Definition and classification of fracture non-unions

Is surgery necessary for femoral insufficiency fractures after long-term bisphosphonate therapy?

BACKGROUND

Prolonged use of bisphosphonates in patients with osteoporosis reportedly induces femoral insufficiency fractures. However, the natural course of these fractures and how to treat them remain unknown.

QUESTIONS/PURPOSES

We determined the rates of fracture displacement and subsequent operations of undisplaced insufficiency fractures of the femur in patients treated with prolonged bisphosphonate therapy.

PATIENTS AND METHODS

We retrospectively collected and reviewed the clinical course of 11 patients (14 fractures) who had been diagnosed as having an insufficiency fracture of the femur after prolonged use (mean, 4.5 years; range, 3-10 years) of bisphosphonate. All patients were women with a mean age of 68 years (range, 57-82 years). The fracture site was subtrochanteric in six and femoral shaft in eight. The minimum followup was 12 months (mean, 27 months; range, 12-60 months).

RESULTS

During the followup period, secondary displacement of the fracture occurred in five of the 14 fractures after a mean of 10 months (range, 1-19 months). Three fractures were treated with internal fixation using a compression hip screw and two with intramedullary nailing. Because five additional fractures were treated surgically owing to intractable pain, surgery was performed in 10 of 14 insufficiency fractures during the followup period. All 10 fractures healed during followup. The remaining four patients (four fractures) not undergoing any surgery had persistent pain.

CONCLUSIONS

Femoral insufficiency fractures after prolonged bisphosphonate therapy seldom healed spontaneously and most patients had surgery either for fracture displacement or persistent pain.

Proximal humeral nonunions treated with fixed-angle locked plating and an intramedullary strut allograft

OBJECTIVE

To determine if the use of a fixed-angle locked plate plus an intramedullary allograft in the treatment of proximal humeral nonunions resulted in improved union.

DESIGN

Retrospective clinical analysis of patients' medical charts and radiographs.

SETTING

Clinical practice of senior authors.

PATIENTS/PARTICIPANTS

Eighteen patients who presented to the senior authors' clinic between 2001 and 2007 with clinical and radiographic evidence of symptomatic proximal humeral nonunions that were treated with the described method were included for analysis. Patients with severe humeral head bone loss, avascular necrosis, evidence of arthrosis, and less than 12-month clinical follow-up were excluded.

INTERVENTION

All patients with a symptomatic viable nonunion of the proximal humerus were treated with a fixed-angle locked plate and an intramedullary cortical allograft.

MAIN OUTCOME MEASUREMENT

Patients were followed until radiographic union was achieved, with this being the principle determinant of a successful outcome.

RESULTS

Radiographic union was achieved in 17 of 18 patients (94%). The average follow-up was 26.5 months (range 12-49 months). The average time from surgery to radiographic union was 5.4 months (range 2.5-8.8 months). There was 1 failure of fixation, and 2 patients developed transient neurologic sequelae. Range of motion measurements obtained from the most recent clinical follow-up were 115 degrees (range 20-180 degrees) active forward elevation, 37 degrees (range 0-70 degrees) passive external rotation, and active internal rotation was to the 10th thoracic vertebrae. American Shoulder and Elbow Surgeon scores improved from a level of 40 preoperatively to 81 postoperatively, and visual analog scale scores improved from 6.7 to 1.5.

CONCLUSION

Intramedullary strut allograft insertion combined with fixed-angle plating is an effective technique for treating viable nonunions of the proximal humerus and was successful in achieving union in 94% of our patients.

Application of rhBMP-7 and platelet-rich plasma in the treatment of long bone non-unions: a prospective randomised clinical study on 120 patients

The purpose of this prospective randomised clinical study was to compare the efficacy of recombinant bone morphogenetic protein 7 (rhBMP-7) and platelet-rich plasma (PRP) as bone-stimulating agents in the treatment of persistent fracture non-unions. One hundred and twenty patients were randomised into two treatment groups (group rhBMP-7 vs. group PRP). Sixty patients with sixty fracture non-unions were assigned to each group (median age: 44 years, range 19-65, for the rhBMP-7 group and 41 years, range 21-62, for the PRP group, respectively). In the rhBMP-7 group, there were 15 tibial non-unions, 10 femoral, 15 humeral, 12 ulnar, and 8 radial non-unions. In the PRP group, there were 19 tibial non-unions, 8 femoral, 16 humeral, 8 ulnar, and 9 radial non-unions. The median number of operations performed prior to our intervention was 2 (range 1-5) and 2 (range 1-5) with autologous bone graft being used in 23 and 21 cases for the rhBMP-7 and PRP groups, respectively. Both clinical and radiological union occurred in 52 (86.7%) cases of the rhBMP-7 group compared to 41 (68.3%) cases of the PRP group, with a lower median clinical and radiographic healing time observed in the rhBMP-7 group (3.5 months vs. 4 months and 8 months vs. 9 months, respectively). This study supports the view that in the treatment of persistent long bone non-unions, the application of rhBMP-7 as a bone-stimulating agent is superior compared to that of PRP with regard to their clinical and radiological efficacy.