Internal fixation of nonunions

Distal blocking screw augmentation in ulnar intramedullary nail fixation of adult forearm diaphyseal fractures

PURPOSE

This study aimed to evaluate the effect of distal blocking screws on the stability and healing of ulnar diaphyseal fractures treated with intramedullary (IM) nails. The primary research question was whether the addition of distal blocking screws enhanced fracture stabilization and promoted faster healing than the standard IM nailing techniques.

METHODS

This retrospective study reviewed medical records of 30 patients with ulnar diaphyseal fractures treated from February 2018 to September 2023. The patients were divided into two groups: those treated using IM nails alone (n = 17) and those treated with using IM nails with distal blocking screws (n = 13). The surgical time, medullary canal space, fracture healing time, and complications were assessed. Functional outcomes were evaluated using the Grace and Eversmann rating system, the DASH scores, and the VAS scores.

RESULTS

The addition of distal blocking screws resulted in a slightly longer surgical time (56 min vs 47 min). However, the group with distal blocking screws had smaller medullary canal space and showed significantly faster fracture healing times (2.3 months vs 3.9 months; p = .036). There were no reported complications of nonunion, nerve injury, or infection in the distal blocking screw group, whereas the IM nail-only group had one case of nonunion (5.7%).

CONCLUSION

The use of distal blocking screws in conjunction with IM nails for ulnar diaphyseal fractures improves fracture stability and promotes faster healing.

Effectiveness and safety of augmentative plating technique in managing nonunion following intramedullary nailing of long bones in the lower extremity: A systematic review and meta-analysis

PURPOSE

To methodically assess the effectiveness of augmentative plating (AP) and exchange nailing (EN) in managing nonunion following intramedullary nailing for long bone fractures of the lower extremity.

METHODS

PubMed, EMBASE, Web of Science, and the Cochrane Library were searched to gather clinical studies regarding the use of AP and EN techniques in the treatment of nonunion following intramedullary nailing of lower extremity long bones. The search was conducted up until May 2023. The original studies underwent an independent assessment of their quality, a process conducted utilizing the Newcastle-Ottawa scale. Data were retrieved from these studies, and meta-analysis was executed utilizing Review Manager 5.3.

RESULTS

This meta-analysis included 8 studies involving 661 participants, with 305 in the AP group and 356 in the EN group. The results of the meta-analysis demonstrated that the AP group exhibited a higher rate of union (odds ratio: 8.61, 95% confidence intervals (CI): 4.12 - 17.99, p < 0.001), shorter union time (standardized mean difference (SMD): -1.08, 95 % CI: -1.79 - -0.37, p = 0.003), reduced duration of the surgical procedure (SMD: -0.56, 95 % CI: -0.93 - -0.19, p = 0.003), less bleeding (SMD: -1.5, 95 % CI: -2.81 - -0.18), p = 0.03), and a lower incidence of complications (relative risk: -0.17, 95 % CI: -0.27 - -0.06, p = 0.001). In the subgroup analysis, the time for union in the AP group in nonisthmal and isthmal nonunion of lower extremity long bones was shorter compared to the EN group (nonisthmal SMD: -1.94, 95 % CI: -3.28 - -0.61, p < 0.001; isthmal SMD: -1.08, 95 % CI: -1.64 - -0.52, p = 0.002).

CONCLUSION

In the treatment of nonunion in diaphyseal fractures of the long bones in the lower extremity, the AP approach is superior to EN, both intraoperatively (with reduced duration of the surgical procedure and diminished blood loss) and postoperatively (with an elevated union rate, shorter union time, and lower incidence of complications). Specifically, in the management of nonunion of lower extremity long bones with non-isthmal and isthmal intramedullary nails, AP demonstrated shorter union time in comparison to EN.

The effect of valgus reduction on resistant subtrochanteric femoral non-unions: a single-centre report of twenty six cases

PURPOSE

Re-revision of subtrochanteric non-unions is technically challenging and lacks robust evidence. The results of managing subtrochanteric fractures after multiple failed procedures have rarely been reported in the literature. This study aims to evaluate the effect of valgus reduction on non-united subtrochanteric fractures with single or multiple failed revision surgeries.

METHODS

Twenty-six patients with aseptic subtrochanteric fracture non-union underwent failed single or multiple revision procedures after index fracture fixation surgery between 2011 and 2019. The exclusion criteria were as follows: septic non-union, peri-prosthetic, and pathological fractures. Lateral-based wedge valgus reduction and compression at the non-union site using a valgus-contoured DCS together with decortication, debridement, and bone grafting were used. The main outcome measurement was radiological union, pain, LLD, HHS, and restoration of pre-fracture activities.

RESULTS

The mean follow-up was 4.5 years (range 3 to 7); prior revision surgeries range from two to five and union at 6.5 months (range 3 to 10) and the delayed union in one case and an infected non-union in one case. The mean LLD was 4 cm (range 3 to 5), which improved to 1.5 cm (range 1 to 4) (P-value < 0.001). The mean VAS was 7 (range 6 to 8), and 24 patients achieved painless ambulation without a walking aid after the union. The mean HHS was 40 (range 25 to 65), which improved to 85 (range 55 to 95) (P-value < 001), achieving 15 excellent, ten good, and one poor results.

CONCLUSION

Mechanical optimisation by lateral closing wedge and stable fixation with pre-contoured DCS with biological enhancement resulted in a successful outcome in recalcitrant subtrochanteric non-unions.

