡骨茎突骨瓣移植及BMP复合物植入法,治疗腕舟骨陈旧性骨折骨不连,操作简单,成骨作用强,并可促进骨折愈合。     

A new vascularized bone graft for scaphoid nonunion

Nonunion and avascular necrosis after scaphoid fractures continue to be problem sequelae because of unrecognized injuries, inadequate immobilization techniques, or insufficient treatment time. Screw fixation and inlay bone grafting techniques remain the options of choice, with successful union reported in approximately 90% of patients. However, prolonged immobilization with plaster up to 4 to 6 months is required with conventional techniques. With the use of standard latex injection techniques with vascular filling of vessels to less than 0.1 mm diameter in ten fresh cadaver dissections, we discovered a consistent vascularized bone graft source from the distal dorsoradial radius. We have used this vascularized bone graft source with good results in eleven patients with long-standing nonunion of the scaphoid. It is technically easy and seemingly offers the advantages of a decreased period of immobilization and a higher union rate.     

Free vascularized bone graft for nonunion of the scaphoid

We used a free vascularized small periosteal bone graft to treat scaphoid nonunion. The graft consisted of periosteum, full-thickness cortex, and the underlying cancellous bone and was harvested from the supracondylar region of the femur. The graft was nourished by the articular branch of the descending geniculate artery and vein. Unlike the currently used vascularized bone grafts, this graft can be easily harvested and shaped to accommodate the bone defect of the scaphoid without disturbing its vascularity and can then be transferred with microvascular anastomosis of the nutrient vessels to the radial artery and its venae commitantes. Ten patients with longstanding nonunion of the scaphoid secondary to avascular necrosis, confirmed by radiologic and intraoperative findings, were treated with this vascularized bone graft. Union was achieved in all 10 patients at an average of 12 weeks after surgery. The average follow-up period for all fractures was 3.5 years. The scores for overall outcome, according to the Mayo wrist scoring system, were excellent in 4 patients, good in 4, and fair in 2. Two unsatisfied patients had preoperative signs of early periscaphoid osteoarthrosis. This free vascularized small bone graft from the supracondylar region of the femur is an attractive alternative to the conventional vascularized bone grafting procedures.     

Screw fixation without bone grafting for scaphoid fracture nonunion

IntroductionWe previously reported the classification of the scaphoid fracture nonunions as linear, cystic, and sclerotic or displaced types based on radiographic findings. We have been treating the linear and cystic type fractures via screw fixation without bone grafting and the sclerotic or displaced type fractures via screw fixation with bone grafting. In this retrospective study, we report the treatment outcomes of the linear and cystic types of scaphoid fracture nonunions.MethodsNineteen patients with linear and cystic type scaphoid fracture nonunions were included. Two patients had linear type and 17 had cystic type fractures. All the patients were male, their mean age was 29.2 years. All patients were treated with screw fixation alone by a single surgeon.ResultsBone union was achieved in 17 cases. The mean time to bone union was 3.7 months. Bone union was not achieved in one case of linear type and one case of cystic type fracture. The former was thought to be due to misdiagnosis of displaced type as linear type fracture; however, no obvious reason could be found for the latter.DiscussionScrew fixation alone could help achieve bone union in linear type scaphoid fracture nonunions. However, if the type of the fracture is difficult to diagnose based on plain radiography, evaluation using computed tomography should be performed. The cystic type fractures may need to be subclassified according to the location or size of the cyst as well as the viability of the proximal bone fragment.     

自体骨移植与骨形成蛋白治疗成人长骨骨折不愈合的Meta分析

目的：系统评价自体骨移植与骨形成蛋白治疗成人长骨骨折不愈合相关指标,为成人长骨骨折不愈合治疗提供参考依据。方法：计算机检索PuMed、Embase、Cochrane图书馆、中国知网（CNKI）、万方数据期刊全文数据库及中国生物医学文献数据库（CBM）发表的对于自体骨移植与骨形成蛋白治疗成人长骨骨折不愈合的随机对照试验,检索时间从建库至2019年3月。由2名研究者按照纳入和排除标准独立进行筛选文献,提取资料,并采用Jadad评价量表对纳入的文献进行质量评价。采用RevMan 5.3统计学软件对两种方法的感染发生率、成功愈合率、二次手术率、住院时间及术中失血量进行Meta分析。结果：共纳入7个随机对照试验研究,共652例患者,自体骨移植组有410例,骨形成蛋白组有242例。Meta分析结果显示：自体骨移植组与骨形成蛋白组在感染发生率［RR=1.32,95%CI（0.90,1.93）,P=0.16］,成功愈合率［RR=0.95,95%CI（0.84,1.08）,P=0.43］,二次手术率［RR=1.16,95%CI（0.43,3.12）,P=0.76］及住院时间［MD=0.69,95%CI（-0.38,1.75）,P=0.21］方面比较差异无统计学意义。自体骨移植组术中失血量明显高于骨形成蛋白组［MD=223.00,95%CI（32.72,413.28）,P=0.02］。结论：对于成人长骨骨折不愈合的治疗,骨形成蛋白可以获得和自体骨移植一样的骨折愈合率,同时可以明显减少术中失血量。骨形成蛋白可能更适合成人长骨骨折不愈合的治疗。     

