Pelvic ring and acetabular fracture: Concepts of traumatological forensic interest.

Fractures of the pelvic ring and acetabulum generally result after high energy trauma. Pelvic fractures, especially, are considered complex injuries from a therapeutic point of view, in relation to the frequent coexistence of skeletal and / or parenchymal lesions affecting other areas, and the abundant bleeding invariably associated with the latter. The systematic study of these injuries, starting from the 1950s, has led to a significant prognostic improvement, while generally remaining a non-negligible degree of disability. The knowledge of the characteristics of the lesions and of the classification systems, as well as an accurate assessment of the anatomo-functional repercussions, represent therefore the fundamental prerequisites for the correct assessment of physical damage. Herein, we aim to examine whether the medico-legal assessment parameters of physical damage being used in Italy and Europe are appropriate and consistent with the complexity of similar injuries.

Promotion of hand hygiene: the experience of the orthopaedic hospital Gaetano Pini-CTO, Milan, Italy.

BACKGROUND: Hand hygiene is the primary preventive measure against health care-associated infections in terms of cost-effectiveness. In 2005, the WHO proposed the "Global Patient Safety Challenge" campaign, with the aim of reducing the overall incidence of such infections, through multimodal programs and strategies, interactive training tools and standardised methods for monitoring compliance. STUDY DESIGN: On the basis of project "Rimani", sponsored by the Health and Social Care Authority of Emilia-Romagna, the Istituto Ortopedico Gaetano Pini has implemented a project which seeks to increase healthcare staff's compliance with hand hygiene. METHODS: A multidisciplinary working group was created to prepare the project documents. Starting from 5th April 2015, twenty operational units were asked to produce information and training material. On 5th May, during a conference, a committee selected the three best works. The material was distributed on a monthly basis to the various departments. In addition to the training, the specifically trained operators of the Medical Monitoring Department carried out direct hand washing tests, filling out appropriate checklists. Non-compliance relating to the technique recorded in 2014 and 2015 was compared and a statistical analysis was conducted using Student's t-test for paired data. RESULTS: Three tests were carried out in 2014. Ninety-nine cases were monitored and 5 non-compliance cases were reported, concerning the execution of the procedural steps, the running time and closing the tap with one's hands at the end of the wash. In 2015 two tests, involving 30 operational units, were carried out. 60 observations were performed, and no non-conformities emerged concerning the technique. Statistical analysis showed a significant reduction of non-compliances between the 2014 and 2015 P = 0.000). CONCLUSION: The results obtained agree with the main findings in literature. The comparison between the 2014 and 2015 tests shows a trend of improvement in the wash technique. This confirms the effectiveness of a multidisciplinary approach and recognises the active and participatory involvement suggested by the WHO.

Soft-tissue defects of the Achilles tendon region: Management and reconstructive ladder. Review of the literature.

INTRODUCTION: Defects of the Achilles tendon region represent a challenge for reconstructive surgeons. Several options are available but there is still no reconstructive ladder for this specific and tricky area. An up-to-date reconstructive ladder according to local and general conditions is proposed based on our multicentre experience and an extensive review of the English literature on PubMed. MATERIALS AND METHODS: An extensive review of the English literature was performed on PubMed using the following key-words: "Achilles region", "heel", "soft-tissue reconstruction", "flaps", "grafts" and "dermal substitutes". RESULTS: A total of 69 complete papers were selected, covering the last thirty years' literature. Although most of the studies were based on limited case-series, local and general conditions were always reported. A comprehensive reconstructive ladder of all the available reconstructive techniques for the Achilles region has been created based on our personal multicentre experience and the results of the literature review. CONCLUSIONS: The reconstructive ladder is a concept that is still a mainstay in plastic surgery and guides decisions in the repair strategy for soft tissue defects. The optimal solution, according to the experience of the surgeon and the wishes of the patient, is the one that implies less sacrifice of the donor site. Perforator flaps should be the first-line option for small-to-moderate defects; the distally-based sural flap is the most reported for moderate-to-large defects of the Achilles region, and free flaps should be reserved mainly for complex and wide reconstructions.

The use of Reamer-irrigator-aspirator in the management of long bone osteomyelitis: an update.