Treatment Effect of Platelet Gel on Reconstructing Bone Defects and Nonunions: A Review of In Vivo Human Studies

In ideal circumstances, a fractured bone can heal properly by itself or with the aid of clinical interventions. However, around 5% to 10% of bone fractures fail to heal properly within the expected time even with the aid of clinical interventions, resulting in nonunions. Platelet gel is a blood-derived biomaterial used in regenerative medicine aiming to promote wound healing and regeneration of damaged tissues. The purpose of this paper is to review relevant articles in an attempt to explore the current consensus on the treatment effect of platelet gel on reconstructing bone defects and nonunions, hoping to provide a valuable reference for clinicians to make treatment decisions in clinical practice. Based on the present review, most of the studies applied the combination of platelet gel and bone graft to reconstruct bone defects and nonunions, and most of the results were positive, suggesting that this treatment strategy could promote successful reconstruction of bone defects and nonunions. Only two studies tried to apply platelet gel alone to reconstruct bone defects and nonunions, therefore a convincing conclusion could not be made yet regarding the treatment effect of platelet gel alone on reconstructing bone defects and nonunions. Only one study applied platelet gel combined with extracorporeal shock wave therapy to reconstruct nonunions, and the results were positive; the hypothetical mechanism of this treatment strategy is reasonable and sound, and more future clinical studies are encouraged to further justify the effectiveness of this promising treatment strategy. In conclusion, the application of platelet gel could be a promising and useful treatment method for reconstructing bone defects and nonunions, and more future clinical studies are encouraged to further investigate the effectiveness of this promising treatment method.

Bone Healing Materials in the Treatment of Recalcitrant Nonunions and Bone Defects

The usual treatment for bone defects and recalcitrant nonunions is an autogenous bone graft. However, due to the limitations in obtaining autogenous bone grafts and the morbidity associated with their procurement, various bone healing materials have been developed in recent years. The three main treatment strategies for bone defects and recalcitrant nonunions are synthetic bone graft substitutes (BGS), BGS combined with bioactive molecules, and BGS and stem cells (cell-based constructs). Regarding BGS, numerous biomaterials have been developed to prepare bone tissue engineering scaffolds, including biometals (titanium, iron, magnesium, zinc), bioceramics (hydroxyapatite (HA)), tricalcium phosphate (TCP), biopolymers (collagen, polylactic acid (PLA), polycaprolactone (PCL)), and biocomposites (HA/MONs@miR-34a composite coating, Bioglass (BG)-based ABVF-BG (antibiotic-releasing bone void filling) putty). Bone tissue engineering scaffolds are temporary implants that promote tissue ingrowth and new bone regeneration. They have been developed to improve bone healing through appropriate designs in terms of geometric, mechanical, and biological performance. Concerning BGS combined with bioactive molecules, one of the most potent osteoinductive growth factors is bone morphogenetic proteins (BMPs). In recent years, several natural (collagen, fibrin, chitosan, hyaluronic acid, gelatin, and alginate) and synthetic polymers (polylactic acid, polyglycolic acid, polylactic-coglycolide, poly(e-caprolactone) (PCL), poly-p-dioxanone, and copolymers consisting of glycolide/trimethylene carbonate) have been investigated as potential support materials for bone tissue engineering. Regarding BGS and stem cells (cell-based constructs), the main strategies are bone marrow stromal cells, adipose-derived mesenchymal cells, periosteum-derived stem cells, and 3D bioprinting of hydrogels and cells or bioactive molecules. Currently, significant research is being performed on the biological treatment of recalcitrant nonunions and bone defects, although its use is still far from being generalized. Further research is needed to investigate the efficacy of biological treatments to solve recalcitrant nonunions and bone defects.

A Review of Recent Developments in the Molecular Mechanisms of Bone Healing

Between 5 and 10 percent of fractures do not heal, a condition known as nonunion. In clinical practice, stable fracture fixation associated with autologous iliac crest bone graft placement is the gold standard for treatment. However, some recalcitrant nonunions do not resolve satisfactorily with this technique. For these cases, biological alternatives are sought based on the molecular mechanisms of bone healing, whose most recent findings are reviewed in this article. The pro-osteogenic efficacy of morin (a pale yellow crystalline flavonoid pigment found in old fustic and osage orange trees) has recently been reported, and the combined use of bone morphogenetic protein-9 (BMP9) and leptin might improve fracture healing. Inhibition with methyl-piperidino-pyrazole of estrogen receptor alpha signaling delays bone regeneration. Smoking causes a chondrogenic disorder, aberrant activity of the skeleton's stem and progenitor cells, and an intense initial inflammatory response. Smoking cessation 4 weeks before surgery is therefore highly recommended. The delay in fracture consolidation in diabetic animals is related to BMP6 deficiency (35 kDa). The combination of bioceramics and expanded autologous human mesenchymal stem cells from bone marrow is a new and encouraging alternative for treating recalcitrant nonunions.

Treatment options for aseptic tibial diaphyseal nonunion: A review of selected studies

In aseptic tibial diaphyseal nonunions after failed conservative treatment, the recommended treatment is a reamed intramedullary (IM) nail.Typically, when an aseptic tibial nonunion previously treated with an IM nail is found, it is advisable to change the previous IM nail for a larger diameter reamed and locked IM nail (the rate of success of renailing is around 90%).A second change after an IM nail failure is also a good option, especially if bone healing has progressed after the first change.Fibular osteotomy is not routinely advised; it is only recommended when it interferes with the nonunion site.In delayed unions before 24 weeks, IM nail dynamization can be performed as a less invasive option before deciding on a nail change.If there is a bone defect, a bone graft must be recommended, with the gold standard being the autologous iliac crest bone graft (AICBG).A reamer-irrigator-aspirator (RIA) system might also obtain a bone autograft that is comparable to AICBG.Although the size of the bone defect suitable to perform bone transport techniques is a controversial issue, we believe that such techniques can be considered in bone defects > 3 cm.Non-invasive therapies and biologic therapies could be applied in isolation for patients with high surgical risk, or could be used as adjuvants to the aforementioned surgical treatments. Cite this article: EFORT Open Rev 2020;5:835-844. DOI: 10.1302/2058-5241.5.190077.

