Subtrochanteric femur nonunion - Chasing the elusive an analysis of two techniques to achieve union: Nail-plate fixation and plate-structural fibula graft fixation.

INTRODUCTION: The subtrochanteric region is known for its unique biomechanical properties that contribute to challenges in fracture reduction. To ensure optimal fracture healing, achieving robust mechanical stability is essential. There are very few studies in the literature describing the treatment of subtrochanteric fracture nonunion. PURPOSE: To analyze the outcomes of two techniques of revision fixation of nonunion in subtrochanteric femur fracture, namely, nail-plate fixation and plate-structural fibula graft fixation. METHODS: This was a retrospective analysis of subtrochanteric femur nonunion between January 2011 and December 2019. The demographic details, details of the index surgery, details of the revision surgery and the time to final union were collected. The nonunion was divided based on the level of the fracture into high subtrochanteric and low subtrochanteric. Two revision techniques were used: plate-structural fibula graft for high subtrochanteric and nail-plate construct for low subtrochanteric femur fractures RESULTS: Out of the 54 patients that were included, there was malalignment in 53.70 %, medial comminution in 46.3 %, distraction at the fracture site in 44.4 %, lateral trochanteric wall break in 37.03 % and implant failure in 70.37 % of the patients. There were 20 high subtrochanteric and 34 low subtrochanteric fractures. Union was achieved in 53 patients (98.14 %). The mean LEFS score was 71.4 in the nail-plate group and 66.2 in the plate-structural fibula graft group (p 0.003). CONCLUSION: The treatment of subtrochanteric femur fracture nonunion can be a daunting task. The goal is to correct the varus and restore the medial support which will prevent the occurrence of collapse and another failure. We were able to achieve this with both the nail-plate and the plate- structural fibula graft revision methods.

Induced membrane technique versus one-stage autografting in management of atrophic nonunion of long bone in the lower limb: clinical and health burden outcomes.

OBJECTIVE: In this study, we aimed to compare the outcomes of the two-stage induced membrane technique (IMT) and one-stage autografting in the treatment of aseptic atrophic nonunion in lower limb long bones. METHODS: From January 2014 to January 2022, we reviewed all surgically treated long bone nonunion patients, including patients aged 18 years or older with atrophic nonunion, who were either treated with the two-stage induced membrane technique (IMT) or one-stage autografting. Outcome parameters interns of clinical, quality of life and healthcare burden were recorded and retrospectively analysed between the two treatment populations. The follow-up time was at least 1 year. RESULTS: In total, 103 patients who met the criteria for aseptic atrophic nonunion were enrolled. Among them, 41 (39.8%) patients were treated with two-stage IMT, and 62 (60.2%) patients were treated with one-stage autologous bone grafting. The follow-up time was 12 to 68 months, with an average of 28.4 months. The bone healing rate was comparable in both groups (IMT: 92.7% vs. one-stage grafting: 91.9%, P = 0.089) at 12 months post-operation, and the bone healing Lane-Sandhu score was superior in the IMT group (mean: 8.68 vs. 7.81, P = 0.002). Meanwhile, the SF-12 scores of subjective physical component score (PCS) (mean: 21.36 vs. 49.64, P < 0.01) and mental health component score (MCS) (mean: 24.85 vs. 46.14, P < 0.01) significantly increased in the IMT group, as well as in the one-stage grafting group, and no statistically significant difference was found within groups. However, the total hospital stays (median: 8 days vs. 14 days, P < 0.01) and direct medical healthcare costs (median: ¥30,432 vs. ¥56,327, P < 0.05) were greater in the IMT group, while the complications (nonunion 8, infection 3, material failure 2, and donor site pain 6) were not significantly different between the two groups (17.1% vs. 19.4, P = 0.770). CONCLUSION: The data indicate that two-stage method of IMT serves as an alternative method in treating atrophic nonunion; however, it may not be a preferred option, in comprehensive considering patient clinical outcomes and healthcare burden. More evidence-based research is needed to further guide clinical decision-making.

