Despite continued advances in the treatment of long bone fractures, nonunion remains a rare but difficult challenge. Numerous etiologies exist, including interposition of soft tissues, distraction at the fracture site, infection, decreased vascular supply, and excessive motion.
To successfully overcome nonunions, one must address all of the potentially correctable factors. Once the goal of stable fixation has been met, attention may then be given to other local factors that contribute to delayed healing. These include the availability of recruitable healthy multipotential cells and local growth factors.
Because autologous cancellous bone grafting has been the standard, an alternative substance or method must be equally successful in achieving union, as well as providing some increased benefit, to justify its use. Percutaneous administration of autologous bone marrow and allograft demineralized bone matrix (DBM) offers the advantage of decreased morbidity associated with the classic open grafting techniques. Additional advantages include decreased cost and hospital stay, as the procedures are performed in an outpatient setting.
This article details the experience in a prospective series of patients with established long bone nonunions and stable fixation who underwent percutaneous grafting with a combination of autologous bone marrow and allograft DBM.
MATERIALS AND METHODS
The following criteria were used for inclusion in this study:
* Established nonunion >6 months after injury with no evidence of progressive healing for the previous 3 months. In many patients, tomograms were necessary to adequately document the nonunion.
* No evidence of motion at the nonunion site. Preoperative work-up included appropriate roentgenographic investigation to document the presence of a stiff nonunion. Often, stress radiographs or intraoperative fluoroscopic demonstration of an absence of motion was necessary. Only patients with rigid nonunions were included in the study.
* No surgical or treatment intervention in the past 3 months.
* No evidence of active infection, although a history of a resolved infection was not a contraindication.
* No smoking for 6 weeks before and during the treatment period. If patients were smoking at the time of the first evaluation, they were asked to discontinue. These patients were then reevaluated at 6 weeks with new studies to document that there had been no progressive healing. If there was a question as to the patient's nonsmoking compliance, carboxyhemoglobin levels were obtained. Likewise, if there was a question of compliance throughout the study, these levels were again performed.
Postoperative Radiographic and Clinical Evaluation
* A state of good overall health. No concurrent interfering medications such as cortisone preparations or antimetabolic drugs were allowed in the study.
Patients meeting all of the above criteria were entered into the protocol. Sixty-six patients with nonunions underwent 69 percutaneous grafting procedures. Overall, 37 men and 29 women with an average age of 42 years (range: 15-81 years) were studied.
Nonunion etiology included 27 open fractures, 30 closed fractures, and 12 postoperative nonunions (6 ankle fusions and 6 tibial or femoral osteotomies). Twenty-four of 66 patients (36%) had a previous history of infection^ There were a variety of nonunion sites (N=69); the tibia was the most common bone injected (36), followed by the femur (16), failed ankle fusion (6), humerus (4), ulna (4), radius (2), and fibula (1). Of the types of nonunions at initial presentation, 22 were hypertrophic and 47 were atrophic.
Following the outpatient procedure, each participant was followed on a regular basis with clinical examinations, roentgenograms, and functional evaluations. Union was determined on the basis of clinical evaluation and strict roentgenographic criteria (Table). Roentgenograms were taken at 3, 6, and 1 2 weeks, and then every 2 to 3 months until a determination could be made with regard to healing. Anteroposterior, lateral, and two oblique views were taken during office visits and, in cases where bony bridging was questionable, tomograms were also obtained.
In addition, patients evaluated their pain, activity, emotional acceptance, functional ability, and need for assistive devices at each office visit by completing the Musculoskeletal Tumor Society's Functional Evaluation, which had been modified to a patient-based format.
Radiographically, a patient was considered healed when cortical bridging was at least 75% of the circumference of the bone and pain at the nonunion site had resolved. Four patients who had an initial partial response with symptomatic relief were reinjected a second time in an attempt to complete the cortical bridging. The average follow-up period was 2 1 .7 months (range: 3 months to 4.5 years).
Figure 1. Intertrochanteric nonunion showing cannula/trocar used to access the defect under fluoroscopic guidance.
Patients were taken to the operating room where, under general or spinal anesthetic, the procedure was performed. For purposes of consistency, a hematologist/oncologist experienced in bone marrow transplantation harvested the autologous marrow from either the anterior or posterior iliac crest using standard technique.1
After appropriate prepping and draping, the area of the nonunion was located and mapped out using fluoroscopic control A 1.5-cm skin incision was made over each grafting area. The skin incisions were located in a manner so that the grafting material could be placed circumferentially around the nonunion site. In the majority of patients, two incisions were necessary.