Prospective Clinical Trial of Surgical Intervention for Painful Rib Fracture Nonunion

We performed a prospective clinical trial of resection with or without plate fixation for symptomatic rib fracture nonunion three or more months postinjury with 6-month postoperative followup. The McGill Pain Questionnaire (MPQ) and RAND 36 Health Survey were administered and activity level (sedentary, ambulatory, moderately active, vigorous), functional status (disabled, nonphysical labor, physical labor), and work status (employed, unemployed, retired, student) were queried pre- and postoperatively. Twenty-four patients 4 to 197 months (median, 16 months) postinjury underwent surgical intervention for one to four rib fracture nonunions (median, two nonunions). Evidence of intercostal nerve entrapment was present in nine patients (38%). MPQ Present Pain Intensity and Pain Rating Index and RAND 36 Physical Functioning, Role Physical, Social Functioning, Role Social, Bodily Pain, Vitality, Mental Health, and General Health were significantly improved at six months compared with study entry ( P < 0.05). Activity levels significantly improved ( P < 0.0001) but functional and work status did not change. Twenty-four-hour morphine equivalent dosage of opioids at study entry was 20.3 ± 30.8 (mean ± standard deviation) and at study completion was 9.4 ± 17.5 ( P = 0.054). Complications included one wound infection, two partial screw backouts, and one chest wall hernia at one year after resection of adjacent nonunions with significant gaps repaired with absorbable plates. Surgical intervention for rib fracture nonunion may improve chronic pain and disability but without change in functional or work status. Resection of adjacent nonunions with significant gaps may lead to chest wall hernia.

CXCR4 Antagonism to Treat Delayed Fracture Healing

A significant number of fractures develop nonunion. Stem cell homing is regulated through stromal cell-derived factor 1 (SDF1) and its receptor CXCR4. Stem/progenitor cell populations can be endogenously mobilized by administering growth factors with a pharmacological antagonist of CXCR4, AMD3100, which may be a means to improve fracture healing. A 1.5 mm femoral osteotomy in Wistar rats was stabilized with an external fixator. Rats were pretreated with phosphate buffered saline [PBS(P)], vascular endothelial growth factor [VEGF(V)], insulin-like growth factor-1 [IGF1(I)], or granulocyte colony stimulating factor [GCSF(G)] before AMD3100. A control group (C) did not receive growth factors or AMD3100. Bone formation after 5 weeks was analyzed. Group P had a significant increase in total bone volume (BV) (p = 0.01) and group I in percentage bone in the fracture gap (p = 0.035). Group G showed a decrease in BV. All treated groups had an increase in trabecular thickness. Histology showed decreased cartilage tissue associated with increased bone in groups with improved healing, and increased fibrous tissue in poorly performing groups. Antagonism of SDF1-CXCR4 axis can boost impaired fracture healing. AMD3100 given alone was the most effective means to boost healing, whereas pretreatment with GCSF reduced healing. AMD3100 is likely mobilizing stem cells into the blood stream that home to the fracture site enhancing healing.

Diaphyseal forearm fractures, 20 years after surgical treatment. Is there still an indication for percutaneous fixation?

OBJECTIVE

This is a retrospective study of 98 diaphyseal forearm fractures in adults, treated by a percutaneous technique with intramedullar Kirchner wires.

MATERIALS AND METHOD

We reviewed 64 patients with 98 forearm fractures with a radiographic follow-up, assessing the presence of pseudarthrosis or delayed bone union and evaluating functional outcomes with the Anderson and the Disability of the Arm, Shoulder and Hand scale.

RESULTS

Clinical and radiological bone union was achieved in an average of 12 weeks. We obtained 77% of excellent and good results following Anderson's scale. There were 4 cases of pseudarthrosis and 6 cases of delayed bone union.

CONCLUSION

This surgical technique provides several advantages, such as a low incidence of complications and a total absence of infections, refractures and iatrogenic neurovascular injuries. It allows a lower hospital stay and a shortening of the surgery time compared with other techniques such as plates and intramedullary nails, that have similar results, in terms of bone union and functional outcomes, as we have verified from the published literature.

Plate Fixation Versus Intramedullary Nailing for Both-Bone Forearm Fractures: A Meta-analysis of Randomized Controlled Trials and Cohort Studies

OBJECTIVE

The aim of this study was to compare the radiographic and functional outcomes of operative intervention in patients with both-bone forearm fractures treated by open reduction and internal fixation (ORIF) with plates or intramedullary (IM) nailing.

METHODS

Studies published in PubMed, EMBASE, Web of Science, SinoMed (Chinese BioMedical Literature Service System, China), and CNKI (China National Knowledge Infrastructure, China) were systematically searched. The main outcomes included time to union, union rate, operation time, magnitude and location of radial bow, loss of forearm rotation, and complication rates. Results were expressed with weighted mean difference or risk ratio with 95 % confidence intervals. Pooled estimates were calculated using a fixed-effects or random-effects model according to the heterogeneity among studies.

