Management of scaphoid nonunion with iliac crest bone graft and K-wire fixation

Purpose

Scaphoid nonunion can occur in both non-operative and operatively treated scaphoid fractures. Without treatment, this can lead to a predictable pattern of carpal collapse and degenerative arthritic change and patients can experience both pain and functional loss in the early and late phases of progression. An operative technique with a high success rate for union is important. This paper describes a technique for treatment of scaphoid nonunion with K-wire fixation and iliac crest cancellous bone graft.

Methods

A retrospective review from 1996 to 2010 was performed on a single senior surgeon’s private university-based practice. Patient demographic information and fracture characteristics were obtained to evaluate for influence on success and time to union.

Results

There were 32 patients identified for inclusion in this study. Union was achieved in 100% of the patients, including 44% that had proximal pole fractures. The median time from injury to surgery was 41.86 weeks. The median time from surgery to healing was 17.93 weeks. Time to union was not affected by patient age, fracture location, smoking, alcohol use, or time to treatment.

Conclusion

K-wire fixation and ICBG for treatment of scaphoid nonunion using our technique have equal or superior union rates compared to other techniques in the literature. This paper highlights the keys to success using this method.

Level of evidence

Therapeutic Level IV.

     

骨形态发生蛋白复合物联合自体骨髓移植治疗四肢长管状骨骨不连

目的:观察骨形态发生蛋白复合物联合自体红骨髓移植治疗四肢长管状骨骨不连的临床疗效.方法:自2004年1月至2010年12月,采用骨形态发生蛋白复合物联合自体红骨髓移植法治疗四肢长管状骨骨不连患者36例,男22例,女14例;年龄22～68岁,平均36.8岁.骨不连部位:肱骨6例,尺骨4例,桡骨3例,股骨10例,胫骨13例.伤后距治疗时间8～24个月,平均13.7个月.增生性骨不连22例,萎缩性骨不连14例 患者主要临床症状为骨折部位负重时疼痛,肢体肿胀X线片提示骨折线清晰伴骨缺损.术后通过观察手术切口愈合、植骨区及骨髓穿刺区反应、骨折愈合、邻近的关节功能恢复等情况评估手术疗效.结果:术后患者切口均甲级愈合,未发现过敏和免疫排斥反应.骨髓穿刺区无感染及血肿形成.36例患者均获随访,时间3～28个月,平均16.2个月.无骨髓穿刺区慢性疼痛、植骨区骨质感染、切口周围皮肤红肿或窦道形成.骨不连均获得骨性愈合,愈合时间3～12个月,平均6.2个月,无畸形愈合.骨不连愈合后骨折部位负重时疼痛消失、肢体肿胀消退.5例患者遗留邻近关节功能部分受限,其余患者均完全恢复.结论:骨形态发生蛋白复合物联合自体红骨髓移植在治疗四肢长管状骨骨不连中具有来源广泛、安全可靠、加速骨愈合等优点,是其理想的植骨材料之一.     

Treatment of scaphoid nonunion with combined vascularized distal radius graft and iliac crest bone graft

The optimal treatment of scaphoid nonunion is a controversial and challenging task in hand surgery. Although advances in internal fixation techniques have resulted in improved union rates, fractures with impaired vascularity have less than satisfactory results with conventional grafting techniques. We describe the technique of using a tricortical iliac crest graft and a vascularized distal radius graft in cases of nonunion with avascular necrosis. The principle of our technique is to improve union rates over previously described procedures by addressing the issues of stability using a tricortical graft with compression through internal fixation and by improving biology using a cancellous vascularized graft.     

滑槽植骨自体骨髓移植治疗下肢长管状骨骨不连

[目的]评价滑槽+自体红骨髓移植治疗下肢长管状骨骨不连的效果。[方法]2000年1月~2007年8月,采用滑槽植骨+自体红骨髓治疗下肢长管状骨骨不连32例,其中男19例,女13例;平均年龄36岁,骨折术后至此次手术时间最短8个月,最长48个月,平均18个月。术后摄X线片,观察骨折愈合情况。[结果]本组32例患者均获随访,随访时间18~37个月,平均22个月,32例患者全部愈合,愈合时间最短6个月,最长20个月,平均12个月。[结论]滑槽植骨+自体红骨髓移植治疗下肢长管状骨骨不连愈合率高、效果满意。     

Recombinant human bone morphogenetic protein-2 versus autogenous iliac crest bone graft for lumbar fusion: a meta-analysis of ten randomized controlled trials

Background

Recombinant human bone morphogenetic protein-2 (rhBMP-2) as a substitute for iliac crest bone graft (ICBG) has been increasingly widely used in lumbar fusion. It has been proven non-inferior in fusion success and clinical outcomes when compared with ICBG. However, increasingly, some potentially uncommon and serious complications associated with the use of rhBMP-2 have been of great concern to surgeons. The purpose of this study was to determine whether rhBMP-2 could be considered an effective and, more importantly, a relatively safe substitute for ICBG in lumbar fusion.