PURPOSE: Reamer-irrigator-aspirator (RIA) is an innovative device that its indications have recently been expanded to the management of long bone infections. METHODS: In this narrative review, we summarise the most important studies in the field and we present the current open questions pertaining to the use of RIA in the management of osteomyelitis of long bones. RESULTS: The relevant literature is sparse and low quality. Nevertheless, the use of RIA for infected cases has yielded promising outcomes in specialised centres. Technical aspects that merit special attention in osteomyelitis of long bones are its inapplicability in small diameter long bones, the inadequate debridement of wide metaphyseal areas and the potential bleeding sequelae. The use of RIA in open fracture management to reduce infection risk has not gained acceptance. The antibiotic impregnated nails and rods constitute a complimentary strategy for the management of infections. CONCLUSIONS: The use of RIA for the management of long bone infections is an innovative and promising strategy. High quality studies are needed to shed light in its efficacy compared to conventional methods of management of osteomyelitis of long bones.

A sneaky surgical emergency: Acute compartment syndrome. Retrospective analysis of 66 closed claims, medico-legal pitfalls and damages evaluation.

BACKGROUND: Acute compartment syndrome (ACS) is a clinical condition with potentially dramatic consequences, therefore, it is important to recognise and treat it early. Good management of ACS minimises or avoids the sequelae associated with a late diagnosis, and may also reduce the risk of malpractice claims. The aim of this article was to evaluate different errors ascribed to the surgeon and to identify how the damage was evaluated. MATERIALS AND METHODS: A total of 66 completed and closed ACS cases were selected. The following were analysed for each case: clinical management before and after diagnosis of ACS, imputed errors, professional fault, damage evaluation and quantification. Particular attention was paid to distinguishing between impairment because of primary injury and iatrogenic impairment. Statistical analyses were performed using Fisher's exact test and Pearson's correlation. RESULTS: The most common presenting symptom was pain. Delay in the diagnosis, and hence delay in decompression, was common in the study. A total of 48 out of 66 cases resolved with the verdict of iatrogenic damage, which varied from 12% to 75% of global capability of the person. A total of $394,780 out of $574,680 (average payment) derived from a medical error. CONCLUSIONS: ACS is a clinical emergency that requires continuous clinical surveillance from both medical and nursing staff. The related damage should be evaluated in two parts: damage deriving from the trauma, so that it is considered inevitable and independent from the surgeon's conduct, and damage deriving from a surgeon's error, which is eligible for an indemnity payment.

Validation of the Non-Union Scoring System in 300 long bone non-unions.

INTRODUCTION: Non-union of long bones is a significant consequence of fracture treatment. The ideal classification for non-union of long bones would give sufficient significant information to the orthopaedic surgeon to enable good management of the treatment required and to facilitate the creation of comparable study groups for research purposes. The Non-Union Scoring System (NUSS) is a new scoring system to assist surgeons in the choice of the correct treatment in non-union surgery. The aim of this study was to determine the evidence supporting the use of the NUSS classification in the treatment of non-unions of long bones and to validate the treatment algorithm suggested by this scoring system. MATERIALS AND METHODS: A total of 300 patients with non-union of the long bones were included in the clinical study. RESULTS: A radiographic and clinical healing was reached in 60 of 69 non-unions (86%) in group 1 (0-25 points), in 102 of 117 non-unions (87%) in group 2 (26-50 points), and in 69 of 84 (82%) in group 3 (51-75 points). The mean time to clinical healing was 7.17 ± 1.85 months in group 1, 7.30 ± 1.72 months in group 2 and 7.60 ± 1.49 months in group 3. The mean time to radiographic healing was 8.78 ± 2.04 months in group 1, 9.02 ± 1.84 months in group 2 and 9.53 ± 1.40 months in group 3. DISCUSSION: There are few articles in the scientific literature that examine the classification systems for non-union. CONCLUSIONS: A statistical analysis of the first results we have obtained with the use of NUSS showed significant rates of union in all the evaluated groups. This indicates that NUSS could be an appropriate scoring system to classify and stratify non-unions and to enable the surgeon to choose the correct treatment.

Megaprosthesis in post-traumatic and periprosthetic large bone defects: Issues to consider.