Matched-Pair Analysis: Large-Sized Defects in Surgery of Lower Limb Nonunions.

BACKGROUND: The treatment of large-sized bone defects remains a major challenge in trauma and orthopaedic surgery. Although there are many treatment options, there is still no clear guidance on surgical management, and the influence of defect size on radiological and clinical outcome remains unclear due to the small number of affected patients. The aim of the present study was to determine the influence of defect size on the outcome of atrophic and infected nonunions of the tibia or the femur based on the diamond concept in order to provide recommendations for treatment guidance. PATIENTS AND METHODS: All medical records, surgical reports, laboratory data and radiological images of patients treated surgically for atrophic or infected nonunions of the lower limbs (femur or tibia) between 1 January 2010 and 31 December 2020 were examined. Patients with proximal, diaphyseal or distal nonunions of the femur or tibia who were surgically treated at our institution according to the "diamond concept" and attended our standardised follow-up program were included in a database. Surgical treatment was performed as a one- or two-step procedure, depending on the type of nonunion. Patients with a segmental bone defect ≥5 cm were matched with patients suffering a bone defect <5 cm based on five established criteria. According to our inclusion and exclusion criteria, 70 patients with a bone defect ≥5 cm were suitable for analysis. Two groups were formed by matching: the study group (bone defect ≥5 cm; n = 39) and control group (bone defect <5 cm; n = 39). The study was approved by the local ethics committee (S-262/2017). RESULTS: The mean defect size was 7.13 cm in the study and 2.09 cm in the control group. The chi-square test showed equal consolidation rates between the groups (SG: 53.8%; CG: 66.7%). However, the Kaplan-Meier curve and log-rank test showed a significant difference regarding the mean duration until consolidation was achieved, with an average of 15.95 months in the study and 9.24 months in the control group (α = 0.05, p = 0.001). Linear regression showed a significant increase in consolidation duration with increasing defect size (R2 = 0.121, p = 0.021). Logistic regression modelling showed a significant negative correlation between consolidation rate and revision performance, as well as an increasing number of revisions, prior surgeries and total number of surgeries performed on the limb. Clinical outcomes showed equal full weight bearing of the lower extremity after 5.54 months in the study vs. 4.86 months in the control group (p = 0.267). CONCLUSION: Surprisingly, defect size does not seem to have a significant effect on the consolidation rate and should not be seen as a risk factor. However, for the treatment of large-sized nonunions, the follow-up period should be prolonged up to 24 months, due to the extended time until consolidation will be achieved. This period should also pass before a premature revision with new bone augmentation is performed. In addition, it should be kept in mind that as the number of previous surgeries and revisions increases, the prospects for consolidation decrease and a change in therapeutic approach may be required.

The Diamond Concept Enigma: Recent Trends of Its Implementation in Cross-linked Chitosan-Based Scaffolds for Bone Tissue Engineering.

An increasing number of publications over the past ten years have focused on the development of chitosan-based cross-linked scaffolds to regenerate bone tissue. The design of biomaterials for bone tissue engineering applications relies heavily on the ideals set forth by a polytherapy approach called the "Diamond Concept". This methodology takes into consideration the mechanical environment, scaffold properties, osteogenic and angiogenic potential of cells, and benefits of osteoinductive mediator encapsulation. The following review presents a comprehensive summarization of recent trends in chitosan-based cross-linked scaffold development within the scope of the Diamond Concept, particularly for nonload-bearing bone repair. A standardized methodology for material characterization, along with assessment of in vitro and in vivo potential for bone regeneration, is presented based on approaches in the literature, and future directions of the field are discussed.

Rare Bi-focal Presentation of Avascular Necrosis of the Femoral Head: Successful Targeted Treatment as per the Diamond Concept and Review of the Literature.