Methods

Randomized controlled trials that compared rhBMP-2 with ICBG for lumbar fusion were identified by computer and manual searching. The risk of bias and clinical relevance of the included studies were assessed. Publication bias was explored using funnel plot and statistical tests (Egger??s test and Begg??s test). Meta-analyses were performed using the Cochrane systematic review methods.

Results

Ten randomized controlled trials (1,342 patients) met the inclusion criteria. Compared with ICBG, the use of rhBMP-2 significantly decreased the risk of fusion failure at all time intervals (6?months: p?<?0.0001, RR?=?0.55, 95?% CI?=?0.42?C0.72; 12?months: p?=?0.0003, RR?=?0.53, 95?% CI?=?0.37?C0.75; 24?months: p?<?0.00001, RR?=?0.31, 95?% CI?=?0.21?C0.46) and the rate of reoperation (p?=?0.0001, RR?=?0.52, 95?% CI?=?0.37?C0.72). There was no statistical difference in clinical improvement on the Oswestry Disability Index, although a favorable trend in the rhBMP-2 group was found (p?=?0.12, RR?=?0.73, 95?% CI?=?0.49?C1.08). Subgroup analyses stratified by the type of surgical procedure yielded similar results. Owing to the different data formats, meta-analysis on adverse events was not performed.

Conclusion

RhBMP-2 was superior to the ICBG for achieving fusion success and avoiding reoperation. However, evidence from the Food and Drug Administration document and subsequent independent studies has demonstrated that original, industry-sponsored trials underestimated rhBMP-2-related adverse events. There are still security risks in the use of rhBMP-2.     

Randomized clinical trial: expanded autologous bone marrow mesenchymal cells combined with allogeneic bone tissue,compared with autologous iliac crest graft in lumbar fusion surgery

BACKGROUND CONTEXTAlthough autogenous iliac crest bone graft (AICBG) is considered the gold-standard graft material for spinal fusion, new bone substitutes are being developed to avoid associated complications and disadvantages. By combining autologous bone marrow mesenchymal stromal cells (MSCs) expanded ex vivo and allogenic cancellous bone graft, we obtain a tissue-engineered product that is osteoconductive and potentially more osteogenic and osteoinductive than AICBG, owing to the higher concentration of MSCs.PURPOSEThis study aimed to evaluate the feasibility and safety of implanting a tissue-engineered product consisting of expanded bone marrow MSCs loaded onto allograft bone (MSC+allograft) for spinal fusion in degenerative spine disease, as well as to assess its clinical and radiological efficacy.STUDY DESIGN/SETTINGA prospective, multicenter, open-label, blinded-reader, randomized, parallel, single-dose phase I-II clinical trial.PATIENT SAMPLEA total of 73 adult patients from 5 hospitals, with Meyerding grade I-II L4–L5 degenerative spondylolisthesis and/or with L4–L5 degenerative disc disease who underwent spinal fusion through transforaminal lumbar interbody fusion (TLIF).OUTCOME MEASURESSpinal fusion was assessed by plain X-ray at 3, 6, and 12 months and by computed tomography (CT) at 6 and 12 months post-treatment. An independent radiologist performed blinded assessments of all images. Clinical outcomes were measured as change from baseline value: visual analog scale for lumbar and sciatic pain at 12 days, 3, 6, and 12 months posttreatment, and Oswestry Disability Index and Short Form-36 at 3, 6, and 12 months posttreatment.METHODSPatients who underwent L4–L5 TLIF were randomized for posterior graft type only, and received either MSC+allograft (the tissue-engineered product, group A) or AICBG (standard graft material, group B). Standard graft material was used for anterior fusion in all patients. Feasibility was measured primarily as the percentage of randomized patients who underwent surgery in each treatment group. Safety was assessed by analyzing treatment-emergent adverse events (AEs) for the full experimental phase and appraising their relationship to the experimental treatment. Outcome measures, both radiological and clinical, were compared between the groups.RESULTSSeventy-three patients were randomized in this study, 36 from the MSC+allograft group and 37 from the AICBG group, and 65 were surgically treated (31 group A, 34 group B). Demographic and comorbidity data showed no difference between groups. Most patients were diagnosed with grade I or II degenerative spondylolisthesis. MSC+allograft was successfully implanted in 86.1% of randomized group A patients. Most patients suffered treatment-emergent AEs during the study (88.2% in group A and 97.1% in group B), none related to the experimental treatment. X-ray-based rates of posterior spinal fusion were significantly higher for the experimental group at 6 months (p=.012) and 12 months (p=.0003). CT-based posterior fusion rates were significantly higher for MSC+allograft at 6 months (92.3% vs 45.7%; p=.0001) and higher, but not significantly, at 12 months (76.5% vs 65.7%; p=.073). CT-based complete response (defined as the presence of both posterior intertransverse fusion and anterior interbody fusion) was significantly higher at 6 months for MSC+allograft than for AICBG (70.6% vs 40%; p=.0038), and remained so at 12 months (70.6% vs 51.4%; p=.023). Clinical results including patient-reported outcomes improved postsurgery, although there were no differences between groups.CONCLUSIONSCompared with the current gold standard, our experimental treatment achieved a higher rate of posterior spinal fusion and radiographic complete response to treatment at 6 and 12 months after surgery. The treatment clearly improved patient quality of life and decreased pain and disability at rates similar to those for the control arm. The safety profile of the tissue-engineered product was also similar to that for the standard material, and no AEs were linked to the product. Procedural AEs did not increase as a result of BM aspiration. The use of expanded bone marrow MSCs combined with cancellous allograft is a feasible and effective technique for spinal fusion, with no product-related AEs found in our study.     