INTRODUCTION: The recent evolution of prosthesis technology has enabled the surgeon to replace entire limbs. These special prostheses, or megaprostheses, were developed for the treatment of severe oncological bone loss; however, the indications and applications of these devices have expanded to other orthopaedic and trauma situations. For some years, surgeons have been implanting megaprostheses in non-oncological conditions, such as acute trauma in severe bone loss and poor bone quality; post-traumatic failures, both aseptic and septic (represented by complex non-unions and critical size bone defects); major bone loss in prosthetic revision, both aseptic and septic; periprosthetic fractures with component mobilisation and poor bone stock condition. The purpose of this study was to evaluate retrospectively the complications during and after the implantation of megaprosthesis of the lower limb in post-traumatic and prosthetic bone loss, and to propose tips about how to avoid and manage such complications. MATERIALS AND METHODS: All the complications and difficulties we have encountered during or after the implantation of megaprosthesis in non-oncology patients were evaluated retrospectively. A total of 72 patients were treated with large resection mono-and bi-articular prostheses between January 2008 and January 2014. RESULTS: The main critical problems found in the study were: restoration of the correct length and rotation of the limb; reconstruction of the knee extensor mechanism; trochanteric reconstruction; stability/dislocation of the implant; mobility/range of motion (ROM) of the implant; skin cover; sepsis, and bone quality. CONCLUSION: Megaprosthesis in severe bone loss can be considered as an available solution for the orthopaedic surgeon in extreme, appropriately selected cases. This type of complex surgery must be performed in specialised centres where knowledge and technologies are present. Patients with severe bone loss should not be treated in the same way as oncology patients because life expectancy is definitely longer; therefore, the surgical technique and the system implantation must be extremely rigorous to ensure longevity of the prosthesis. The characteristics of the bone and soft tissue conditions in these patients are very different from those presented by oncology patients, which creates critical problems that the surgeon should be able to manage to avoid serious complications.

Incidence of donor site morbidity following harvesting from iliac crest or RIA graft.

INTRODUCTION: Clinical management of non-union of long bone fractures and segmental bone defect is a challenge for orthopaedic surgeons. The use of autologous bone graft (ABG) is always considered the gold standard treatment. Traditional techniques for harvesting ABG from iliac crest usually involve several complications, particularly at the donor site. The Reamer-Irrigator-Aspirator (RIA) is an intramedullary reaming system that generates a large volume of cancellous bone material in a single-step reaming process; this bone material can be collected and potentially used as an ABG source. Our interest is to compare the complications associated with the standard technique of harvesting from iliac crest with those of the innovative RIA harvesting device. MATERIALS AND METHODS: A database of 70 patients with long bone non-unions was studied. The patients were divided into two groups according to the surgical harvesting technique used: RIA system ABG (35 patients) and iliac crest ABG (35 patients). RESULTS: At the 12-month follow-up, pain at the donor site was reported in no patients in the RIA system ABG group and five of 35 patients (14.28%) in the iliac crest ABG group. Local infections at the donor site were found in no patients in the RIA system ABG group compared with five patients (14.28%) in the iliac crest ABG group. There were no fractures in the RIA system ABG group and one case (2.85%) of anterior superior iliac spine (ASIS) dislocation in the iliac crest ABG group. No systemic infections were detected in either group. DISCUSSION: We analysed the scientific literature on the use of RIA technique to collect ABG for use in patients with anthropic-oligotrophic non-unions, with a focus on the complications associated with this technique. CONCLUSION: RIA bone graft for the treatment of non-unions and segmental bone defect of long bones seems to be a safe and efficient procedure with low donor site morbidity.

Posterior tibial artery perforator flaps for coverage of Achilles region defects.

BACKGROUND: Defects of the Achilles tendon region still represent a tricky issue in lower limb surgery. Among the several reconstructive possibilities, local propeller perforator flaps have gained popularity in the last decade. MATERIALS AND METHODS: We report our experience with eight patients affected by small-to-moderate soft-tissue defects of the Achilles tendon region, who underwent surgical reconstruction with local flaps based on posterior tibial perforator branches. RESULTS: All patients healed successfully in terms of aesthetic and functional aspect. In only one case a transient venous congestion was observed and this resolved spontaneously. CONCLUSIONS: Although the surgical technique requires much care and skill, including an extremely gentle dissection of perforator vessels, local propeller flaps should be considered the first-line choice for reconstruction in small-to-medium size soft-tissue defects in the Achilles region.

Reinforcing good practice: Implementation of guidelines at hospital G. Pini.