RESULTS

A total of 13 studies met the inclusion criteria and were included in this meta-analysis. Compared with ORIF, IM nailing significantly reduced the operation time and complication rate. However, no significant differences were observed between the two surgical techniques in several outcomes, including time to union, union rate, radial bow magnitude, and loss of forearm rotation. Except in complications, these findings were consistent across the subgroup analysis of children and adult patients.

CONCLUSION

IM nailing is associated with shorter operation time and lower complication rate compared with ORIF. It is an effective and safe treatment option for children and adults with both forearm fractures. However, considering the limitations in this study, large-scale, high-quality randomized controlled trials are needed to indentify these findings.

Conservative Treatment for Minimally Displaced Type B Periprosthetic Femoral Fractures

BACKGROUND

Surgical treatment has been invariably indicated for Vancouver type B periprosthetic femoral fractures (PFFs), which involve femoral diaphysis around stem. We evaluated the outcomes of nonoperative management in patients with minimally displaced type B PFFs around cementless stem.

METHODS

From October 2009 to March 2016, 60 type B PFFs were treated at 1 institution. Among them, 19 minimally (<5 mm) displaced PFFs (31.7%, 19/60), which occurred around cementless stems, were treated nonsurgically with use of teriparatide. There were 6 men and 13 women. The mean age was 77.9 years (range, 51-98 years) at the time of PFF. The femoral stem was stable (type B1) in 11 patients and unstable (type B2) in 8. Teriparatide was injected from 1 to 4 months (mean, 3.2 months). We evaluated time to radiologic union and union rate.

RESULTS

A successful union was obtained in 16 patients (89.5%, 17/19) at 2 to 6 months (mean, 3.5 months). The union rate was 100% (11/11) in type B1 fractures and 75% (6/8) in type B2 fractures.

CONCLUSION

Our study showed that conservative treatment is feasible for the cases of type B1 minimally displaced periprosthetic fractures, and it may also be considered as an alternative option for type B2 minimally displaced periprosthetic fractures.

Management of resistant distal femur non-unions with allograft strut and autografts combined with osteosynthesis in a series of 22 patients

INTRODUCTION AND PURPOSE

Challenges to the surgeon in managing cases of resistant non-union of the distal femur include poor bone stock, disuse osteopenia and joint contractures. Procedures varying from simple bone grafting to megaprosthesis revision have been described. We successfully managed such cases using our technique of combining cortical allograft struts to augment the defect in the femoral condyle coupled with autogenous iliac crest bone grafting and locking plate osteosynthesis.

MATERIALS AND METHODS

Between April 2012 and May 2014, 22 patients who presented with resistant nonunions of the distal femur following initial surgery were managed using this technique. Cortical allograft struts were taken from the tissue bank of our institution. All patients were followed up post operatively and their time to union was noted. Functional outcome was calculated using LEFS (Lower extremity functional score). The average follow up of all our patients was 24 months.

RESULTS

All patients went on to achieve complete bony union. The average union time was 6.2 months (5 to 8 months). One patient who was a diabetic had superficial infection post operatively which was treated successfully with IV antibiotics. Average knee flexion was 110 degrees (80 to 130 degrees). The mean LEFS score was 72 (59 to 79).

CONCLUSION

Combing a locking plate fixation with the bone grafting technique of using an allograft strut to support the metaphyseal medial bone defect and autografts gives a good union and a good functional outcome in the management of resistant non-unions of the distal femur by enhancing the biology and providing a good structural support to the distal femur.

Treatment of aseptic non-union after intramedullary nailing without removal of the nail

Failure of bone healing after intramedullary nailing of a diaphyseal long bone fracture is a severe complication that requires an effective management to ensure the best chances for successful bone-union and termination of a long period of incapacity and morbidity for the sufferers. Traditional procedures require removal of the existing nail and re-fixation with wider nail, plate or external fixation constructs. The concept that bone union can be obtained with the existing nail in situ is gaining popularity as its removal adds trauma and potential complications and prolongs the operating time. This article reviews all techniques that have been proposed for the management of aseptic diaphyseal long bone non-unions that stimulate bone healing without removing the existing nail.

Adult diaphyseal both-bone forearm fractures: A clinical and biomechanical comparison of four different fixations

BACKGROUND

Although there have been a small number of studies reporting single bone fixation of either radius or ulna as well as hybrid fixation, the paucity of data for the hybrid fixation method still remains.

HYPOTHESIS

Hybrid fixation with plate and IM nailing would achieve good fixation and functional outcome, minimal damage to soft tissues and lower re-fracture risk.

MATERIALS AND METHODS

Forty cadavers (20 males, 20 females; mean age 68.06, SD 1.58years) were selected in biomechanical study under axial loading, bending loading, and torsional loading. Eighty-seven patients (47 males, 40 females; mean age 38.03±0.88years) were enrolled in the clinical study and randomly received different fixation: both-bone plate fixation or both-bone intramedullary nailing, plate fixation of ulna and intramedullary nailing of radius and intramedullary nailing of ulna and plate fixation of radius.

RESULTS

In the biomechanical study, intramedullary nailing of ulna and plate fixation of radius had similar results with that using both-bone plate method under axial, bending and torsional loading (All P>0.05), suggesting the more stable fixation compared with the other two groups (All P<0.05). In clinical research, both-bone intramedullary nailing was related to shortest operative time, smallest wound size and periosteal stripping area compared with other three groups (P<0.05). Patients receiving intramedullary nailing of ulna and plate fixation of radius showed the lowest incidence of postoperative complications and the best functional recovery outcome comparing with other three groups of patients (Both P<0.05).