A cost analysis of bone morphogenetic protein versus autogenous iliac crest bone graft in single-level anterior lumbar fusion

An economic model was developed to compare costs of stand-alone anterior lumbar interbody fusion with recombinant human bone morphogenetic protein 2 on an absorbable collagen sponge versus autogenous iliac crest bone graft in a tapered cylindrical cage or a threaded cortical bone dowel. The economic model was developed from clinical trial data, peer-reviewed literature, and clinical expert opinion. The upfront price of bone morphogenetic protein (3380 dollars) is likely to be offset to a significant extent by reductions in the use of other medical resources, particularly if costs incurred during the 2 year period following the index hospitalization are taken into account.     

Donor site morbidity in the iliac crest bone graft.

BACKGROUND: Open iliac crest bone grafting is a common surgical procedure with recognized short-term complications. The present paper documents the medium- to long-term complications and level of patient satisfaction following the procedure. METHODS: Seventy-three patients undergoing an open iliac crest bone graft over the past 6 years at Wellington Hospital were retrospectively reviewed. All patients completed a postal questionnaire which assessed their current pain, sensory changes in and below the scar, scar appearance and overall appearance with the bone graft donor site. RESULTS: Sixteen patients (21.9%) reported pain, 11 patients (15%) stated that their scar was sensitive to touch and 19 patients (22%) reported a degree of sensory change below the scar. Six patients (8.2%) felt that the scar appearance was totally unacceptable. Overall satisfaction, however, was high with 70 patients (95.8%) 'fairly satisfied' or 'totally satisfied' with their iliac crest donor site. CONCLUSIONS: Bone grafting from the iliac crest is a relatively benign procedure in terms of patient satisfaction, and the most significant morbidity is pain.     

髂骨移植并发症的相关研究

[目的]探讨髂骨移植的并发症的原因及预防措施.[方法]回顾研究1990年～2005年10月828例髂骨移植患者,对出现的并发症进行统计分析.[结果]浅感染45例;深部感染10例;局部血肿60例;深部血肿4例;神经损伤30例;血管损伤3例,均发生在髂骨后部取骨时,为臀上动脉断裂;髂骨骨折2例,腹壁疝1例.[结论]取骨位置及操作不当是引起并发症的主要原因,了解髂骨解剖特点,正确选择取骨位置、微创操作是预防并发症的主要措施.     

Vascularized bone graft from the iliac crest for the treatment of nonunion of the proximal part of the scaphoid with an avascular fragment.

