Non-Union Treatment Based on the "Diamond Concept" Is a Clinically Effective and Safe Treatment Option in Older Adults.

BACKGROUND: Patients >60 years suffering from non-unions are often unable to perform activities of daily living and often become dependent on nursing care. Evidence regarding treatment options and outcome is nonexistent. This study sought to determine the clinical effectiveness and safety of one- or two-step non-union therapy in elderly patients. METHODS: This study was a single-site retrospective database analysis of older adults with long bone non-unions treated via "diamond concept". All medical records of patients receiving surgical treatment of non-unions between 01/01/2010 and 31/12/2016 were reviewed. Clinical and radiological outcome subsequent to non-union therapy were evaluated. RESULTS: A total of 76 patients (37 patients were treated with one-step and 39 patients with Masquelet therapy) suffering from a non-union older than 60 years treated between 01/01/2010 and 31/12/2016 in our institution were included into the current study. Bone consolidation was achieved in 91.9% after one-step and 76.9% after the Masquelet therapy. Analysis of age as a risk factor in the outcome of non-union therapy revealed no significant differences in patients treated with the one-step procedure according to the "diamond concept". On the contrary, age had a significant negative influence on the outcome of the Masquelet therapy (p = 0.027). CONCLUSION: Non-union therapy according to the "diamond concept" is an effective and reliable treatment option in elderly patients. According to findings of the current study, older adults suffering from an infected non-union benefit from a two-stage procedure, whereas in patients suffering from a non-infected non-union, a one-step surgical treatment is beneficial.

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.

Comparison of the clinical effectiveness of Bone Morphogenic Protein (BMP) -2 and -7 in the adjunct treatment of lower limb nonunions.

BACKGROUND: Substantial evidence exists demonstrating the individual effectiveness of both rhBMP-2 and -7 in the treatment of nonunions, data comparing the clinical effectiveness of adjunct rhBMP-2 and -7 remains scarce. Therefore, we examined our large single-center case series to compare the clinical effectiveness of both rhBMP-2 and -7 in non-union therapy aiming to answer: - Does a certain type of BMP have an advantageous effect on radiological outcome of applied lower limb non-union therapy? - Does application of a certain type of BMP have an advantageous effect on radiological outcome of infected lower limb nonunions? - Are there any additional risk factors associated with inferior outcome in context with an adjunct BMP treatment? HYPOTHESIS: Both BMPs have the same effect on the radiological outcome of surgically treated lower limb nonunions. PATIENTS AND METHODS: Single-center retrospective database analysis of a case series of patients with lower limb long bone nonunions receiving either a one- or two-stage (Masquelet-) procedure based on the "diamond concept" with application of rhBMP-2 or -7. The "diamond concept" summarizes core factors that need to be present to achieve bone healing. In particular, these factors relate to the optimization of the mechanical (stability) and biological environment (sufficient osteogenic and angiogenic cells, osteoconductive scaffolds and growth factors). All medical data from patients that received surgical treatment between 01/01/2010 and 31/12/2016 were assessed. In total, 356 patients were treated with BMPs and 156 patients 18 years or older with non-union of their tibia or femur having a follow-up of at least 1 year were included. Consolidation in context with type of rhBMP was compared and the influence of relevant risk factors assessed. RESULTS: Consolidation rate was significantly higher in patients treated with rhBMP-2 (rhBMP-2: 42/46 (91%) vs. rhBMP-7: 64/110 (58%); p<0.001). In particular, application of rhBMP-2 increased the likelihood of consolidation for tibial nonunions (OR 32.744; 95%CI: 2.909-368.544; p=0.005) and when used in two-stage therapy (OR 12.095; 95% CI: 2.744-53.314; p=0.001). Furthermore, regression modeling revealed a higher correlation between application of rhBMP-2 and osseous consolidation in infected nonunions (OR 61.062; 95% CI: 2.208-1688.475; p=0.015) than in aseptic nonunions (OR 4.787; 95% CI: 1.321-17.351; p=0.017). Risk factors negatively influencing the outcome of non-union treatment in context with rhBMPs were identified as active smoking (OR 0.357; 95% CI: 0.138-0.927; p=0.024), atrophic nonunion (OR 0.23; 95% CI: 0.061-0.869; p=0.030), higher BMI (OR 0.919; 95% CI: 0.846-0.998; p=0.046) and a larger defect size (OR 0.877; 95% CI: 0.784-0.98; p=0.021). DISCUSSION: Patients who received rhBMP-2 for the treatment of tibial nonunions and as part of the two-stage treatment had a significantly higher rate of healing compared to patients treated with rhBMP-7 regardless of infection. LEVEL OF EVIDENCE: III, retrospective case-control study.