CONCLUSION

The hybrid fixation method of intramedullary nailing of ulna and plate fixation of radius showed good stability in biomechanics, fewer complications and better functional clinical outcomes.

LEVEL OF EVIDENCE

Level II, prospective randomised study.

Infected Gap Non Union of Radius Treated with Modified Nicoll's Technique-A Case Report

Management of atrophic non union of forearm bones is a challenging task. Various methods of treatment available in the literature are cortical tibial graft (Boyd), ulnar segment graft (Miller and Phalen), iliac crest graft (Spira), cancellous insert graft (Nicoll), vascularized fibular graft (Jupiter), and bone transport by ring fixator (Tesworth). We here report a case of infected non union of radius managed with modified Nicoll's method. Here, intra medullary nailing is preferred over plating which was originally described by Nicoll. At two years follow up, the patient is symptom free and is able to carry out his daily activities with ease.

Results in treatment of distal femur fractures using polyaxial locking plate

Indications and techniques of locked plate fixation for the treatment of challenging fractures continue to evolve. As design variant of classic locked plates, the polyaxial locked plate has the ability to alter the screw angle and thereby, enhance fracture fixation. The aim of this observational study was to evaluate clinical and radiographic results in 89 patients with 90 fractures of the distal femur treated, between June 2006 and November 2011, with such a polyaxial locked plating system (Polyax™ Locked Plating System, DePuy, Warsaw, IN, USA). Seventy-seven fractures formed the report of this study. These cases were followed up until complete fracture healing or for a mean time of 77 weeks. At the time of last follow-up, 58 of 77 fractures (75.3 %) progressed to union without complication and radiographic healing occurred at a mean time of 16.3 weeks. Complications occurred in ten fractures that did not affect the healing and in nine fractures that showed delayed or non-union. The mean American Knee Society Score at the time of final follow-up was 83 for the Knee Score and 71.1 for the Functional Score. In conclusion, there is a high union rate for complex distal femoral fractures associated with a good clinical outcome in this series.

Plate osteosynthesis versus intramedullary nailing for both forearm bones fractures

PURPOSE

Given the continuing improvements in nail implants, intramedullary nailing could become an alternative treatment option to osteosynthesis for the treatment of fractures in both forearm bones, with the proper indication. The aim of this prospective study was to evaluate and compare the results of plate osteosynthesis and intramedullary nailing for the treatment of diaphyseal fractures in both forearm bones.

METHODS

Sixty-seven patients (mean age, 41 years; range, 22-76 years) of this prospective study were divided into two groups according to treatment randomly: ORIF group (plate osteosynthesis) and IMN group (intramedullary nail). The results were assessed on the basis of the time to union, functional recovery (range of motion and functional outcomes [Grace and Eversmann rating system and DASH]), restoration of the ulna and the radial bow, operating time, exposure time to fluoroscopy, complications, and patient satisfaction. The ratio of the magnitude of the maximum radial bow on the injured side to that on the contralateral side (i.e., "the ratio of the contralateral side") was determined to evaluate the effectiveness of radial bow restoration between groups.

RESULTS

The time to union and the exposure time to fluoroscopy were significantly shorter in ORIF group than in IMN group. The presence of butterfly segment and severe displacement were factors leading to the increase in the time of union in IMN group. No intergroup differences were observed in the restoration and magnitude of the maximum radial bow on the injured side. However, ORIF group showed a significantly improved ratio of the contralateral side compared to IMN group. In terms of the location of maximum radial bow and ratio of the contralateral side, significant differences were found between groups. The functional outcomes did not significantly differ between the two groups, irrespective of the time of assessment. All patients achieved union in both groups, with the exception of a single case of nonunion in IMN group and one case of refracture after implant removal in ORIF group.

CONCLUSION

Based on the significant differences in the ratio of the contralateral side, plate osteosynthesis resulted in a more excellent extent of restoration to the conditions prior to the injury. Nevertheless, such significant differences in the restoration of the bow had no effect on the final clinical outcome. If the indication is properly selected, our results suggested intramedullary nailing can be acceptable and effective treatment options for fractures in both forearm bones.

Exchange reamed nailing compared to augmentation compression plating leaving the inserted nail in situ in the treatment of aseptic tibial non-union: a two-centre study

BACKGROUND

A remarkable number of investigations are available treating tibial non-unions by exchange reamed nailing (ERN). Only few authors reported positive results after augmentation compression plating (ACP) for the same entity. To our knowledge no systematic study is published comparing ERN vs. ACP, so that this trial compares ACP leaving the already inserted un-reamed nail in situ against ERN in the treatment of aseptic tibial non-union, analysing success rate, time for union and operation time.

PATIENTS AND METHODS

Forty-eight patients with aseptic hypertrophic diaphyseal tibial non-union treated previously by un-reamed nailing were included retrospectively in this two-centre study. Group A consisted of 25 patients with ERN and group B of 23 patients with ACP leaving the underlying un-reamed nail in situ.

RESULTS

Mean follow-up was 3.8 years. Union was achieved in 24 out of 25 cases (96 %) for group A and in 22 out of 23 cases (95.6 %) for group B. Time needed for union varied; an average of 29 weeks for group A and 14 weeks for group B. The mean operation time for group A was 99 min, while it was 65 min for group B.

