Bone Morphogenetic Protein in Scaphoid Nonunion: A Systematic Review

The role of orthobiologics in bone healing and joint and tendon degeneration in the upper limb

This review article examines the role of orthobiologics, specifically platelet-rich plasma (PRP), mesenchymal stem cells (MSCs) and bone morphogenetic protein (BMP), in bone healing and the treatment of joint and tendon degeneration in the upper limb. The historical development, theorized mechanisms and clinical applications of these orthobiologics are explored, focussing on their effectiveness in fracture non-unions, osteoarthritis and tendinopathies. The evidence for bone healing shows promising results, particularly for MSCs and BMP in the treatment of non-unions. However, despite preclinical evidence of regenerative abilities of PRP and MSCs, the clinical trials do not support their use for tendinopathies or osteoarthritis. Before widespread clinical application of PRP or MSCs for upper limb degenerative conditions, their efficacy needs to be established through large, high-quality trials.

Management of Distal Femoral Non-union: A Systematic Review

Introduction

Managing distal femur fracture nonunion is complex, with unpredictable results. The present investigation systematically updates current evidence, reviews existing modalities, innovations and related outcomes, and discusses future perspectives on the management of nonunion of the distal femur.

Methods

This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the 2020 PRISMA statement. In April 2024, PubMed, Web of Science, Google Scholar, and Embase were accessed without time constraints. No additional filters were used in the database search. All the clinical studies investigating treatment options for nonunion of distal femur fractures were accessed.

Results

35 clinical studies (832 patients) were included. Of them, 34.2% (239 of 698 patients) reported an open fracture, and 24.5% (78 of 319 patients) reported infection at the fracture site. The mean length of the follow-up was 28.9 ± 13.2 months. The mean age of the patients was 53.8 ± 14.7 years.

Conclusion

84.5% (703 of 832) of patients reached complete union without major complications, and 3.8% (32 of 832) reached complete union with major complications at a mean of 21.7 ± 20.9 months. 8.7% (72 of 832) patients showed signs of persistent non-union.

Level of evidence

Level III, systematic review.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-024-01205-4.

Bone Graft and Fixation Options in the Surgical Management of Scaphoid Nonunion

Scaphoid nonunions are a complex challenge that are frequently encountered by hand surgeons. Because of the tenuous blood supply of the scaphoid and secondary deformities that occur as a result of delayed or unsuccessful treatment, the treatment of scaphoid nonunions frequently requires the use of internal fixation and supplemental bone graft. There are multiple bone graft sources and techniques that can be employed based on the patient, the viability of the proximal pole fragment, and the presence of a deformity. Without osteonecrosis or disruption of the scaphoid blood supply, nonvascularized autologous grafts can be used from the distal radius, proximal ulna, or iliac crest. In cases where there is concern for an insufficient blood supply, vascularized bone graft sources can be employed, including pedicled local grafts and free flap grafts. When there is a nonviable and fragmented proximal pole, using osteochondral autografts has become increasingly used to reconstruct the scaphoid. Bone graft substitutes can additionally be used to supplement the fixation construct. This review focuses on the indications and role of bone grafts in scaphoid nonunions to help augment internal fixation, promote healing, and restore carpal alignment.