Prevention of atrophic nonunion development by recombinant human bone morphogenetic protein-7.

Severe periosteal and soft tissue disruption at the time of fracture may result in the formation of an atrophic nonunion. We have developed a reproducible atrophic nonunion in an animal model. The purpose of this study was to evaluate whether the immediate application of recombinant human BMP-7 to the fracture site could rescue the healing process in this nonunion model. A total of 56 three month old Fisher 344 rats were utilized. A 1.25 mm diameter K-wire was inserted into the femur in a retrograde fashion, and a mid-diaphyseal closed transverse fracture was created using a standard three point bending device. To create a nonunion, the fracture site was exposed and 2 mm of the periosteum was cauterized on each side of the fracture. The fracture site was immediately treated with either the application of rhBMP-7 50 microg in 25 microl of rat tail tendon collagen buffer (BMP-7 group), or with 25 microl of rat tail tendon collagen buffer only (Control group). Fracture healing was evaluated with serial radiographs every two weeks for an eight weeks period. Specimens at four and eight weeks were subjected to biomechanical and histological evaluation. None of the Control group healed throughout the eight weeks experimental duration. At four weeks 63% of the BMP-7 group had healed, and all had healed by six weeks. This investigation showed pronounced differences between the BMP-7 group and the Control group both histologically and biomechanically. In conclusion, we have demonstrated that the immediate application of BMP-7 may rescue the fracture healing process and prevent the development of nonunion following severe periosteal disruption.     

Trephine bone grafting technique for the treatment of scaphoid nonunion

A simple, minimally invasive trephine bone grafting technique for the treatment of scaphoid fracture nonunions is described. The method has a short surgical time, good results, and minimal donor site morbidity.     

Management of scaphoid nonunion

The primary risk factor for nonunion of the scaphoid is displacement/instability, but delayed or missed diagnosis, inadequate treatment, fracture location, and blood supply are also risk factors. Untreated nonunion leads to degenerative wrist arthritis-the so-called scaphoid nonunion advanced collapse wrist. However, the correlation of symptoms and disease is poor; the true "natural history" is debatable because we evaluate only symptomatic patients presenting for treatment. It is not clear that surgery can change the natural history, even if union is attained. The diagnosis of nonunion is made on radiographs, but computed tomography or magnetic resonance imaging scans can be useful to assess deformity and blood supply. Treatment options vary from percutaneous fixation to open reduction and internal fixation with vascularized or nonvascularized bone grafting to salvage procedures involving excision and/or arthrodesis of carpals.     

A vascularized bone graft for repair of scaphoid nonunion.

The majority of scaphoid fractures respond to casting, splinting, or open reduction and internal fixation. In patients who fail to heal a scaphoid fracture, several factors may contribute, including delay in treatment, fracture displacement, proximal third location, avascular necrosis, and associated carpal instability.     

Bicolumnar fusion for scaphoid nonunion advanced collapse without bone grafting

Scaphoid nonunion advanced collapse leading to wrist osteoarthritis is treated by 4-corner fusion, capitolunate arthrodesis, and 3-corner fusion with a variety of hardware and bone grafting techniques as reported in the literature. However, such procedures have been associated with complications such as nonunion, hardware failure, and deep infection. On the basis of the same concept of these intercarpal fusions with the aim to transmit the load of the wrist, we present bicolumnar fusion to fuse the capitolunate articulation and the triquetrohamate articulation and preserve the articulation between the 2 columns, maintaining much of the normal anatomy and physiology of the normal wrist. This technique has allowed the use of screws for compression of both articulations and achieve union without the use of bone grafting.     

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