CONCLUSIONS

ERN and ACP with remaining pre-existing nail in situ are both safe and straightforward surgical procedures with equivalent high success rates of about 95 %. ACP has the advantage of less time for union and operating time in this series, but is associated with the disadvantage of requiring an additional incision and complaints associated to the plate requiring implant removal.

High success rate for augmentation compression plating leaving the nail in situ for aseptic diaphyseal tibial nonunions

OBJECTIVES

To evaluate adjunctive compression plating leaving the previously unreamed inserted intramedullary nail (URIMN) in situ for treating a resultant diaphyseal tibial nonunion.

DESIGN

Retrospective study.

SETTING

Level 1 trauma center (University Hospital).

PATIENTS/PARTICIPANTS

Patients treated by URIMN for diaphyseal tibial fractures that developed an aseptic hypertrophic nonunion.

INTERVENTION

Dynamization of the nail and compression plating leaving the URIMN in situ.

MAIN OUTCOME MEASUREMENTS

Radiographic and clinical parameters.

RESULTS

The mean follow-up was 3.8 years (range 2-7 years). Mean time for healing was 15 weeks with a mean operation time of 63 minutes. Union occurred in 27/28 (96.4%). There were no infections.

CONCLUSIONS

This simple technique seems to have a high success rate and should be considered when a nonunion occurs after URIMN. The need for an additional incision and removal of symptomatic implants remains a disadvantage.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Teriparatide, a nonsurgical solution for femoral nonunion? A report of three cases

We medicated teriparatide in three patients, who had a nonunion of the femur even after the initial surgical intervention. Teriparatide was administered for 3-9 months after a diagnosis of nonunion. A successful union was obtained in all three patients without further surgical intervention, and no adverse events related to the use of teriparatide were observed. Our report showed that teriparatide could be an alternative to surgical intervention in nonunion of the femur.

Judet decortication and compression plate fixation of long bone non-union: Is bone graft necessary?

Non-union occurs in 5-10% of all fractures and is caused by a variety of mechanical and biological factors. Stable fixation is essential and many authors recommend the addition of bone graft. Our aim was to evaluate the results of internal fixation using Judet decortication and compression plating for long bone fractures and assess the impact of bone grafting on union rates. Our study group comprised all the patients undergoing compression plate fixation under a single surgeon over a fourteen year period (n=96). AO principles were used and the standard technique involved Judet decortication, compression plating and lag screws. Autologous bone graft was harvested from the iliac crest. The mean age was 45 years and 62% were male. The fracture site was the clavicle (n=20); humerus (n=23); radius and ulna (n=5); femur (n=31) and tibia (n=17). The primary fracture treatment was non-operative (n=41); IM nail (n=22); plate fixation (n=28) and external fixation (n=5). Deep infection was present in 6 cases. Bone graft was used in 40 cases. 91/96 non-unions treated with compression plating healed (95%). Bone grafting was used in all cases for the initial part of the series but its use declined as the surgeon became more confident that the non-unions would heal without the use of bone graft. The case mix and complexity remained constant throughout the study period and the union rate also remained constant. The mean time to radiological union was 6.4 months. In those treated with a compression plate without bone graft the union rate was 94.6% whilst the addition of bone graft resulted in a union rate of 95% (p=0.67). From our study we concluded that the routine use of autologous bone graft may not be necessary and, based upon the union rates observed in this study, a prospective randomised study to evaluate the use of bone graft in non-union surgery would need a sample size of 194,000 to detect a significant increase in union with 80% power. In terms of Numbers Needed Treat (NNT), we would need to give 1179 patients a bone graft to prevent one additional failure of healing.

Management of aseptic tibial nonunion

Tibial nonunion remains a significant clinical challenge despite advances in surgical management. New techniques to help manage tibial nonunion include extracorporeal shock wave therapy and percutaneous application of bone marrow aspirate. Management strategies vary based on the type of nonunion: aseptic or infected, and atrophic or hypertrophic. Extracorporeal shock wave therapy has been shown to be as effective as surgical management in patients with stable hypertrophic nonunion. New fixation options include locked plates and intramedullary compression nails. Novel methods of external fixation have been developed for bone graft harvest from the intramedullary canal. Several biologic adjuncts also are available, including bone marrow aspirates, stem cells, and bone morphogenetic protein.

The treatment of established non-union of the proximal humerus using the Polarus locking intramedullary nail

INTRODUCTION

Non-union following fracture of the proximal humerus is not uncommon, particularly in the elderly. This can be associated with significant morbidity due to pain, instability and functional impairment. The Polarus device (Acumed) is a locked, antegrade intramedullary nail designed to stabilize displaced 2-, 3- and 4-part fractures of the proximal humerus. We report our experience with the Polarus nail for the treatment of established non-union of the proximal humerus.

MATERIALS AND METHODS

A total of 7 Polarus nails were inserted for the treatment of non-union of the proximal humerus between June 2000 and July 2007. Each fracture site was opened, debrided, stabilized with a Polarus nail and then grafted with autologous cancellous iliac crest bone. The time between injury and surgery ranged from 6 to 102 months. One patient had undergone previous fixation of her fracture using Rush intramedullary rods. All patients were females, and mean age at surgery was 63.6 years (range, 49-78 years). A retrospective review of notes and radiographs was carried out. Patients were reviewed at varying intervals postoperatively (range, 13-68 months) and assessed using the Constant shoulder-scoring system.

RESULTS

All un-united fractures progressed to union. There were no wound complications and no postoperative nerve palsies. Functional outcome was good, even in those cases with a long interval between injury and surgery. The mean Constant score was 63 (range, 54-81). Migration of a single proximal locking screw was seen in 2 patients, and these screws required removal at 5 and 12 months, respectively, postoperatively.