Avascular necrosis of the femoral head (AVNFH) is relatively infrequent, but if undiagnosed or untreated, it may result in significant functional disability, and due to severe ongoing pain, a total hip replacement (THR) may be necessitated. Most cases are associated with trauma, but a number of established risk factors exist. Diagnosis can be challenging but relies on clinical history, physical examination, and radiology. X-ray and MRI are used to stage avascular necrosis (AVN) lesions, which in turn influence management decisions. We present a male in his early 40s, diagnosed with a right-sided AVNFH (Ficat-Arlet stage I) five years previously at another centre. A number of risk factors were identified, such as chronic alcohol abuse, smoking, obesity, and Klinefelter's syndrome. A 'watch and wait' approach was adopted, which included advice on reducing risk factors and commencement on aspirin and alendronic acid. However, his pain had recently increased, resulting in a significant reduction in mobility and an increased reliance on opiates. MRI demonstrated progression to Ficat-Arlet stage II, and the appearance of an additional smaller, second lesion located more medially in the same femoral head. Due to his symptom severity, he was offered a THR. In view of his young age, he came to our tertiary referral centre for a second opinion. He elected for a simultaneous dual surgical decompression of both AVN lesions and biological stimulation for bone-guided regeneration. This involved the delivery of growth factor (bone morphogenetic protein), progenitor cells, and a scaffold/matrix. At 36 months post-operatively, he continued to have the full, pain-free weight-bearing functional capacity, with radiographic imaging demonstrating no residual AVN or femoral head structural collapse. This was a unique case of bi-focal femoral head lesions, treated successfully with decompressions and biological enhancement using the 'diamond concept' for bone repair. In similar situations, when salvage of the femoral head is the preferred treatment option, such a strategy should be considered in the surgeon's armamentarium.

[Reconstruction of a metadiaphyseal bone defect after open comminuted fracture of the proximal femur using a modified Masquelet technique]. / Rekonstruktion eines metadiaphysären Knochendefekts nach offener, mehrfragmentärer Fraktur des proximalen Femurs in modifizierter Masquelet-Technik.

The reconstruction of segmental bone defects after surgical treatment of infected delayed unions as well as nonunions, places the highest demands on the surgical technical implementation. After treating the fracture-related infection, guaranteeing biomechanical stability is crucial for the success of the treatment. The presented case describes the successful treatment of an infected delayed union after an open metadiaphyseal comminuted fracture of the proximal femur using a modified Masquelet technique. A solid allogeneic bone graft in combination with autologous cancellous bone were inserted into a 7 cm subtrochanteric defect zone and stabilized with a combined plate and nail osteosynthesis.

Bridge plating with decortication, autologous bone graft, and tight closure: a "stepwise surgical diamond concept" for treatment of nonunion in a series of fifty five patients.

PURPOSE: This study was conducted to assess a stepwise surgical procedure applied to treat a continuous series of patients with aseptic atrophic nonunion of long bones. METHODS: A retrospective review was performed of the medical files of patients treated by the senior author between January 2014 and January 2021 for aseptic atrophic nonunion of long bones using a standard stepwise surgical procedure consisting of four successive surgical steps: bridge locked plating, aggressive osteoperiosteal decortication, copious autologous iliac bone grafting, and tight closure without drainage. Patients were clinically and radiographically evaluated until bone healing, then at final follow-up for the purpose of the study. The primary objective of the study was to assess completion of bone healing; secondary objectives were the time required reaching bone union, the occurrence of complications at the iliac bone graft donor site, and the achievement of bone consolidation after a second attempt of treatment when indicated following failure of the index procedure. RESULTS: There were a total of 55 patients. One patient died from myocardial infarction before reaching bone healing and another one lost from early follow-up. There were remaining 53 patients with 37 years of mean age. The affected bone was the clavicle in five patients, humerus in 14, ulna in four, radius in one, femur in 13, and tibia in 16. The mean follow-up period was 3.4 years. A total of 52 patients (98.1%) achieved bone healing at a mean of 14.8 weeks from the index procedure. The only patient who did not reach bone healing after the index procedure was successfully revised using decortication-bone graft and new fixation with intra-medullary femoral nailing. Four patients (7.5%) developed local complications at the site of iliac bone harvesting. CONCLUSION: Our stepwise surgical procedure was very effective treating aseptic atrophic nonunion of long bones. However, as this study is a retrospective review of a limited series of one surgeon's experience, prospective comparative studies with large number of patients are suitable to define the advantages and indications of the procedure herein described.

