Treatment Of Long Bone Nonunion Research Articles

Treatment of long bone non-unions with polytherapy: Indications and clinical results

The incidence of long bone non-unions has been estimated to range between 5 and 10%. Autologous bone graft usually harvested from the iliac crest continues to be the gold standard for biological enhancement of atrophic non-unions. However, its use has been hampered by minor and major donor site complications. Moreover despite possessing the properties of osteogenecity, osteoconductivity and some osteoinductivity the overall results of treatment have not been consistent with disappointing success rates at times. The concept of polytherapy for the treatment of non-unions, namely the simultaneous application of the three fundamental elements of the diamond concept, osteoprogenitor cells, growth factor and osteoconductive scaffold, appears to be an attractive alternative but more studies are desirable to validate this strategy.

Treatment of long-bone nonunions Does bone morphogenic protein help?

Summary Results from four randomized controlled trials （class of evidence （CoE 11） suggest that the addition of rhBMP to fixation in long-bone nonunion neither impeded nor facilitated fracture union compared with fixation plus other grafting material.

Treatment of long-bone nonunions

Results from four randomized controlled trials (class of evidence (CoE) II) suggest that the addition of rhBMP to fixation in long-bone nonunion neither impeded nor facilitated fracture union compared with fixation plus other grafting material.

Unicortical fixation with locking compression plate for treatment of long bone nonunion following intramedullary nailing

Objective To investigate the effects of locking compression plate(LCP)used in unicortical fixation for treating nonunion of long bone fracture following intramedullary nailing.Methods From July 2004 to March 2007, 8 cases of long bone nonunion after intramedullary nailing were treated with unicortical LCP fixation and iliac bone graft, without removal of intramedullary nails.The treatment lasted 12 to 28(mean, 19.8)months.Results All cases were followed up for 8 to 20(mean, 14)months.Bony callus appeared at the broken ends of fracture 6 months after the operation.Firm unions were obtained within 8 to 16(mean, 12.6)months, and no such complications as loosening of inserts were found.Conclusions LCP unicortical fixation and iliac bone graft can be applied for patients suffering from long bone nonunions after failed intramedullary nailing.The advanced locking design of the plate can allow the patients to achieve satisfactory healing when walking naturally. Key words: Femur; Tibia; Facture fixation,internal; Fracture,ununited

Electrical stimulation: Nonunions.

The current paper attempts to provide an overview on the currently available fundamental, preclinical, and clinical evidence on the biologic rationale and therapeutic efficacy of electrical stimulation devices applied in patients with long-bone nonunions. Electrical stimulation (ES) involves the generation of an electrical or electromagnetic current through the ununited fracture. Such currents, which are present in physiologically healing bone, provide stimuli that favor a healing response to bone cells. These stimuli include the enhancement of transmembrane and intracellular calcium-mediated signal transduction and an increased synthesis of paracrine and autocrine growth factors by osteoblasts. Favorable healing union rates, ranging from 43% to 90%, as found by several clinical case series, have prompted the orthopedic community to, at least partially, adopt ES for the treatment of long bone nonunions. Nonetheless, randomized controlled trials have not provided definitive evidence of ES causing nonunions to heal more often than sham devices. This impediment is probably formed by small sample sizes, lack of consistency regarding the definition of union and nonunion, and variability in ES current used.

Application of rhBMP-7 and platelet-rich plasma in the treatment of long bone non-unions: A prospective randomised clinical study on 120 patients

