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Injury
journal homepage: www.elsevier.com/locate/injury
Long bone non-unions treated with the diamond concept: a case series of
64 patients
Peter V. Giannoudisa,b,*, Suri Gudipatia, Paul Harwooda, Nikolaos K. Kanakarisa
a
Academic Department of Trauma and Orthopaedics, Floor A, Clarendon Wing, LGI, University of Leeds, Leeds, UK
b
NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, UK
K E Y W O R D S A B S T R A C T
non-union The aim of this retrospective study with prospectively documented data was to report the clinical results
diamond concept of treatment of long bone non-unions using the “diamond concept”. Over a 4-year period, patients that
long bone presented with a long bone non-union and were managed with the diamond conceptual framework of
growth factors
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 inter-
ventions 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 infec-
tion (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 provid-
ing 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.
© 2015 Elsevier Ltd. All rights reserved.
Fig. 6. Patient referred to our institution. Biochemical profile was normal (WBC, CRP,
ESR). Clinically, no rotational deformity but 1.5 cm shorter. In pain since operation,
unable to weight bear. Non-union score (NUSS) = (bone component = 16, soft
tissue component = 2, patient component = 8). Total points 26X 2 = 52. a) Images
of harvesting RIA graft from the contralateral femur. b) Harvesting of bone marrow
aspirate for concentration of osteoprogenitor cells.
Fig. 8. a) Using osteotome fragments being apart are mobilized for reduction. b) Insertion of guide wire. c),d),e),f) Insertion of
Affixus proximal femoral nail for stabilization of non-union.
Fig. 9. Composite bone graft (polytherapy) preparation prior to implantation. Fig. 10. a),b),c) Using the nail as a template fragments were mobilized and reduced
to reconstitute the femoral bone (tube);BMP-2 sponge is used around the mobilized
fragments for protection and induction prior to circulage wiring application for
the above parameters would assist the treating surgeon to make maintenance of reduction.
the right decisions in terms of the timing of intervention and the
method of treatment to be applied. Smoking impairs bone healing which has been proven both by
Fracture healing can be affected by several factors and m edical basic science and clinical studies [26-29]. Only 21.9% of patients
conditions, including diabetes and peripheral vascular [23-25]. were smokers and were advised to stop smoking during their
In this study, only 9 patients (14.1%) had diabetes of whom only course of treatment. Most of the patients had sustained lower
2 patients were insulin dependent. Two of the patients had been limb injuries (89% femur and tibia) and 11 of them had sustained
diagnosed with hypothyroidism and 1 patient had o steogenesis previously open fractures. This is in agreement with the higher
imperfecta with a history of multiple fractures. Most of the incidence of non –union following open fractures previously
remaining patients either had hypertension, asthma, migraine, reported by Gustillo et al. [30].
depression or previous skeletal injuries alone or in combination. Evaluation of the biological state and the mechanical environ-
Whilst a number of patients were suffering from asthma, none ment of the non-union are crucial. Analysis of the original frac-
was on long term steroid therapy. ture pattern, the type of implant used, the number of previous
S52 Peter V. Giannoudis et al. / Injury, Int. J. Care Injured 46 S8 (2015) S48–S54
Fig. 11. a),b) Application of composite graft over non-union site. Fig. 13. 6 months’ radiographic examination.
Fig. 12. 3 months’ radiographic examination. Fig. 14. 8 months’ radiographic examination.
surgeries, and the overall state of the vascularity potential of the stimulus. It is not a surprise therefore that we noted such a high
non-union area can assist the clinician to decide the type and the union rate. Previously, BMP’s were considered as the most potent
extent of biological enhancement being necessary. Similarly, the inductive stimuli for bone repair. Despite this, their implantation
state of the mechanical stability (presence of osteolysis around was not associated always with a successful outcome. This can
the screws, loosening of plate/nail, breakage of the implant) will be attributed to the following parameters: a) poor containment,
dictate the necessity for revision of the fixation. The ‘diamond b) not adequate local availability of progenitor cells to accept
concept’ was proposed to make aware the clinician of the impor- the message of induction, c) inappropriate timing of implanta-
tance of both the biological and the mechanical environments. It tion, d) not optimum dose selection, and e) suboptimal carrier
assists the clinician in the understanding of the requirements in properties.
fracture healing and provides a simplified process for decision It is of note that implantation of the autologous bone graft
making in the successful management of non-union [13-15]. in isolation has achieved a good rate of union ranging from
In our cohort of patients all the issues raised in the diamond 60%-100% [31-35] although in another study a failure rate of
conceptual framework for fracture healing were addressed. 50% using ABG was reported [33]. Other biological enhancement
Optimisation of the mechanical environment was achieved by options have been used with limited success [35-40]. We had the
revision of the fixation in the vast majority of the patients and same experience over the years using autologous bone graft or
given the complexity of these cases and the compromised bio- BMP alone in patients with aseptic long bone non-unions.
logical healing potential, the osteogenic potential was enhanced It is our belief that delivering locally all of the essential con-
by the implantation of composite grafting consisting of the com- stituents of bone repair creates an optimum molecular milieu
bination of osteoinductive protein (BMP-7), osteoconductive in a previous deprived biological environment. While such an
scaffold (RIA graft) and osteoprogenitor cells (MSC’s from the approach could also contribute to an accelerated healing pro-
iliac crest). This strategy was noted to be associated with a high cess, and in spite of observing such a phenomenon in a number
percentage of success rate (almost 100%). of cases, we are not in a position to accurately report on this
Such biological enhancement of implanting a growth factor matter due to the small number of patients studied in each
(signal), cells and a matrix (scaffold) for cell homing, prolifera- different anatomical site. Future studies should address this
tion and differentiation can be considered as a potent osteogenic important issue.
Peter V. Giannoudis et al. / Injury, Int. J. Care Injured 46 S8 (2015) S48–S54 S53
Table 1
Literature search showing options for treatment of aseptic non-union and associated complications.
Single stage
Amorosa LF et al, 87/104 (62 aseptic nonunion) Single stage revision, culture 58/62 healed 4/62-persistent non-union
JOT Oct 2013 [43] Average age-49.6yrs samples and ORIF or Exchange
nailing
Augementation technique
Atesch Ateschrang et al 28/104 Dynamization of nail 27/28 healed 1 persistent non-union- need
Mar 2013 [44] Avg age-47yrs + plate augmentation grafting later
Birjandinejad A et al. 38 Locking compression plate 36/38 healed 2 tibial non-union persisted
Orthopedics Jun 2009 [46] Avg age-31.4 + Iliac crest graft
Exchange Nailing
Paul A. Banaszkiewicz 18patients Femoral exchange nail 17 healed ( some after 2 nonunion, 2infection and
Injury (34) 2003 [48] Avg age 36y repeat surgery) 2 implant failure
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