[Application of "diamond concept" in treatment of femoral shaft fractures nonunion after intramedullary fixation].

OBJECTIVE: To investigate the effectiveness of the treatment under the guidance of "diamond concept" for femoral shaft fractures nonunion after intramedullary fixation. METHODS: Between January 2014 and December 2016, 21 cases of femoral shaft fractures nonunion after intramedullary fixation were treated with auxiliary plate fixation combined with autogenous iliac graft, and autologous bone marrow concentrate and platelet-rich plasma (PRP) gel under the guidance of the "diamond concept". There were 13 males and 8 females, with an average age of 32.5 years (range, 17-48 years). All fractures were closed femoral shaft fractures. Four patients underwent internal fixation with plate and resulted in nonunion, then they were fixed with intramedullary nails, but did not heal either. The rest 17 patients were fixed with intramedullary nailing. Fracture nonunion classification: 4 cases of hypertrophic nonunion, 17 cases of atrophic nonunion; the length of bone defect was 1-3 mm; the duration from the last treatment to the current treatment was 10-23 months (mean, 14.3 months). The operation time, intraoperative blood loss, the time between operation and full loading, fracture healing time, and complications were recorded. The visual analogue scale (VAS) score and the imaging system of fracture healing of the extremities (RUST) of patients before operation and at last follow-up were recorded to evaluate the fracture healing; the function of the affected limb was evaluated according to the Schatzker-Lambert efficacy score standard at last follow-up. RESULTS: The operation time was 105-160 minutes, with an average of 125.6 minutes; the intraoperative blood loss was 160-580 mL, with an average of 370.5 mL. All incisions healed by first intention, without vascular or nerve injury. All patients were followed up 22-46 months (mean, 26.5 months). All the fractures healed, with a fracture healing time of 3-7 months (mean, 4.8 months). During the follow-up, there was no infection, loosening, implant breakage, re-fracture, and other complications. The VAS score at last follow-up was 0.8±0.3, showing significant difference ( t=7.235, P=0.000) when compared with preoperative score (5.2±3.7); the RUST score was 3.4±0.3, which was significantly higher than the preoperative score (1.5±0.7) ( t=8.336, P=0.000). According to the Schatzker-Lambert effectiveness evaluation standard, the limb function was excellent in 16 cases, good in 4 cases, fair in 1 case, and the excellent and good rate was 95.42%. CONCLUSION: Nonunion after intramedullary fixation of femoral fracture treated with auxiliary plate combined with autogenous iliac graft, autogenous bone marrow concentration and PRP gel in accordance with the "diamond concept" can not only restore the stability of the fracture ends, but also improves the biological environment of the fracture site, and can improve the rate of fracture healing.

The Treatment of Acute Diaphyseal Long-bones Fractures with Orthobiologics and Pharmacological Interventions for Bone Healing Enhancement: A Systematic Review of Clinical Evidence.