The purpose of this prospective randomised clinical study was to compare the efficacy of recombinant bone morphogenetic protein 7 (rhBMP-7) and platelet-rich plasma (PRP) as bone-stimulating agents in the treatment of persistent fracture non-unions. One hundred and twenty patients were randomised into two treatment groups (group rhBMP-7 vs. group PRP). Sixty patients with sixty fracture non-unions were assigned to each group (median age: 44 years, range 19-65, for the rhBMP-7 group and 41 years, range 21-62, for the PRP group, respectively). In the rhBMP-7 group, there were 15 tibial non-unions, 10 femoral, 15 humeral, 12 ulnar, and 8 radial non-unions. In the PRP group, there were 19 tibial non-unions, 8 femoral, 16 humeral, 8 ulnar, and 9 radial non-unions. The median number of operations performed prior to our intervention was 2 (range 1-5) and 2 (range 1-5) with autologous bone graft being used in 23 and 21 cases for the rhBMP-7 and PRP groups, respectively. Both clinical and radiological union occurred in 52 (86.7%) cases of the rhBMP-7 group compared to 41 (68.3%) cases of the PRP group, with a lower median clinical and radiographic healing time observed in the rhBMP-7 group (3.5 months vs. 4 months and 8 months vs. 9 months, respectively). This study supports the view that in the treatment of persistent long bone non-unions, the application of rhBMP-7 as a bone-stimulating agent is superior compared to that of PRP with regard to their clinical and radiological efficacy.

Expandable intramedullary nailing and platelet rich plasma to treat long bone non-unions

BackgroundRoentgenographic and functional outcomes of expandable self locking intramedullary nailing and platelet rich plasma (PRP) gel in the treatment of long bone non-unions are reported.Materials and methodsTwenty-two patients suffering from atrophic diaphyseal long bone non-unions were enrolled in the study. Patients were treated with removal of pre-existing hardware, decortication of non-union fragments, and fixation of pseudoarthrosis with expandable intramedullary nailing (Fixion™, Disc’O Tech, Tel Aviv, Israel). At surgery, PRP was placed in the pseudoarthrosis rim.ResultsThe thirteen-month follow-up showed 91% (20/22 patients) of patients attaining bony union. The average time to union was 21.5 weeks. No infection, neurovascular complication, rotational malalignment, or limb shortening >4 mm were observed. The healing rate of non-unions was comparable to that observed in previous studies but with a lower complication frequency.ConclusionsThe combined use of self locking intramedullary nailing and PRP in the management of atrophic diaphyseal long bone non-unions seems to produce comparable results with less complications than previously reported. Further data are warranted to investigate the single contribution of PRP gel and Fixion nail.

(iv) The use of bone morphogenetic proteins (BMPs) in long-bone non-unions

The use of bone morphogenetic proteins (BMPs) in treating the clinical challenge posed by fracture delayed and non-union is still under investigation. When used to supplement basic surgical management clinical trials while few in number have demonstrated that BMPs are effective and safe for human application and have an efficacy comparable with that of autologous bone-grafting and eliminate donor site morbidity and reduces the risk of infection at the recipient site. Level one evidence has shown that recombinant human bone morphogenetic protein-7 (rh-BMP-7 or OP-1) is a reasonable alternative to autologous bone grafting in the treatment of long bone non-unions. The use of bone morphogenetic proteins (BMPs) in treating the clinical challenge posed by fracture delayed and non-union is still under investigation. When used to supplement basic surgical management clinical trials while few in number have demonstrated that BMPs are effective and safe for human application and have an efficacy comparable with that of autologous bone-grafting and eliminate donor site morbidity and reduces the risk of infection at the recipient site. Level one evidence has shown that recombinant human bone morphogenetic protein-7 (rh-BMP-7 or OP-1) is a reasonable alternative to autologous bone grafting in the treatment of long bone non-unions.