A special set of percutaneous instruments (Wright Medical Technology, Ine, Arlington, Tenn) was designed to facilitate percutaneous localization, dissection, biopsy, and graft introduction around the nonunion site. A trocar was placed through a cannula into the incision and gently inserted down to bone (Figure 1). Care was taken to prevent direct injury or traction of the neurovascular structures throughout the procedure.
Generally, the recognized principles for placement of external fixation pins as reported by Paley et al2 were followed. After the trocar was placed down to bone, the position was checked with fluoroscopy. The trocar was then removed leaving the cannula sheath in place.
Case 1. A 55-year-old man with malignant fibrocystic sarcoma of the right proximal tibia. The patient was treated with wide local resection with replacement of the resected tibia with a cemented allograft intercalary construct. The patient has union at the proximal iunction site 8 months postoperative, but he does not have bridging bone at the distal site. At this time, the patient was treated percutaneously with a mixture of demineralized bone matrix and autologous marrow (A). Anteroposterior roentgenogram 2 months after the percutaneous treatment shows mature bridging callus (B). Anteroposterior roentgenogram 8 months after percutaneous treatment shows mature remodeled callus in the area of the graft placement (C). At this point in treatment, the patient was asymptomatic for weight bearing and resumed normal activities.
Case 2. A 52-year-old woman with an atrophic humerus fracture secondary to an automobile accident. The patient was treated for her nonunion with an intramedullary rod and autologous iliac crest graft (A). The patient still had a painful nonunion 6 months after surgery. The patient has new callus bridging the nonunion site 2 months after percutaneous treatment with autologous marrow and demineralized bone matrix (B). She was asymptomatic and resumed normal activities at this time. The patient had corticalization of the nonunion site 5 months after percutaneous injection.
Figure 2. Ignite ICS Biocomposite (Wright Medical Technology, Ine, Arlington, Tenn) used in an intertrochanteric fracture. The preoperative film 10 months before injury (A). Intraoperative image showing the Ignite ICS Cannula (Wright Medical Technology, Ine) (B). Eight-week postoperative film showing callus formation and apparent bony union (C).
Depending on the consistency of the tissue, various percutaneous periosteal elevators were used to develop a subperiosteal envelope around the nonunion site. A modified curetting instrument was used to obtain tissue from the nonunion for biopsy and culture. The anatomy and consistency of the tissue dictated whether a debridement was performed. In most cases, this was not necessary, and the intramedullary space and intracortical fibrous tissue were not otherwise disturbed.
Once an adequate potential space was created by developing this subperiosteal envelope, the cannula was then positioned for intrusion of the graft material.
Aspirated autologous marrow was mixed with a DBM composite. The material was briefly mixed and inserted into a funnel device that was placed onto the cannula. A plunger was then used to insert the combined material into the space previously developed.
The goal was to have a layer of injected material surrounding the entire circumference of the bone and approximately 1-2 cm proximal and distal to the bony discontinuity. This was usually accomplished via two incisions. Care was taken to avoid excessive volume in areas where compartment syndrome or neurovascular compromise were of concern. The incision for the bone marrow harvest was closed with an adhesive strip closure. The recipient's grafting incisions were closed with either a subcuticular absorbable suture or adhesive strips. No other procedure was performed, such as screw removal or dynamization, nor was a tourniquet used (Figure 2).
Postoperatively, patients recovered and were discharged through the outpatient department. No other changes were made in the patients' management, immobilization, or weight bearing status. For example, if patients were weight bearing in an orthosis preoperatively, they continued using such a device postoperatively. If they were partially weight bearing preoperatively, they continued with this activity restriction. No changes in fixation or other variables were instituted subsequent to the percutaneous procedure.
The average follow-up period was 21.7 months (range: 3 months to 4.5 years). A total of 61 sites (88%) healed following percutaneous treatment. Eight nonunions required a second percutaneous procedure for delayed healing, of which seven went on to achieve union. At the last followup, one nonunion persisted, most likely due to continued nicotine use by the patient. Six nonunions were interpreted as frank failures.
The average time from the date of injury to the injection was 21 months (range: 6 months to 16 years). The average time to union after the bone marrow and DBM injection was 8.1 months (range: 2 months to 3 years), which correlates with previous marrow injection studies35 as well as open iliac crest grafting results.6,7
There were no perioperative complications that could be attributed to the percutaneous harvesting and grafting technique. Most patients had only moderate discomfort at their donor iliac crest site, as well as their recipient site, which generally resolved in a few days. Several patients developed subcutaneous, hard bony masses several centimeters in diameter at the injection site. These areas were first evident 3-6 weeks post injection and resolved without intervention over several months.