INTRODUCTION: Surgical site infections (SSIs) in orthopaedic surgery are a demanding complication for the patient and in terms of economics. Many guidelines (GLs) are available on antibiotic prophylaxis as an effective preventive measure; however, these GLs are often ignored in practice. A surveillance study of SSIs in arthroplasty, promoted by the Italian Study Group of Hospital Hygiene of the Italian Society of Public Health (SitI), showed a high percentage of non-adherence to GLs on antibiotic prophylaxis. OBJECTIVES: The purpose of this study was to review the existing GLs, share them within the hospital and then monitor their implementation. MATERIALS AND METHODS: Information and training are considered to be great tools for implementation and sharing of GLs, which leads to significant improvements in clinical practice. A multidisciplinary team comprising infectious disease specialists, orthopaedic surgeons, nurse epidemiologists and public health specialists was established at the G. Pini Hospital in Milan to revise GLs, and to organise educational events for their implementation, sharing and dissemination. A checklist was devised for monitoring purposes. RESULTS: GLs were presented to orthopaedic surgeons and nurse coordinators during two educational events. Meetings were organised in each unit to present the results of the surveillance of SSIs in arthroplasty and to discuss the reasons why the prophylaxis regimens adopted were not consistent with GLs. It was emphasised that the most important issue, on which there is consensus in the scientific literature, was related to the duration of prophylaxis beyond 24h. The review process for GLs was presented and pocket-sized GLs were given to surgeons. The importance of documenting on medical record any deviations from the GLs was emphasised. CONCLUSIONS: Any changes in behaviour in clinical practice must be monitored and evaluated regularly. The monitoring of GLs in terms of correct choice of drug, timing of administration and duration of prophylaxis is made using a special checklist on a representative sample of medical records.

Treatment of AVN using the induction chamber technique and a biological-based approach: indications and clinical results.

OBJECTIVE: To determine the efficacy of core decompression (CD) technique combined with recombinant morphogenetic proteins, autologous mesenchymal stem cells (MSCs) and xenograft bone substitute into the necrotic lesion of the femoral head on clinical symptoms and on the progression of osteonecrosis of the femoral head. PATIENTS AND METHODS: A total of 38 patients (40 hips) with early stage osteonecrosis of the femoral head were studied over a 4-year period. RESULTS: CD technique combined with recombinant morphogenetic proteins, autologous MSCs and xenograft bone substitute was associated with a significant reduction in both pain and joint symptoms and reduced the incidence of fractural stages. At 36 months, 33 patients achieved clinical and radiographic healing. CONCLUSION: This long-term follow-up study confirmed that CD technique combined with recombinant morphogenetic proteins, autologous MSCs and xenograft bone substitute may be an effective treatment for patients with early stage osteonecrosis of the femoral head.

Voice disorders in primary school teachers.

Previous reports focusing on the high prevalence of voice disorders in teachers have suggested that vocal loading might be the main causal factor. The aim of our study was to assess the prevalence of voice disorders in a sample of primary school teachers and evaluate possible cofactors. Our sample was composed of 157 teachers (155 females, mean age 46 years). Participants were asked to complete two selfadministrated questionnaires: one with clinical data, and the second an Italian validated translation of VHI (voice handicap index). On the same day they also underwent a laryngostroboscopic exam and logopedic evaluation. The results were compared with those of a control group composed of accompanying individuals. Teachers presented a higher rate of abnormalities at laryngostroboscopic examination than the control group (51.6% vs. 16%, respectively). Among these, 7.1% presented nodules. In our sample, vocal fold disorders were not correlated with years of teaching, smoking, coffee consumption, or levels of anxiety. Our findings are in agreement with previous reports on the prevalence of pathologic disorders among teachers; nonetheless, the prevalence of nodules was lower than in previous investigations, and voice loading was not correlated with laryngostroboscopic findings. Current Italian law does not include any guidance regarding voice education and screening in subjects with high vocal loading. Our work stresses the need for such legislation.

Megaprosthesis in large bone defects: opportunity or chimaera?

