SLR - April 2014 - Christine Nolan
Reference: Flierl MA, Smith WR, Mauffrey C, Irgit K, Williams AE, Ross E, Peacher G, Hak DJ, Stahel PF. Outcomes and Complication Rates of Different Bone Grafting Modalities in Long Bone Fracture Nonunions: A Retrospective Cohort Study in 182 Patients. J Orthop Surg Res. 2013 Sep 9; 8:33
Scientific Literature Review
Reviewed By: Christine Nolan, DPM
Residency Program: Temple University Hospital, Philadelphia, PA
Podiatric Relevance: Foot and ankle surgeons often encounter the difficulty of treating non-unions in the lower extremity and doctors must weight the risks and benefits of the different available methods of treatment.
Methods: This is a retrospective study that was conducted out of two level-one trauma centers on patients that had sustained long bone fractures. Patients were included in the study if non-union occurred. Non-union was defined as a fractured bone that has not healed within nine months of injury. The patients were further broken down into cohorts based on their method of treatment of the non-union. There were four cohorts: autograft, allograft, autograft and allograft combined, and human bone morphogenetic protein-2 (rhBMP2). Each patient was followed until union or with at least 12 months of follow up. The primary outcome measurement defined by the authors was time to union. Union was defined as painless weight bearing and lack of tenderness at the non-union site. Other outcomes that were measured were complication rates and the rate of revision procedures and revision bone grafting.
Results: A total of 182 patients were enrolled in the study. The numerical breakdown of the cohorts was as follows: autograft (n=105), allograft (n=38), autograft and allograft combined (n=16) and rhBMP2 (n=23). Patients in the autograft cohort had statically significant shorter time to union compared to allograft cohort: 198 days vs. 416 days respectively. There was no statically significant difference between autograft versus the allograft and autograft combination group and rhBMP-2. The autograft cohort also has a significantly lower rate of surgical revision (17.1 percent) and need for revisional bone grafts (8.6 percent) when compared to allograft (47.4 percent and 31.6 percent). Incidence of post-operative infection was highest in the allograft group at 26.3 percent, with rhBMP-2 at 17.4 percent followed by autograft at 12.4 percent and allograft and autograft combination at 10 percent.
Conclusion: Autologous bone grafting remains the most practical form of treatment of long bone non-unions. With advancements in minimally invasive surgical donor site, morbidity can be minimized decreasing the possible complications. While advancements have been made in orthobiologics, healing time and need for revisional surgery remain higher then with autografts.