Treatment of femoral diaphyseal non-unions: our experience

Operative treatment of nonunions in the elderly: Clinical and radiographic outcomes in patients at minimum 75 years of age

BACKGROUND

Limited information exists on nonunion treatment in the elderly. This retrospective study evaluates whether results of operative treatment of nonunion of the humerus or femur in patients aged ≥ 75 years are comparable to those in younger patients.

METHODS

We identified patients age ≥ 75 years with a nonunion of humerus or femur treated with open reduction and internal fixation. The Non-Union Scoring System was calculated. Complications, clinical outcome, and radiographic findings were assessed. Primary endpoint was nonunion healing. A literature review compared time to healing of humeral and femoral nonunion in younger populations.

RESULTS

We identified 45 patients treated for a nonunion of humerus or femur with > 12 months follow-up. Median age was 79 years (range 75-96). Median time to presentation was 12 months (range 4-127) after injury, median number of prior surgeries was 1 (range 0-4). Union rate was 100%, with median time to union 6 months (range 2-42). Six patients underwent revision for persistent nonunion and healed without further complications.

CONCLUSIONS

Using a protocol of debridement, alignment, compression, stable fixation, bone grafting and early motion, patients aged 75 years or older can reliably achieve healing when faced with a nonunion of the humerus or femur.

LEVEL OF EVIDENCE

IV.

Treatment of nonunion in neglected long bone shaft fractures by osteoperiosteal decortication

In emerging countries, nonunion in the shaft of fractured long bones is common.

PATIENTS AND METHODS

In a 3-year long prospective study, 50 patients (38 men, 12 women) with an average age of 40.9 years (range 17-60) were treated for neglected diaphyseal nonunion an average of 11 months (range 6-48) after the fracture event. The femur was involved 14 times, tibia 22 times, humerus eight times and forearm bones six times. All of these patients had consulted initially with a traditional bone setter at the time of fracture. The surgical procedure consisted of osteoperiosteal decortication followed by repermeabilization of the medullary canal and then internal fixation. Compression plating was used for the humerus, radius and ulna. Nonunion of the middle-third of the femur and tibia was treated by intramedullary nailing and nonunion of the proximal third of the femur with an inverted DCS screw-plate. Patients were reviewed clinically and with X-rays on postoperative days 21, 45, 90 and 120.

RESULTS

Bone union was obtained in under 90 days in the upper limb and under 120 days in the lower limb. No additional grafting was needed. There were only two cases of leg length differences.

DISCUSSION

Osteoperiosteal decortication is a reliable technique that leads to predictable, satisfactory results, given the limited materials required to treat long bone nonunion in emerging countries.

Operative treatment for femoral shaft nonunions, a systematic review of the literature

The objective of this article is to systematically review the currently available literature to formulate evidence-based guidelines for the treatment of femoral shaft nonunions for clinical practice and to establish recommendations for future research. Articles from PubMed/MEDLINE, Cochrane Clinical Trial Register, and EMBASE, that presented data concerning treatment of nonunions of femoral shaft fractures in adult humans, were included for data extraction and analysis. The search was restricted to articles from January 1970 to March 2011 written in the English, German, or Dutch languages. Articles containing data that were thought to have been presented previously were used once. Reports on nonunion after periprosthetic fractures, review articles, expert opinions, abstracts from scientific meetings, and case reports on 5 or fewer patients were excluded. The data that were extracted from the relevant articles included: type of nonunion, type of initial and secondary treatments, follow-up, union rate, and general complications. Most studies had different inclusion criteria and outcome measures, thus prohibiting a proper meta-analysis. Therefore, only the union rate and number of complications were compared between the different treatments. Methodological quality was assessed by assigning levels of evidence as previously defined by the Centre for Evidence-Based Medicine. This systematic review provides evidence in favour of plating if a nail is the first treatment; after failed plate fixation, nailing has a 96 % union rate. After failed nailing, augmentative plating results in a 96 % union rate compared to 73 % in the exchange nailing group.

Novel 3D hexapod computer-assisted orthopaedic surgery system for closed diaphyseal fracture reduction

BACKGROUND

Long-bone fractures are very common in trauma centers. The conventional Arbeitsgemeindschaft fur Osteosynthesefragen (AO) technique contributes to most fracture healing problems, and external fixation technology also has several disadvantages, so new techniques are being explored.

METHOD

A novel hexapod computer-assisted fracture reduction system based on a 3D-CT image reconstruction process is presented for closed reduction of long-bone diaphyseal fractures. A new reduction technique and upgraded reduction device are described and the whole system has been validated.

RESULTS

Ten bovine femoral fracture models were used with random fracture patterns. Tests results were as follows: residual deviation 1.24 + 0.65 mm for the axial deflection, 1.19 + 0.37 mm for the translation, 2.34 + 1.79° for the angulation, and 2.83 + 0.9° for the rotation.

CONCLUSION

The reduction mechanism has the advantages of high positioning, reduction and computer accuracy, and intra-operative stability for both patients and surgical team. With further investigation, it could be applied in many kinds of long-bone diaphyseal fractures.

Orthopaedic research in italy: state of the art

The most significant results in experimental and clinical orthopaedic research in Italy within the last three years have been primarily in major congenital diseases, bone tumors, regenerative medicine, joint replacements, spine, tendons and ligaments. The data presented in the following discussion is comparable with leading international results, highlighting Italian orthopaedic research excellemce as well as its shortcomings.

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.