Abstract
BackgroundNovel bone substitutes have challenged the notion of autologous bone grafting as the ‘gold standard’ for the surgical treatment of fracture nonunions. The present study was designed to test the hypothesis that autologous bone grafting is equivalent to other bone grafting modalities in the management of fracture nonunions of the long bones.MethodsA retrospective review of patients with fracture nonunions included in two prospective databases was performed at two US level 1 trauma centers from January 1, 1998 (center 1) or January 1, 2004 (center 2), respectively, until December 31, 2010 (n = 574). Of these, 182 patients required adjunctive bone grafting and were stratified into the following cohorts: autograft (n = 105), allograft (n = 38), allograft and autograft combined (n = 16), and recombinant human bone morphogenetic protein-2 (rhBMP-2) with or without adjunctive bone grafting (n = 23). The primary outcome parameter was time to union. Secondary outcome parameters consisted of complication rates and the rate of revision procedures and revision bone grafting.ResultsThe autograft cohort had a statistically significant shorter time to union (198 ± 172–225 days) compared to allograft (416 ± 290–543 days) and exhibited a trend towards earlier union when compared to allograft/autograft combined (389 ± 159–619 days) or rhBMP-2 (217 ± 158–277 days). Furthermore, the autograft cohort had the lowest rate of surgical revisions (17%) and revision bone grafting (9%), compared to allograft (47% and 32%), allograft/autograft combined (25% and 31%), or rhBMP-2 (27% and 17%). The overall new-onset postoperative infection rate was significantly lower in the autograft group (12.4%), compared to the allograft cohort (26.3%) (P < 0.05).ConclusionAutologous bone grafting appears to represent the bone grafting modality of choice with regard to safety and efficiency in the surgical management of long bone fracture nonunions.
Highlights
Fracture nonunions of long bones continue to represent a significant clinical challenge and socioeconomic burden, associated with high complication rates and the potential for poor long-term outcomes [1,2,3,4,5]
The introduction of new generation bone substitutes and recombinant molecules with osteoinductive properties has recently challenged the role of autologous bone grafting as the ‘gold standard’ for the surgical treatment of nonunions [10,11,12]
Patients in the autograft group had a significantly shorter average time to union (198 days, 95% confidence interval (95% CI) 172–225 days), when compared to the allograft group (416 days, 95% CI 290–543 days), while no statistically significant differences were found among the autograft group, the autograft/ allograft cohort (389 days, 95% CI 159–619 days), and the recombinant human bone morphogenetic protein-2 (rhBMP-2) cohort (217 days, 95% CI 158–277 days)
Summary
Fracture nonunions of long bones continue to represent a significant clinical challenge and socioeconomic burden, associated with high complication rates and the potential for poor long-term outcomes [1,2,3,4,5]. Autologous bone grafting has received a negative reputation in the past, mainly due to the high risk of postoperative complications related to the harvesting procedure [6]. The introduction of new generation bone substitutes and recombinant molecules with osteoinductive properties has recently challenged the role of autologous bone grafting as the ‘gold standard’ for the surgical treatment of nonunions [10,11,12]. In light of the immense market potential for bone graft substitutes and related products, estimated to be US$1 billion in the USA alone, the push for new ‘osteobiologicals’ may in large part be industry-driven, rather than based on objective patient safety and quality data [13,14,15]. Novel bone substitutes have challenged the notion of autologous bone grafting as the ‘gold standard’ for the surgical treatment of fracture nonunions. The present study was designed to test the hypothesis that autologous bone grafting is equivalent to other bone grafting modalities in the management of fracture nonunions of the long bones
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