BACKGROUND: It was hypothesized that nonunion of the proximal third of the scaphoid associated with avascular necrosis could be treated successfully with a free vascularized bone graft obtained from the iliac crest. METHODS: Fifteen patients who had a nonunion of the proximal part of the scaphoid that had been present for an average of two years and three months (range, nine months to seven years) were managed with use of a free vascularized bone graft obtained from the iliac crest. Avascularity of the scaphoid, as assessed on preoperative radiographs, was characterized by loss of trabecular structure, collapse of subchondral bone, and formation of bone cysts. The results of the procedure were assessed in terms of osseous union, pain, active motion of the wrist, and osteoarthritis. Postoperatively, vascularity of the scaphoid was evaluated with use of magnetic resonance imaging and color Doppler ultrasonography. The average duration of follow-up was six years and one month (range, two years and one month to eight years and one month). RESULTS: Preoperatively, one patient had had pain with any movement of the wrist and fourteen had had pain after strenuous manual labor or sports activity. The average pain score, derived with use of a 10-point visual analog scale, was 2.4 points (range, 1.0 to 6.7 points). Postoperatively, union was achieved in twelve patients; six were pain-free, and six had occasional pain during strenuous manual labor or sports activity, or both. The average pain score for these twelve patients was 1.1 points (range, 0.0 to 4.2 points) on the visual analog scale. Preoperatively, osteoarthritis was limited to the region between the radial styloid process and the distal part of the scaphoid in fourteen patients and to the radioscaphoid region in one patient. Postoperatively, the degree of osteoarthritis remained unchanged in seven of the twelve patients who had union and progressed to the radioscaphoid region in five. Vascularity, as seen on the imaging studies, was restored in all twelve patients who had union. The nonunion persisted in three patients, all of whom had progressive osteoarthritis leading to carpal collapse. CONCLUSIONS: The index procedure was successful in twelve of the fifteen patients who had a symptomatic nonunion of the proximal part of the scaphoid associated with avascular necrosis and osteoarthritis that was limited to the radioscaphoid joint.     

A cost analysis of treatment of tibial fracture nonunion by bone grafting or bone morphogenetic protein-7

The parameter of health economics in the use of any contemporary medical module plays a dominant role in decision making. A prospective nonrandomised comparative study of the direct medical costs on the first attempt of treating aseptic nonunions of tibial fractures, with either autologous-iliac-crest-bone-graft (ICBG) or bone morphogenetic protein-7 (BMP-7), is presented. Twenty-seven consecutive patients, who were successfully treated for fracture nonunions, were divided into two groups. Group 1 (n = 12) received ICBG and group 2 (n = 15) received BMP-7. All patients healed their nonunions, and the financial analysis presented represents a best-case scenario. Three out of 12 of the ICBG group required revision surgery while just one out of 15 required it in the BMP-7 group. Average hospital stay was 10.66 vs. 8.66 days, time-to-union 6.9 vs. 5.5 months, hospitals costs £2,133.6 vs. £1,733.33, and theatre costs were £2,413.3 vs. £906.67 for the ICBG and BMP-7 groups, respectively. The BMP-7 cost was £3002.2. Fixation-implant was £696.4 vs. £592.3, radiology £570 vs. £270, outpatient £495.8 vs. £223.33, and other costs were £451.6 vs. £566.27 for the ICBG and BMP-7 groups, respectively. The average cost of treatment with BMP-7 was 6.78% higher (P = 0.1) than with ICBG, and most of this (41.1%) was related to the actual price of the BMP-7. In addition to the satisfactory efficacy and safety of BMP-7 in comparison to the gold standard of ICBG, as documented in multiple studies, its cost effectiveness is advocated favourably in this analysis.     

Complications following autologous bone graft harvesting from the iliac crest and using the RIA: a systematic review

Bone grafting is a commonly performed surgical procedure to augment bone regeneration in a variety of cases in orthopaedic and maxillofacial surgery. Autologous bone graft remains to be the 'gold standard' and the iliac crest to be the most common harvesting site. The intramedullary canal of long bones represents another potential site for large volume of autologous bone graft harvesting and is recently being used as an alternative donor site. However, harvesting of autologous bone graft is associated with morbidity and a number of complications. The aim of this systematic review was to collect and summarise the existing data on reported complications after harvesting autologous bone from the iliac crest (anterior and posterior) and the long bone intramedullary canal using the RIA device. We searched the PubMed Medline and Ovid Medline databases, from January 1990 to October 2010, to retrieve all relevant articles. A total of 92 articles (6682 patients) were included in the analysis. Overall, the complication rate following RIA was 6% (14 complications in 233 patients) and 19.37% after iliac crest bone graft harvesting (1249 complications in 6449 patients). The rate of each of the reported complications was assessed and, when the donor site was properly documented, comparison within the anterior and posterior iliac crest donor sites was performed. Although the difference of the overall morbidity rates between the two harvesting sites was not statistically significant (p=0.71); the rates of certain complications were found to significantly differ when anterior or posterior iliac crest was used. The rates of infection (p=0.016), haematoma formation (p=0.002), fracture (p=0.017), and hyperthrophic scar (p=0.017) were significantly higher when the donor site was the anterior iliac crest compared to the posterior iliac crest; whereas the rates of chronic donor site pain (p=0.004) and sensory disturbances (p=0.003) were significantly lower. The incidence of bone graft harvesting related complications can be reduced further if certain principles are followed depending on the performed harvesting methods; but overall the use of RIA device as harvesting method seems a promising alternative with a low complication rate.