BACKGROUND: The healing of long bones diaphyseal fractures can be often impaired and eventually end into delayed union and non-union. A number of therapeutic strategies have been proposed in combination with surgical treatment in order to enhance the healing process, such as scaffolds, growth factors, cell therapies and systemic pharmacological treatments. Our aim was to investigate the current evidence of bone healing enhancement of acute long bone diaphyseal fractures. METHODS: A systematic review was conducted by using Pubmed/MEDLINE; Embase and Ovid databases. The combination of the search terms "long-bones; diaphyseal fracture; bone healing; growth factors; cell therapies; scaffolds; graft; bone substitutes; orthobiologics; teriparatide". RESULTS: The initial search resulted in 4156 articles of which 37 papers fulfilled the inclusion criteria and were the subject of this review. The studies included 1350 patients (837 males and 513 females) with a mean age of 65.3 years old. CONCLUSIONS: General lack of high-quality studies exists on the use of adjuvant strategies for bone healing enhancement in acute shaft fractures. Strong evidence supports the use of bone grafts, while only moderate evidence demineralized bone matrix and synthetic ceramics. Conflicting results partially supported the use of growth factors and cell therapies in acute fractures. Teriparatide showed promising results, particularly for atypical femoral fractures and periprosthetic femoral fractures.

The biology and treatment of acute long-bones diaphyseal fractures: Overview of the current options for bone healing enhancement.

Diaphyseal fractures represent a complex biological entity that could often end into impaired bone-healing, with delayed union and non-union occurring up to 10% of cases. The role of the modern orthopaedic surgeon is to optimize the fracture healing environment, recognize and eliminate possible interfering factors, and choose the best suited surgical fixation technique. The impaired reparative process after surgical intervention can be modulated with different surgical techniques, such as dynamization or exchange nailing after failed intramedullary nailing. Moreover, the mechanical stability of a nail can be improved through augmentation plating, bone grafting or external fixation techniques with satisfactory results. According to the "diamond concept", local therapies, such as osteoconductive scaffolds, bone growth factors, and osteogenic cells can be successfully applied in "polytherapy" for the enhancement of delayed union and non-union of long bones diaphyseal fractures. Moreover, systemic anti-osteoporosis anabolic drugs, such as teriparatide, have been proposed as off-label treatment for bone healing enhancement both in fresh complex shaft fractures and impaired unions, especially for fragility fractures. The article aims to review the biological and mechanical principles of failed reparative osteogenesis of diaphyseal fractures after surgical treatment. Moreover, the evidence about the modern non-surgical and pharmacological options for bone healing enhancement will discussed.

Lateral Cortical Notching in Revision of a Subtrochanteric Fracture Non-union with Breakage of a Cephalomedullary Nail.

INTRODUCTION: Trochanteric fractures are common in elderly patients. Subtrochanteric fracture patterns are challenging due to the risk for non-union. CASE REPORT: We report a case of an 87-year-old woman with a subtrochanteric fracture treated with a cephalomedullary nail. A cutout of the blade occurred in the early follow-up and was treated with exchange nailing elsewhere. Late nail breakage due to non-union more than 4 years after exchange nailing was noted. The fracture healed uneventfully after revision at our institution with exchange nailing including the lateral cortical notching technique whilst applying osteoinductive supplements. CONCLUSION: From our point of view, the concept of lateral cortical notching should be taken into consideration to enhance treatment of subtrochanteric non-unions by exchange nailing.

Application of "diamond concept" in treatment of femoral shaft fractures nonunion after intramedullary fixation / 中国修复重建外科杂志

