Long bone non-unions treated with the diamond concept: a case series of 64 patients

doi:10.1016/S0020-1383(15)30055-3

Injury

Volume 46, Supplement 8, December 2015, Pages S48-S54

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Abstract

The aim of this retrospective study with prospectively documented data was to report the clinical results of treatment of long bone non-unions using the “diamond concept”. Over a 4-year period, patients that presented with a long bone non-union and were managed with the diamond conceptual framework of bone repair were evaluated. Exclusion criteria were hypertrophic, pathological, and infected non-unions. Fixation was revised as it was indicated whilst biological enhancement included the implantation of RIA graft, BMP-7 and concentrated bone marrow aspirate. Data recorded included patient demographics, initial fracture pattern and type of stabilisation, number of previous interventions, time to reoperation, time to union and functional outcome. Painless full weight bearing defined clinical union. Radiological union was defined as the presence of mature callous bridging to at least 3 bone cortices. The minimum follow up was 12 months (range 12–32). In total 64 patients (34 males) with a mean age of 45 years (17–83) were evaluated. Anatomical distribution of non-unions included the femur (54.68%), tibia (34.38%), humerus (4.68%), radius (3.13%) and clavicle (3.13%). The median number of previous interventions was 1 (range 1–5). The majority of patients (82.62%) underwent revision of fixation whereas only bone grafting was performed 9.38% of patients. Three patients developed superficial wound infection (one was MRSA), 1 had deep vein thrombosis and 1 developed heterotopic bone formation. Union was successful in 63/64 (98.4%) non-unions at a mean time of 6 months (range 3–12). All patients were mobilising pain free and returned to their daily living activities at the final follow up. The application of the “diamond concept” in this cohort of patients was associated with a high union rate by providing an optimal mechanical and biological environment. Such an approach should be considered in the surgeon's armamentarium particularly in such cases where difficulty of bone repair is foreseen.

Introduction

Bone has the natural capacity to heal a fracture without scar formation, a process resembling the embryo bone formation [1]. Any disruption in the physiological cascade of events governing the bone repair pathway can lead to the development of delayed healing or non-union. The incidence of non-union has been estimated to be between 5–10% of all fractures, whereas aetiological factors contributing to this phenomenon include the severity of the initial injury, the profile of the patient, type of fracture, host factors and a genetic predisposition amongst others [2, 3, 4, 5, 6, 7, 8, 9, 10].

Treatment of non-union is challenging for both the patient and the treating physician with not infrequently an unpredictable result. Treatment modalities that have been described for simple and complex cases include revision of fixation, bone grafting, non-invasive means of bone stimulation and the ‘triangular concept’ of biological stimulation (enhancement of the fracture healing response with the implantation of cells, scaffolds and inductive signals (growth factors)) [11, 12].

Lately, a specific management strategy has been described for the treatment of recalcitrant and atrophic non-unions under a generic term ‘diamond concept’ [13, 14, 15] advocating and highlighting that in addition to the ‘triangular concept’ of stimulation, the mechanical environment should also be appropriately addressed and restored, Fig. 1.

The aim of the herein study is to evaluate the results of treatment in a cohort of patients that were managed with the ‘diamond concept’ for long bone non-union at a regional tertiary referral centre for limb reconstruction.

Section snippets

Patients and methods

Over a four-year period (January 2008 and December 2011) consecutive patients that attended our institution or were referred from other units and were treated with the diamond concept for bone repair were eligible to participate in this study. Exclusion criteria were pathological fractures, hypertrophic and infected non-unions. This study was approved by the institutional review board.

Non-union was defined as a fractured bone that had failed to unite within 9 months following injury and did not

Results

Sixty-four patients (34 male) with a mean age of 45yrs (17–83) met the inclusion criteria. 39 patients (60.9%) had at least one associated medical com-morbidity (myocardial infarction, hypertension, chronic obstructive pulmonary disease, depression, psoriasis, migraine, arthritis, etc.). Smoking habits were recorded in 21.8% of the patients. Distribution of non-unions per anatomical site included the femur in 35 patients (54.68%), tibia 22 (34.38%); with distal third tibia being involved in 14

Discussion

The development of fracture non-union remains one of the most common post-fixation bone complications. Its pathogenesis remains obscure although is considered multifactorial. Fortunately, most of the fractures progress to union thus leaving a small number of patients suffering with either delayed union or non-union that usually necessitates further surgical intervention. The management of fracture non-union remains a challenge for the clinician and exploration of innovative techniques is

Conflict of interest

All the authors report no conflict of interest.

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Long bone non-unions treated with the diamond concept: a case series of 64 patients

Abstract

Introduction

Section snippets

Patients and methods

Results

Discussion

Conflict of interest

Mech Dev

Injury

Injury

Injury

Biomaterials

Injury

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Injury

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J Orthop Sci

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Functional bracing for comminuted extra-articular fractures of the distal third of the humerus

J Bone Joint Surg Br