INTRODUCTION: The development of new megaprosthesis for the treatment of large bone defects provides important options to orthopaedic oncologic surgeons for the replacement of skeletal segments, such as the long bones of the upper and lower limbs and the relative joints. We implanted megaprosthesis using either a one-step or two-step technique depending on the patient's condition. The aim of this study was to evaluate retrospectively both clinical and radiological outcomes in patients who underwent lower limb megaprosthesis implant. MATERIALS AND METHODS: A total of 32 patients were treated with mono- and bi-articular megaprosthesis subdivided as follows: proximal femur, distal femur, proximal tibia and total femur. The mean follow-up of patients was about 18 months (range 3 months to 5 years). Clinical and serial radiographic evaluations were conducted using standard methods (X-ray at 45 days, 3, 6, 12, 18 and 24 months) and blood parameters of inflammation were monitored for at least 2 months. RESULTS: Although the mean length of follow-up was only 18 months, the first patients to enter the study were monitored for 5 years and showed encouraging clinical results, with good articulation of the segments, no somato-sensory or motor deficit and acceptable functional recovery. During surgery and, more importantly, in pre-operative planning, much attention should be given to the evaluation of the extensor apparatus, preserving it and, when necessary, reinforcing it with tendon substitutes. DISCUSSION: Megaprosthesis in extreme cases of severe bone loss and prosthetic failure is a potential solution for the orthopaedic surgeon. In oncological surgery, the opportunity to restore functionality to the patient (although not ad integrum) is important for both the patient and the surgeon. The high mortality associated with cancer precludes long-term patient follow-up; therefore, there is a lack of certainty about the survival of this type of prosthesis and any medium- to long-term complications that may occur. Nevertheless, patients should be considered as an oncologic patient, not because of the disease, but because of the limited therapeutic options available. CONCLUSIONS: Megaprosthesis provides a valuable opportunity to restore functionality to patients with highly disabling diseases.

Monotherapy vs. polytherapy in the treatment of forearm non-unions and bone defects.

OBJECTIVE: To determinate the efficacy of "polytherapy", a surgical technique that utilize all the components of the diamond concept (mesenchymal stem cells, bone morphogenetic proteins and scaffold) versus a "monotherapy", a surgical technique that utilize only one component of the diamond conceptin the treatment of severe forearm non-unions. METHODS: We studied a database of 52 patients with 52 forearm non-unions; we classified the patients with the NUSS SCORE and we divided the patients in two group according to the treatment received. So we distinguished a group of patients treated according to the principles of "monotherapy" (33 patients) and a group of patients treated according to the principles of "polytherapy" (19 patients). The minimum follow up was 12 months. RESULTS: In the monotherapy group 21/33 non-unions (63.64%) went on to develop a radiographic and clinical healing within a period of 12 months, the calculated DASH SCORE showed a mean value of 55.15 points. In the polytherapy group 17/19 (89.47%) nonunions went on to develop clinical and radiographic healing within 12 months, and the average DASH score showed a mean value of 45.47 points. CONCLUSION: The polytherapy technique with the use of recombinant morphogenetic proteins, autologous MSCs and scaffold in the same surgical time appears to be an effective treatment for patients with severe forearm non-unions.

Management of shoulder periprosthetic fractures: our institutional experience and review of the literature.

Fractures of the humerus in patients with total shoulder replacement are rare and difficult to treat. The treatment of periprosthetic humeral fractures depends on the location of the fracture in relation to the humeral stem and the stability of the stem/bone interface. We wished to determine the treatment outcomes in a series of patients managed in our institution with periprosthetic humeral fractures. We also carried out a review of the literature. Over a 5 year period, out of 10 patients, 7 were available at the final follow up with a mean age of 72 years (range 68-75). A fall from standing height was the most common mechanism of injury. All patients were found to have stable prosthesis in situ and were treated with angular stable plates and cerclage wiring. The mean time from the total shoulder replacement to injury (fracture) was 11.2 months (range 8-21). All fractures united without complications at a mean time of 5.1 months (range 4-6). The literature review revealed a limited number of publications reporting on the management of approximately 40 patients. The outcome noted in these patients is also presented.

The surgical treatment of lung cancer in patients with previous lymphoproliferative disorders: a historical cohort study.

