Abstract
BackgroundNon-unions are severe complications in orthopaedic trauma care and occur in 10% of all fractures. The golden standard for the treatment of ununited fractures includes open reduction and internal fixation (ORIF) as well as augmentation with autologous-bone-grafting. However, there is morbidity associated with the bone-graft donor site and some patients offer limited quantity or quality of autologous-bone graft material. Since allogene bone-grafts are introduced on the market, this comparative study aims to evaluate healing characteristics of ununited bones treated with ORIF combined with either iliac-crest-autologous-bone-grafting (ICABG) or demineralized-bone-matrix (DBM).Methods and resultsFrom 2000 to 2006 out of sixty-two consecutive patients with non-unions presenting at our Level I Trauma Center, twenty patients had ununited diaphyseal fractures of long bones and were treated by ORIF combined either by ICABG- (n = 10) or DBM-augmentation (n = 10). At the time of index-operation, patients of the DBM-group had a higher level of comorbidity (ASA-value: p = 0.014). Mean duration of follow-up was 56.6 months (ICABG-group) and 41.2 months (DBM-group). All patients were clinically and radiographically assessed and adverse effects related to bone grafting were documented. The results showed that two non-unions augmented with ICABG failed osseous healing (20%) whereas all non-unions grafted by DBM showed successful consolidation during the first year after the index operation (p = 0.146). No early complications were documented in both groups but two patients of the ICABG-group suffered long-term problems at the donor site (20%) (p = 0.146). Pain intensity were comparable in both groups (p = 0.326). However, patients treated with DBM were more satisfied with the surgical procedure (p = 0.031).ConclusionWith the use of DBM, the costs for augmentation of the non-union-site are more expensive compared to ICABG (calculated difference: 160 €/case). Nevertheless, this study demonstrated that the application of DBM compared to ICABG led to an advanced outcome in the treatment of non-unions and simultaneously to a decreased quantity of adverse effects. Therefore we conclude that DBM should be offered as an alternative to ICABG, in particular to patients with elevated comorbidity and those with limited availability or reduced quality of autologous-bone graft material.
Highlights
The development of non-unions depends on several factors, such as energy-level of trauma, type of fracture, soft tissue involvement, type of applied treatment, and various endogenous factors [1,2,3]
No differences were documented between the autologous- and allograft-group concerning demographic data, BMI, smoking behaviour, location of non-union, prior instrumentation at non-union site, and mean time from ununited fracture to index-surgery
There was a lack of bone bridging in two patients treated by iliac crest autologous bone graft (ICABG) whereas all ununited fractures treated by DBM showed completed bone healing during the study period (p = 0.146)
Summary
The development of non-unions depends on several factors, such as energy-level of trauma, type of fracture, soft tissue involvement, type of applied treatment, and various endogenous factors [1,2,3]. First described an osteoinductive substance while preparing soluble extracts from demineralized bone [18] Since this pioneering work, a large body of data obtained by preclinical animal studies has supported the utility of demineralized bone matrix (DBM) in human clinical settings. There still is a lack of clinical studies: A recent MEDLINE search using the term "demineralized bone matrix" restricted to "clinical study" and "English language" demonstrated, that only four references were found that were dealing with DBM-treatment in cases of a non-union of long bones [5,19,20,21,22]. The golden standard for the treatment of ununited fractures includes open reduction and internal fixation (ORIF) as well as augmentation with autologous-bone-grafting. Since allogene bone-grafts are introduced on the market, this comparative study aims to evaluate healing characteristics of ununited bones treated with ORIF combined with either iliac-crest-autologous-bone-grafting (ICABG) or demineralized-bone-matrix (DBM)
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