Surgical treatment of aseptic nonunion in long bones: review of 193 cases

The surgical treatment of aseptic nonunion often represents a more challenging situation for the orthopaedic surgeon than treatment of the primary fracture. In fact, it may be necessary not only to "rivitalize" the nonunion area, but also to exchange the bone fixation devices and to place some refill material in the bone gap. Several surgical techniques and different kinds of bone gap refills have been reported in the literature for the treatment of long bone nonunion. We present the results of 193 cases of long bone nonunion that have been treated in a period of 11 years (1992–2003) by a mostly open approach to the nonunion site with or without autologous bone graft interposition. The site (27 humerus, 44 forearm, 48 femur, 74 tibia) and the type of nonunion (179 atrophic, 19 hypertrophic) were considered in the surgical planning as were the mechanic and biological problems. New osteosynthesis was performed in 139 cases: with plate and screws in 82 cases, with intramedullary nails in 31 cases, with external fixators in 15 cases and with other devices in 11 cases (e.g. interfragmentary screws, k-wires). Cancellous or corticocancellous bone graft, always autologous from the iliac crest or from the anterior tibial tuberosity, was used in 183 cases (94.8%). Healing of the nonunion was successful in 179 cases (92.7%) in a mean time of 5.8 months. 14 patients (7.2%), all atrophic nonunion, healed with further surgery in a mean time of 19.2 months. Best results were obtained by the use of the intramedullary nail (31 cases): 99% healed in 5.2 months for the lower limb and 100% healed in 7.4 months for the upper limb. Good results have been achieved by plate (82 cases): 89.5% healed in 4.5 months for the lower limb and 94.1% in 6 months for the upper one. The worst results were observed with external fixation (15 cases). However, this device was used in the most complex situations, when severe soft tissue sufference was present. In this group, the mean healing time was 7.1 months (69.2% of cases) in the lower limb and 8 months (50%) in the upper one. Bone graft alone (54 cases) led to healing in 34 of 35 cases (97%) in the lower limb in 6 months and in 17 of 19 cases (89.4%) in 6.4 months in the upper limb.

Recombinant human bone morphogenetic protein-7 for treatment of long bone non-union: An observational, retrospective, non-randomized study of 105 patients

Autogenous bone-grafting is frequently used in the treatment of fracture non-union. The donor-site morbidity and potentially limited supply of suitable autogenous bone are commonly recognized drawbacks. Recent studies advocated the benefit and safety of recombinant human bone morphogenetic protein-7 (rhBMP-7) in several anatomical sites. An observational, retrospective, non-randomized study on the use of BMP-7 in treating non-union in various sites has been carried out by the BMP-7 Italian Observational Study (BIOS) Group. The clinical series included 105 patients. Additional grafts were used based on the surgeon's decision. Radiographic and clinical assessments were carried out at progressive time intervals on two groups: BMP-7+autograft (A) or BMP-7 (B). The mean follow-up was 29.2 months. The last assessment showed an 88.8% success rate with an average healing time of 7.9 months. At >/=9 months there was overlapping between the unions recorded in the two groups (PA-PB=1.5%; CI 95%: -0.149; 0.119). This is an observational study that illustrates the efficacy of BMP-7 with and without bone grafting for the treatment of long bone non-unions.

Mechanical and biological treatment of long bone non-unions

Non-union (NU) of bones is a multifactorial phenomenon. Infected non-unions and/or those with bone loss require "biological treatment", such as the excision of the pathological infected non-union site or the "creation" of new bone substance by the use of distraction techniques. The treatment of choice that meets both the biological and mechanical requirements is that of the external fixation, in as much as it has an extremely low septic complication rate and the mechanical environment can be varied automatically or programmed depending on the requirements. The authors report on a total of 287 cases of non-union treated with external fixation, with a 93% success rate.

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.

Percutaneous treatment of long bone nonunions: the use of autologous bone marrow and allograft bone matrix.

Sixty-six patients with 69 "stiff" nonunions (no gross motion) of long bones were entered into a prospective study. The only therapeutic intervention was the percutaneous administration of a mixture of autologous bone marrow and allograft demineralized bone matrix on an outpatient basis. Sixty-one of the percutaneous treatments (88%) resulted in union at an average of 8.1 months (range: 2 months to 3 years). This method of treating nonunions is as successful as standard iliac crest autologous bone grafting and offers the distinct advantages of decreased morbidity, reduced costs, and shorter hospital stay.