OBJECTIVES: We undertook a historical cohort study to compare, in terms of morbidity, mortality and long-term survival associated with lung cancer resection, a group of patients with previous lymphoproliferative disorders and a group without a hematological history. METHODS: We identified 29 patients with a previous lymphoproliferative disorder who underwent lung cancer resection. These subjects (Group-A) were matched with 87 patients without a hematological history who underwent pulmonary resection during the same period (Group-B). RESULTS: We found no significant difference between the two groups in length of hospitalization, comorbidities, spirometric parameters, type of surgery, histology, neoadjuvant chemotherapy, morbidity, mortality, median survival (Group-A = 37 months; Group-B = 52 months) and 5-year survival (Group-A = 37%; Group-B = 42%). The mean age of Group-A patients was significantly lower than that of Group-B patients (62 vs 66 years; p = 0.024). Group-A patients had a well differentiated lung cancer more frequently than Group-B patients (p = 0.001). Group-A patients had transitory bacteraemies more frequently than Group-B patients (p = 0.005). Multivariate Cox regression analysis showed that age (p = 0.01) and lung cancer stage (p = 0.04) were significantly associated with survival. CONCLUSIONS: Patients with lymphoproliferative disorders had a lower age and more differentiated lung cancers than those without lymphoproliferative disorders. Patients with lymphoproliferative disorders and those without a hematological history had similar morbidity, mortality and long-term survival after pulmonary resection. Distinguishing patients with and without a lymphoproliferative disorder seems to be of limited value in the decision-making process of evaluating the indications for surgical treatment of lung cancer.

The use of bone-graft substitutes in large bone defects: any specific needs?

INTRODUCTION: The gold standard for restoring bone defects is still considered to be autologous bone grafting. However, clinical benefits are not guaranteed and donor-site complications and morbidity is not infrequent. Research is on-going for the development of alternative bone substitutes of both biological and synthetic origin. The purpose of this study was to evaluate the type of materials used and their efficacy for the treatment of large bone defects in traumatology and orthopaedic surgery. MATERIALS AND METHOD: A literature review was carried out of Embase and PubMed databases. Inclusion criteria were articles in English language focusing on the use of bone substitutes in trauma and orthopaedic surgery for the treatment of bone defects and included details on the structural, biological or biomechanical properties of the pure product. Furthermore, based on two clinical challenges, fracture non-union and impaction grafting we elaborated on the use of polytherapy for large bone defects as guided by the diamond concept. RESULTS: All the products indicated in this manuscript possess osteoconductive activities but have different resorption times and biomechanical properties. Bone graft substitute materials are used for a wide range of clinical applications even when the level of clinical evidence is low. The size and location of the defect and the local biological and mechanical environment as well as the biomechanical characteristics of the material determine the type of device that can be implanted in a bone defect. CONCLUSION: Proper assessment of the biological and mechanical environment and accurate patient selection are necessary to judge the extent of therapy the injury warrants. A sound understanding of various aspects of biomaterial properties and their relation and influence towards bone healing is of utmost importance. We suggest the application of polytherapy for the treatment of large bone defects and advocate the use of the diamond concept as a guideline.

Polytherapy in bone regeneration: clinical applications and preliminary considerations.

Polytherapy, namely the simultaneous application of three fundamental elements necessary for bone regeneration (growth factors, osteogenic cells and osteoconductive scaffolds) seems to lead to a very high success rate in the treatment of complex non-union (NU) cases and critical bone defects. NU are reported in 5-10% of long bone fractures. The use of autologous bone grafts has been long-considered the gold standard for the treatment of these cases. However the harvesting procedure from the iliac crest increases surgery time and presents some donor site complications which may be elevated. In recent years, surgeons have some alternatives to autologous grafting such as: application of organic or synthetic bone substitute, application of mesenchymal stromal cells (MSC) or growth factors (GF). In the literature there are many studies available about their application in monotherapy, but unfortunately the healing rate doesn't exceed 90%. Polytherapy seems to be a logical option to improve the healing rate, nevertheless, there are not still extensive studies that validate this strategy and moreover, some questions are not resolved.

Treatment of long bone non-unions with polytherapy: indications and clinical results.

The incidence of long bone non-unions has been estimated to range between 5 and 10%. Autologous bone graft usually harvested from the iliac crest continues to be the gold standard for biological enhancement of atrophic non-unions. However, its use has been hampered by minor and major donor site complications. Moreover despite possessing the properties of osteogenecity, osteoconductivity and some osteoinductivity the overall results of treatment have not been consistent with disappointing success rates at times. The concept of polytherapy for the treatment of non-unions, namely the simultaneous application of the three fundamental elements of the diamond concept, osteoprogenitor cells, growth factor and osteoconductive scaffold, appears to be an attractive alternative but more studies are desirable to validate this strategy.