Autologous bone grafting for nonunion remains the standard by which all other techniques are compared. Autologous bone potentially contributes three vital local components: osteoconduction, osteoinduction, and osteogenic cells.811 To be successful, an alternative technique must also provide these osteogenic components. More recently, numerous substitutes to autologous bone grafting have been reported with varying degrees of success.12-19
Connolly et al3,4,20 and Healey et al21 have demonstrated that percutaneous injections of autologous bone marrow can successfully treat between 78% and 95% of nonunions. Tiedeman et al5 and Wilkins and Stringer22 have published data on the use of DBM in the treatment of osseous defects. As reported by Connolly,3 perhaps one of the more important facets of this percutaneous procedure is that it encourages early treatment of fractures when healing problems are anticipated or becoming evident.
In this study, an attempt was made through the inclusion criteria to eliminate as many variables as possible in this group of patients. Basically healthy, nonsmoking patients with rigid or stiff nonunions were entered. Overall, no changes in fixation, activity, or weight bearing status were instituted. The only intervention was the percutaneous procedure and its short perioperative influences. However, variabilities in the osteoinductive activity of DBM are known to exist.
The ability of bone marrow to form bone was first demonstrated in the late 1860s by Goujon.23 Since then, a variety of laboratory and animal studies have demonstrated the presence of osteogenic precursor cells in marrow capable of bone formation.9,10,14,24,25
The clinical use of autologous bone marrow has been shown to also be effective in the treatment of fracture nonunions.3,4,20,21 Despite this success, marrow lacks certain properties, such as readily available growth factors, that are important elements involved in efficient bone healing.
Demineralized bone grafts were also used in the late 1800s by Senn26 for reconstruction of osseous defects. Numerous studies have investigated the use of this material in a variety of situations. Animal studies have demonstrated the reliable use of demineralized grafts to promote osteogenesis and bridge segmental osseous defects.27-30
A clinical study performed by Urist and Dawson31 in 1981 also proved successful using this material. They demonstrated that DBM provides both osteoinduction (the phenotypic conversion of multipotential cells into osteoblasts) and osteoconduction (the scaffolding for bone ingrowth).11,31,32 As already stated, bone marrow provides osteogenic cells that have the potential for differentiation. Therefore, the combination of autogenous bone marrow and allograft DBM theoretically provides the necessary elements to aid in successful bone healing by significantly changing the local milieu.
Numerous animal studies have confirmed the synergistic effect of these two materials,3234 although few clinical studies have been performed. Tiedeman et al5 demonstrated successful use of a composite of DBM and bone marrow in nonunions, intended fusion sites, acute fractures with comminution, and to fill cavitary lesions.
Similarly, our current study also revealed excellent results with these materials, with an overall union rate of 88%. These figures, as well as the time to achieve union, are comparable to those for the standard open techniques using cancellous iliac crest bone graft.
Although open graft harvesting and implantation is thought to be a relatively simple procedure, it has not been without complication. Donor site problems include infection, bleeding, hematoma, chronic pain/painful scar formation, fracture, hernias, sensory loss, and occasional gait disturbances.6,35-40
Aside from these potential complications, additional morbidity can occur with opening the recipient nonunion site. Possible further devascularization in this area can result in increased risks of infection and additional delay in fracture healing.41 As demonstrated in Connolly's work, as well as this study, percutaneous harvesting and graft injection are associated with greatly reduced morbidity compared with the classic open grafting technique. In addition, advantages such as decreased cost and hospital stay have also been observed.
One must include, however, a discussion of the potential of disease transmission when allogeneic material is used. Patients must be counseled and informed of these risks prior to any surgical procedure. Strict screening programs have been instituted for nearly all tissue banks, especially those affiliated and approved by the American Association of Tissue Banks.42
Current data offer encouraging results for the use of percutaneous autologous bone marrow and allograft DBM composite for the treatment of rigid nonunions. Although this technique does not promote more rapid healing than classic open surgical grafting, it offers the benefits of decreased morbidity, reduced costs, and shorter hospital stays. With the successful treatment of nonunions now established, the potential benefits associated with acute fracture management remain to be studied.
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Postoperative Radiographic and Clinical Evaluation