Surgical Treatment of Scaphoid Fractures: Recommendations for Management

Background: Several operative treatments exist for scaphoid fractures, varying by approach (e.g., ercutaneous, volar, or dorsal), implant type (e.g., screw or Kirschner wire), and bone raft choice (e.g., none, nonvascularized, or vascularized). Many previous systematic eviews and meta-analyses have investigated outcomes following different surgicalÚpproaches, the use of vascularized versus nonvascularized bone graft for scaphoidßracture nonunions, and treatment for specific fracture patterns. However, given the advancements n scaphoid fracture treatment in recent years, there is a need for updated treatment recommendations hat would be beneficial to hand surgeons. Purpose: We present a comprehensive review of the operative treatment of scaphoid fractures based on recent literature and propose a unified treatment algorithm for managing these fractures. Methods: The English-language literature was searched from 2002 to 2023 for high evidence level (e.g., randomized trials), review, and meta-analysis articles with the following search terms: "scaphoid, "u8220"scaphoid" AND "nonunion, " and "scaphoid" AND "malunion. " Each article was creened by the authors to determine the scaphoid fracture scenario addressed and ubsequent treatment recommendations. The findings from article reviews were then rganized by scaphoid fracture types in this manuscript. Results: A total of 95 pertinent articles were ultimately selected and used as the basis for reviewing different scaphoid fracture scenarios. A treatment algorithm was then proposed based on literature review. Conclusion: This summary of the recent literature can guide hand surgeons in addressing scaphoidßractures. Future research in scaphoid fracture treatment, particularly for nonunions, would be most beneficial n the form of systematic review, meta-analysis, or multicenter prospective randomized clinical trials. Level of Evidence: IV.

The Integration of Foot and Ankle Instruments to Enhance Orthopedic Hand Surgery: Technical Note

Introduction

The scaphoid fracture is the most common type of carpal fracture, and disruption of the proximal row of carpal bones alters wrist mechanics altering the stabilization that permits the wrist to work efficiently. When the displacement is at least 2 mm, the majority of surgeons would preferentially operatively intervene in this fracture. Non-union of the fracture will occur when left untreated. The gold standard for treatment is open reduction and internal fixation using autologous bone graft. This case report is the first to describe the integration of the Hintermann™ Distractor, used as an integral part of the surgery in scaphoid waist fracture fixation to improve fracture stabilization, preparation, and compression.

Case Report

A 20-year-old male presented with a volar flexed scaphoid non-union, 4 months after the initial injury. Open reduction internal fixation, with the use of the Hintermann™ Distractor, facilitated ease of reduction and placement of Russe graft.

Conclusion

Scaphoid waist non-unions with volar angulation and an associated DISI deformity can lead to a significant decrease in function. This case study is the first to describe the use of a foot and ankle instrument to assist with fracture preparation and distraction to place a corticocancellous strut graft in the scaphoid fracture efficiently. This case study demonstrates the efficiency of the technique.

Efficacy of adjuvant treatment for fracture nonunion/delayed union: a network meta-analysis of randomized controlled trials

BACKGROUND

Fracture nonunion/delayed union seriously affects physical and mental health and quality of life. The aim of this study was to evaluate the relative efficacy of different adjuvant treatments for nonunion/delayed union by network meta-analysis.

METHODS

A comprehensive search was performed to identify randomized controlled trials (RCTs) evaluating adjuvant treatment in the management of nonunion/delayed union. A network meta-analysis reporting on healing rate, healing time, and adverse effect (AE) outcomes was conducted to assess and compare different interventions.

RESULTS

Thirty studies were included in the analysis. For the healing rate outcome, bone marrow aspirate (BMA) + autologous cancellous bone (ACB) was found to be significantly better than ACB alone (odds ratio: 0.12; 95% confidence interval: 0.03, 0.59). In the ranking results, BMA+ platelet-rich plasma (PRP) (96%), BMA + ACB (90%), and BMA alone (82%) showed relative advantages in the healing rate. Low-intensity pulsed ultrasonography (LIUS) intervention significantly shortened the healing time compared with ACB (SMD: -9.26; 95% CI: - 14.64, - 3.87). LIUS (100%), BMA + PRP (74%), and bone morphogenetic proteins (BMPs) (69%) have relative advantages. Compared with the control, electromagnetic field (EMF) (OR: 13.21; 95% CI: 1.58, 110.40) and extracorporeal shock wave (ESWT) (OR: 4.90; 95% CI: 1.38, 17.43) had a higher AE risk.

CONCLUSIONS

Among the current intervention strategies, BMA in combination with PRP and ACB can improve the healing rate of nonunion/delayed union. LIUS can significantly shorten the healing time. EMF and ESWT may have a high risk of AE. However, large-scale, well-designed studies are still needed to confirm the results.

TRIAL REGISTRATION

Retrospectively registered.