CONCLUSION

In our experience, a locked proximal humeral nail used in conjunction with autologous bone grafting is an excellent device for the treatment of proximal humerus non-unions.

Autologous bone graft: when shall we add growth factors?

Although the unquestionable value of autologous bone grafting and the analogous value of the reaming by-products in nonunion treatment have been mentioned extensively in the literature, there is ongoing vivid discussion for the treatment of those case scenarios where the fracture nonunion is complicated by other local environment adverse circumstances. The graft expansion with growth factors as the bone morphogenetic proteins (BMPs) offers the possibility to reduce the number of operative procedures, complications, length of hospital stay, and time to union. In this article, we consider the potential clinical scenarios for graft expansion with BMPs.

Treatment for large skeletal defects by free vascularized fibular graft combined with locking plate

BACKGROUND

Reconstruction of large skeletal defects secondary to osteomyelitis or open fracture is a challenging problem. The purpose of this study was to evaluate the results of using free vascularized fibular graft (FVFG) combined with locking plate in the treatment of large skeletal defects from open fracture and infection.

METHODS

Ten patients with a mean age of 34 years (ranged 13-57 years) and a mean length of 8.7 cm (range 6-17 cm) skeletal defect were treated with FVFG and locking plate. The mean follow-up time was 26 months.

RESULTS

Grafting union occurred in all patients, with a mean healing time of 4.5 months. No recurrence of osteomyelitis and stress fractures was observed. The mean time to full weight-bearing was 10 months, and all patients were pain-free and able to walk without supportive devices.

CONCLUSIONS

FVFG combined with locking plate is a viable option for the management of large skeletal defects from open fracture and infection.

Autologous bone graft: when shall we add growth factors?

Although the unquestionable value of autologous bone grafting and the analogous value of the reaming by-products in nonunion treatment have been mentioned extensively in the literature, there is ongoing vivid discussion for the treatment of those case scenarios where the fracture nonunion is complicated by other local environment adverse circumstances. The graft expansion with growth factors as the bone morphogenetic proteins (BMPs) offers the possibility to reduce the number of operative procedures, complications, length of hospital stay, and time to union. In this article, we consider the potential clinical scenarios for graft expansion with BMPs.

Interlocking contoured intramedullary nail fixation for selected diaphyseal fractures of the forearm in adults

BACKGROUND

Plate osteosynthesis is the most commonly used technique for the treatment of diaphyseal forearm fractures in adults. However, application of a plate can disrupt the periosteal blood supply and necessitates skin incisions that may be unsightly, and there is a risk of refracture if the implant is removed. The purpose of this study was to assess the early results of the use of a contoured interlocking intramedullary nail to stabilize displaced diaphyseal fractures of the forearm.

METHODS

Between January 2004 and July 2006, a total of thirty-eight interlocking intramedullary nails were inserted into the forearms of twenty-seven adults. Eighteen nails were used in the radius and twenty were used in the ulna to stabilize a diaphyseal fracture. The mean follow-up period was seventeen months. Functional outcomes were assessed with use of the Grace and Eversmann rating system, and patient-rated outcomes were assessed by completion of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.

RESULTS

The average time to fracture union was fourteen weeks. There was one nonunion of an open comminuted fracture of the middle third of the ulna. There were no deep infections or radioulnar synostoses. According to the Grace and Eversmann rating system, twenty-two patients (81%) had an excellent result; three (11%), a good result; and two (7%), an acceptable result. The DASH scores averaged 15 points (range, 5 to 61 points).

CONCLUSIONS

Our experience indicates that the advantages of an interlocking intramedullary nail system for the radius and ulna are that it is technically straightforward, it allows a high rate of osseous consolidation, and it requires less surgical exposure and operative time than does plate osteosynthesis. We suggest that the interlocking intramedullary nail system be considered as an alternative to plate osteosynthesis for selected diaphyseal fractures of the forearm in adults.

Humeral nonunion

Humerus fractures comprise 5% to 8% of all fractures. Although uncommon, nonunions can present a frustrating challenge to the orthopedic surgeon. Various risk factors that may predispose patients to nonunion include obesity, osteoporosis, alcoholism, smoking, poor bone quality, and scar tissue. Many methods of treatment have been described with various degrees of success. The rates of healing of humeral nonunions by traditional means of internal fixation with bone graft range from 70% to 92%, although in cases of infection, poorly vascularized beds, and open, segmental, or severely comminuted fractures, secondary bony healing may still be compromised.

Use of low-intensity pulsed ultrasound for posttraumatic nonunions of the tibia: a review of patients treated in the Netherlands

BACKGROUND

Low-intensity pulsed ultrasound is effective in fresh fracture healing, resulting in a 40% reduction in healing time. The aim of this study is to determine the effect of ultrasound treatment on established tibia nonunions.

METHODS

The study group consists of all Dutch patients of posttraumatic consecutive nonunion of the tibia, who started their ultrasound treatment between January 2000 and February 2003. In total, 71 cases have been included, which involve 56 men and 15 women. Mean age was 40 years. Low-intensity pulsed ultrasound was the only new treatment. Strict criteria of enrollment minimized any spontaneous healing chance. According to literature, the spontaneous healing rate was between 5% and 30%. The study outcome, healed or failed, was the primary efficacy parameter. Thirty percent was chosen to represent the maximum expected spontaneous healing and was the basis for statistical evaluation. Stratification was performed for the variables at the ultrasound treatment start.