Objective: To investigate the effectiveness of the treatment under the guidance of "diamond concept" for femoral shaft fractures nonunion after intramedullary fixation. Methods: Between January 2014 and December 2016, 21 cases of femoral shaft fractures nonunion after intramedullary fixation were treated with auxiliary plate fixation combined with autogenous iliac graft, and autologous bone marrow concentrate and platelet-rich plasma (PRP) gel under the guidance of the "diamond concept". There were 13 males and 8 females, with an average age of 32.5 years (range, 17-48 years). All fractures were closed femoral shaft fractures. Four patients underwent internal fixation with plate and resulted in nonunion, then they were fixed with intramedullary nails, but did not heal either. The rest 17 patients were fixed with intramedullary nailing. Fracture nonunion classification: 4 cases of hypertrophic nonunion, 17 cases of atrophic nonunion; the length of bone defect was 1-3 mm; the duration from the last treatment to the current treatment was 10-23 months (mean, 14.3 months). The operation time, intraoperative blood loss, the time between operation and full loading, fracture healing time, and complications were recorded. The visual analogue scale (VAS) score and the imaging system of fracture healing of the extremities (RUST) of patients before operation and at last follow-up were recorded to evaluate the fracture healing; the function of the affected limb was evaluated according to the Schatzker-Lambert efficacy score standard at last follow-up. Results: The operation time was 105-160 minutes, with an average of 125.6 minutes; the intraoperative blood loss was 160-580 mL, with an average of 370.5 mL. All incisions healed by first intention, without vascular or nerve injury. All patients were followed up 22-46 months (mean, 26.5 months). All the fractures healed, with a fracture healing time of 3-7 months (mean, 4.8 months). During the follow-up, there was no infection, loosening, implant breakage, re-fracture, and other complications. The VAS score at last follow-up was 0.8±0.3, showing significant difference ( t=7.235, P=0.000) when compared with preoperative score (5.2±3.7); the RUST score was 3.4±0.3, which was significantly higher than the preoperative score (1.5±0.7) ( t=8.336, P=0.000). According to the Schatzker-Lambert effectiveness evaluation standard, the limb function was excellent in 16 cases, good in 4 cases, fair in 1 case, and the excellent and good rate was 95.42%. Conclusion: Nonunion after intramedullary fixation of femoral fracture treated with auxiliary plate combined with autogenous iliac graft, autogenous bone marrow concentration and PRP gel in accordance with the "diamond concept" can not only restore the stability of the fracture ends, but also improves the biological environment of the fracture site, and can improve the rate of fracture healing.

Does Age Influence the Outcome of Lower Limb Non-Union Treatment? A Matched Pair Analysis.

BACKGROUND: Fractures in elderly patients are common and have severe implications on a socioeconomic level, as musculoskeletal integrity and competence is crucial for independence. Changes in both composition and biology of bones during aging potentially affect fracture healing adversely. The current study sought to determine the influence of age on the outcome of non-union therapy of atrophic and hypertrophic non-unions based on the "diamond concept", as well as to evaluate the well-known risk factors impairing bone healing. PATIENTS AND METHODS: All medical records, operative notes, lab data, and radiological imaging of patients that received surgical treatment of both atrophic and hypertrophic non-unions of the femur or tibia between 1 January 2010 and 31 December 2016 were thoroughly reviewed and analyzed. Patients who participated in our standardized follow-up for at least 12 months were included into a database. Patients older than 60 years were matched with patients younger than 60 based on five established criteria. The study was approved by the local ethics committee (S-262/2017). According to our inclusion criteria, a total of 76 patients older than 60 years were eligible for analysis. Via matching, two groups were formed: study group (SG; >60 years; n = 45) and control group (CG; <60 years; n = 45). RESULTS: Twelve months subsequent to treatment, the consolidation rate was equivalent in both groups (SG: 71% vs. CG: 67%). The consolidation for all patients before matching was 73%. The clinical results for the complete collective were no pain or pain with high or medium strain for 62.5%, whereas 29.6% had pain with low strain or constant pain. 7.87% had no pain levels given. Logistic regression modeling showed no influence of age >60 years on radiological or clinical outcome, whereas a significant negative correlation was revealed between patients aged 40-49 years and radiological non-union consolidation (b = -1.145 and p = 0.048). In addition, diabetes had a negative influence on non-union therapy (b = -1.145 and p = 0.048). As expected, the clinical outcome correlated significantly with the radiological outcome (p < 0.001). CONCLUSION: Surgeons should optimize both modifiable risk factors such as diabetes mellitus, as well as surgical treatment in order to achieve the best possible outcome in elderly patients. Elderly patients benefit from osseous consolidation by enabling and maintaining musculoskeletal competence due to the close correlation between clinical and radiological outcome. Advanced age alone does not negatively influence the outcome of non-union therapy and should, therefore, not be considered a risk factor. In contrast, patients in their fifth decade suffering from lower limb non-unions should be considered as high-risk patients and treatment should be modified accordingly.

