BELFAST, NORTHERN IRELAND — A presenter at the British Orthopaedic Association Annual Congress, here, said orthopaedic surgeons should familiarize themselves with adjuvant treatment options for nonunions, because this is an increasingly challenging problem.
Platelet-rich plasma (PRP), low-intensity pulsed ultrasound (LIPU) and other therapies may prove helpful in difficult cases, but Amer Shoaib, MRCS, FRCS(Orth), said many of these methods lack sufficient scientific evidence.
“There a few types of adjuvant therapy that do not involve open surgery. All of these seem to have good level 4 evidence to support their use, but there are few which have good-quality level 1 evidence,” Shoaib, of Manchester Royal Hospital in the United Kingdom, said.
He also discussed the role of bone marrow aspirate and extracorporeal shock wave therapy (ESWT) in resolving nonunion fractures.
“There seems to be effective treatment, but we cannot be confident quantitatively about how much they add to our fracture treatment because there have not been properly controlled trials. But, they may be a good option when autologous bone grafting has failed or in patients awaiting reconstruction surgery. And often, psychologically for the patients, it is a benefit to them to think they are doing something, especially if we can justify using this on the basis of the level 4 evidence,” he said.
He noted LIPU, of which the Exogen (Bioventus) system is an example, is a device patients wear that transmits low-intensity energy. The technology has many level 4 studies and one level 1 paper, which is the same study the U.K. National Institute for Health and Care Excellence (NICE) cited in its technology assessment, Shoaib said. He said LIPU devices are worn various amounts of time — some up to 3 hours daily — which may be a downside of their use.
Of bone marrow aspirate, Shoaib said high-level evidence is lacking, but “it could be an alternative to autologous bone grafting.”
Shoaib noted PRP has been described as an approach that may help jumpstart healing due to the cytokines it contains. However, “NICE has been less positive because of a lack of evidence,” he said.
For ESWT, “The success rates seem to be fairly high and there are potential savings of 65% to 85% compared to autologous bone grafting, so there may be benefits socially. There may be a role for this in patients awaiting surgery or awaiting referral for limb reconstruction surgery,” he said. – by Susan M. Rapp
Shoaib A. The evidence for adjuvants in the management of nonunions. Presented at: British Orthopaedic Association Annual Congress; Sept. 13-16, 2016; Belfast, Northern Ireland.
Disclosure: Shoaib reports no relevant financial disclosures.