RESULTS

The overall healing rate is 52 of 71 cases (73%). Ultrasound treatment shows a statistical significant higher healing rate compared with that of the spontaneous healing chance (p < 0.0001). Stratification shows no statistical significance for any of the variables analyzed. The long-term follow-up shows high compliance rate and no refractures.

CONCLUSION

Tibia nonunions have a high occurrence rate and cause significant impairment to daily functioning. This study shows that low-intensity pulsed ultrasound is effective in the treatment of established tibia nonunions and can be seen as a good, safe, and cheaper alternative to surgery.

Humeral diaphyseal aseptic non-unions: an Algorithm of management

Successful operative treatment of a humeral shaft non-union may be a challenge for the surgeon. Several treatment options have been reported over the years. A systematic review of the literature was performed. Twenty-three retrieved articles (level of evidence IV) fulfilled our inclusion criteria and dealt with aseptic diaphyseal humeral non-union managed by plating, intramedullary nailing and external fixation based on Ilizarov's principles. Despite an obvious superiority of plating in the treatment of humeral shaft non-unions, there is no doubt that intramedullary nailing as well as external fixation devices have a role. An algorithm of management of the humeral shaft non-unions following a rational approach is suggested.

Biological enhancement of tibial diaphyseal aseptic non-unions: the efficacy of autologous bone grafting, BMPs and reaming by-products

The mandatory stimulus that can optimise the healing pathway can be electrical, mechanical, biological, or a combination of all these parameters. A variety of means has been utilised for biological enhancement, including extracorporeal shock wave, electrical, ultrasound stimulation, the reaming technique of IM nailing, bone graft substitutes, osteogenic cells and bioactive molecules produced by tissue engineering techniques. The aim of this study is to present a review of the existing evidence for the efficacy of reaming, autologous bone grafting and the commercially available growth factors (BMP-2 and BMP-7) for the treatment of aseptic tibial non-unions. The gold standard method of enhancing bone healing in cases of tibial non-union remains the autologous bone graft. Autogenous bone grafts possess osteoconductive, osteoinductive properties and also osteoprogenitor cells. However, their harvesting is associated with high morbidity and many complications reaching percentages of 30%. Intramedullary reamed nailing, either used as an alternative fixation method or as an exchange to a wider implant, offers the unique biomechanical advantages of an intramedullary device, together with the osteoinductive stimulus of the by-products of reaming, and the aptitude for early weight-bearing and active rehabilitation. The safety of administration of the commercial distributed growth factors (BMP-2 and BMP-7), combined with the lack of the morbidity and the quantity restrictions that characterise autologous bone grafts, have given to this family of molecules a principal role between the other bone graft substitutes. On average the union rates reported in the 20 manuscripts that have been evaluated range from 58.3% to 100%, and the average time to union from 12.5 weeks to 48.4 weeks, indicating the significant discrepancies in the reported evidence and the multiplicity of different treatment strategies.

Intramedullary nailing for non-union of the humeral diaphysis: a review

PubMed and Ovid Medline were searched to investigate the role of intramedullary nailing in the treatment of diaphyseal humeral non-union. Of 474 abstracts, 9 retrieved articles fulfilled our inclusion criteria and described management in 166 cases of humeral shaft non-union using several types of intramedullary nails. Union ranged from 40 to 100%; part of the variation could be explained by the quality index of the selected articles. Exchange nailing alone was not effective. Exposure of the fracture site and use of bone grafting were key to successful treatment. The total incidence of severe complications, including radial nerve damage, was very low. Thus, intramedullary nailing in the treatment of humeral shaft non-unions can lead to successful outcomes when associated with autologous bone grafting.

Treatment of diaphyseal forearm nonunions with interlocking intramedullary nails

Fifteen patients with 26 nonunions of diaphyseal forearm fractures were treated with interlocking intramedullary nails and iliac bone grafts. The purpose of our study was to evaluate the rate of successful healing and complications that developed after using this technique. The mean followup was 31 months (range, 25-38 months). The average length of bone loss after freshening the bone ends was 20 mm (range, 10-30 mm). Radiographic union was achieved in 14 patients (96%). Compared with the uninjured contralateral arm, the mean loss of flexion and extension motion at the wrist was 27 degrees. The mean loss of the arc of motion at the elbow was 18 degrees, and the mean loss of rotation of the forearm was 39 degrees. In seven patients, the amount and location of the maximum radial bow on the injured side were significantly different from those of the contralateral arm. Using the rating system of Anderson et al, two patients (13%) had excellent results, six patients (40%) had satisfactory results, six patients (40%) had unsatisfactory results, and one patient (7%) had a failed result. The mean Disabilities of the Arm and Shoulder Score was 35 points (range, 16-56 points), indicating moderate residual impairment. There were three postoperative complications (an incidence of 12%). Our results showed that interlocking intramedullary nailing of nonunions of the diaphysis of the radius or ulna with an open reaming technique should not be considered an adequate alternative to plate fixation of these injuries.

LEVEL OF EVIDENCE

Therapeutic study, Level IV (case series no, historical control group).

Classification of non-union

A substantial number of experimental and clinical studies have established that the cornerstones for successful bone-healing are biomechanical stability and biological vitality of the bone, as they both provide an environment in which new bone can be formed. Non-union of long bones is a significant consequence in treating fractures. Many approaches to prevent fracture non-union have been proposed. Depending on the type and location of the non-union, treatment options include various types of bone fixation, with or without supplemental bone graft or other biophysical enhancements.