The 'diamond concept' for long bone non-union management.

Long bone non-union continues to be a significant worldwide problem. Since its inception over a decade ago, the 'diamond concept', a conceptual framework of what is essential for a successful bone healing response, has gained great acceptance for assessing and planning the management of fracture non-unions. Herein, we discuss the epidemiology of non-unions, the basic science of bone healing in the context of the diamond concept, the currently available results and areas for future research.

Humeral shaft non-union in the elderly: Results with cortical graft plus stem cells.

INTRODUCTION: Humeral shaft is a common site of fracture non-union. Biology and bone quality represent some of the problems that the orthopaedic surgeon has to face up in the elderly. The goals of treatment of humeral shaft non-union are the achievement of mechanical stability and creation of a favourable biologic environment. Bone graft and stem cells are some of the augmentation techniques available to reach these goals. PURPOSE: Evaluation of the outcomes of humeral shaft non-union in elderly population treated with cortical allograft and stem cells. MATERIAL AND METHODS: A cohort of 21 patients with humeral shaft non-union was reviewed. Inclusion criteria were patients aged more than 65 years, with a diagnosis of humeral shaft non-union treated with cortical allograft and stem cells. Primary endpoints were 'bone healing' and 'time-to-union'. Secondary endpoints were shoulder and elbow function and patients' quality of life with Oxford Shoulder Score (OSS), Constant score and EuroQol-5D (EQ-5D). RESULTS: 6 patients met the inclusion criteria. In 5 of them, the cortical allograft was opposite to a plate, whereas in the other one a "Sandwich" technique was chosen because of large osteolysis. 'Bone healing' occurred in all patients after a mean of 3.3 months (range 2-5). In all but two patients, the elbow range of motion was in almost normal range (15-130). The mean OSS was 35.8 (+/- 6.4), whereas the mean Constant was 53.3 (+/- 2.2). The mean EQ-5D index was 0.451 (+/- 0.21). DISCUSSION: Bone healing occurred in all patients, with a time-to-union comparable or even better compared with other series. The use of cortical bone graft provide both stability and biological benefit, whereas stem cells improve the non-union environmental biology. Functional outcomes were lower than other series and patients' quality of life was similar to Italian elderly women. CONCLUSION: The use cortical allograft with stem cells is a viable strategy to treat humeral shaft non-union in the elderly.

Reamer-Irrigator-Aspirator bone graft harvesting for treatment of segmental bone loss: analysis of defect volume as independent risk factor for failure.

INTRODUCTION: The management of segmental bone loss poses a significant clinical challenge. The purpose of this study was to conduct a retrospective evaluation of our experience in treating segmental bone loss, using Reamer-Irrigator-Aspirator (RIA)-harvested autologous bone graft. MATERIALS AND METHODS: Between June 2008 and March 2015, 81 patients were treated with the RIA technique for multiple purposes. Inclusion criteria for this study were skeletal mature patients with segmental bone loss, due to acute trauma or non-union, who were treated with RIA-harvested bone graft. Exclusion criteria were skeletal immaturity, pathological fractures and indications for the RIA system other than bone graft harvesting. The primary outcome parameter was clinical and radiographical bone healing. RESULTS: During the study period, 72 patients met the inclusion criteria. In total, 39 patients (54.2%) were classified as having clinical and radiographical bone healing. Although univariate analysis could not reveal any significant influence of specific risk factors to predict the outcome, there was a trend towards statistical significance for defect volume. Further analysis indeed revealed that smaller defect volumes (< 8 cm3) had a lower risk of non-union. CONCLUSIONS: In approximately half of our study population, the use of the RIA technique for autologous bone graft harvesting in cases of segmental bone loss resulted in a successful outcome with bone healing. Defect size seems to be a critical issue regarding the outcome. Although our results are less promising than previously published, the RIA technique has its place in the treatment algorithm of segmental bone defects.

[Pseudarthroses of the long bones]. / Pseudarthrosen der langen Röhrenknochen.

Pseudarthrosis development is dependent on the presence of individual risk factors in approximately 10% as a result of fractures and are more frequently located in the region of the long bones. The development of non-union regularly results in prolonged pain and reduced functionality of the affected limb. The resulting clearly increased socioeconomic costs are caused by the complex operative treatment strategies and increased indirect costs, which include lost wages, social benefits and compensation. Altogether, non-unions require a differentiated therapeutic treatment strategy. The analysis of the non-union based on the diamond concept is the key for a successful planning and therapy. In this context, the use of focused, high-energy extracorporeal shock waves may be possible under specific circumstances; however, in most cases an operative revision is necessary to optimize the biomechanical stability and/or improve the local biology.

Successful management of femoral trauma in a through-knee amputee with a previous malunited fracture: Implications and functional outcome.

BACKGROUND: After amputation patients are more likely to injure their residual limb. An injury of a previously amputated limb, especially if the residuum is not anatomically normal, poses a dilemma for management. Case Description and Methods: This case report discusses a femoral fracture sustained proximal to a through-knee amputation. Findings and outcomes: The fracture was at the site of a malunited fracture. A shortening osteotomy with bone graft was undertaken to improve alignment and prosthetic fit and remove poor-quality bone. This was stabilised using an intramedullary nail, supplemented with an anti-rotation plate. This fracture went on to uneventful union, and the patient was able to comfortably use a prosthesis with increased functionality compared with prior to the recent injury. DISCUSSION: This management enabled quick healing of the fracture without the need to resort to a more proximal amputation. CONCLUSION: In these unusual cases, careful planning is necessary to ensure all aspects of the problem is dealt with. Each case should be treated on its own merits. Clinical relevance This case demonstrates the difficulty in care of complex limb trauma and offers a solution for management of similar cases. Excellent results are possible when all surgical options are considered.

Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) for the prediction of non-union consolidation.

INTRODUCTION: Non-union perfusion can be visualized with dynamic contrast-enhanced (DCE) MRI. This study evaluated DCE-MRI to predict non-union consolidation after surgery and detect factors that affect bone healing. MATERIALS AND METHODS: Between 2010 and 2015 non-union perfusion was prospectively quantified in 205 patients (mean age, 51.5 years, 129 men, 76 women) before intervention and at 6, 12, 26, 52 and more weeks follow-up. DCE-MRI results were related to the osseous consolidation, the ability to predict successful outcome was estimated by ROC analysis. The relevance of the body mass index (BMI) and the non-union severity score (NUSS) to the healing process was assessed. RESULTS: Tibial (n=99) and femoral (n=76) non-unions were most common. Consolidation could be assessed in 169 patients, of these 103 (61%) showed eventual healing and demonstrated higher perfusion than in failed consolidation at 6 (p=0.0226), 12 (p=0.0252) and 26 (p=0.0088) weeks follow-up. DCE-MRI at 26 weeks follow-up predicted non-union consolidation with a sensitivity of 75% and a specificity of 87% (false classification rate 19%). Higher BMI (p=0.041) and NUSS (p<0.0001) were associated with treatment failure. CONCLUSIONS: DCE-MRI perfusion analysis after non-union surgery predicts successful outcome and could facilitate the decision of early intervention. NUSS and BMI are important prognostic factors concerning consolidation.

Surgical treatment of neglected hip fracture in children with cerebral palsy: case report and review of the literature.

CASE: A clinical case of a 15-year-old cerebral palsy child with a Sandhu type 2 neglected femoral neck fracture is presented. The patient was treated using cannulated screws and cancellous bone graft augmented with mesenchymal stem cells. At 6 months after the surgery complete fracture healing was observed. CONCLUSION: To early diagnose this fractures, it is mandatory to perform a comprehensive clinical and radiological evaluation including also a second level imaging. The use of cannulated screws with cancellous bone graft and MSCs is a viable treatment option in these patients.