Subtrochanteric fracture non-unions with implant failure managed with the “Diamond” concept

Injury (Impact Factor: 2.14). 01/2013; 44:S76–S81. DOI: 10.1016/S0020-1383(13)70017-2


Subtrochanteric femoral non-unions in the setting of failed metalwork pose a challenging clinical problem. This study assessed the clinical outcome of patients treated according to the principles of the “Diamond” concept.Methods
Between 2007 and 2011 all patients presented with a subtrochanteric atrophic aseptic non-union in the setting of metalwork failure (broken cephalomedullary reconstruction nail), and treated in a single tertiary referral unit were included to this study. The hypertrophic and the non-unions of pathologic fractures were excluded. The revision strategy was based on the “Diamond concept”; optimisation of the mechanical and the biological environment (implantation of growth factor (rhBMP-7), scaffold (RIA bone graft from contralateral femur) and concentrated mesenchymal stem cells (MSCs) harvested from the iliac crest). The minimum follow up was 26 months (16–48).ResultsFourteen patients met the inclusion criteria. A specific sequence of metalwork failure was noted with initial breakage of the distal locking screws followed by nail breakage at the lag screw level. The intraoperative examination of the removed nails revealed no gross structural damage indicative of inappropriate drilling at the time of the initial intramedullary nailing. Varus mal-alignment was present in the majority of the cases, with an average of 5.2 degrees (0–11). The average time to distal locking screw failure was 4.4 months (2–8.5) and nail failure was 6.5 months (4–10). The time to union after the revision surgery was 6.8 months (5–12). Complications included two deaths in elderly patients (due to unrelated causes), one pulmonary embolism, one myocardial infarction, one below the knee deep vein thrombosis and one blade plate failure that required further revision with double plating and grafting.Conclusion
Varus mal-alignment must be avoided in the initial stabilisation of subtrochanteric fractures. Distal locking screw failure is predictive of future fracture non-union and nail breakage. In the absence of sepsis, a single stage procedure based on the “Diamond concept” that simultaneously optimizes the mechanical and biological environment is a successful method for managing complex subtrochanteric atrophic non-unions with failed metalwork.

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Available from: G.V. Mineo, Aug 31, 2015
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    • "In summary, the etiology and treatment modalities of nonunion and CSBD continue to be a subject of great interest to clinicians39404142434445. Stem cell therapy could be an option to manage the treatment of large bone defects in the future and to resolve the several problems associated with the current surgical procedures such as the Masquelet technique and the Ilizarov technique. "
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    ABSTRACT: Large bone defects caused by fracture, non-union and bone tumor excision has been a major clinical problem. Autogenous bone grafting and Ilizarov method are commonly performed to treat them. However, bone grafting has limitation in volume of available bone, and Ilizarov method requires long periods of time to treat. Accordingly, there is need for stem cell therapy for bone repair and/or regeneration. Mesenchymal stem cells (MSCs) hold the ability to differentiate into osteoblasts and are available from a wide variety of sources. The route of “intramembranous ossification (direct bone formation)” by transplantation of undifferentiated MSCs has been tested but it did not demonstrate the success initially envisaged. Recently another approach has been examined being the transplantation of “MSCs pre-differentiated in vitro into cartilage-forming chondrocytes” into bone defect, in brief, representing the route of “endochondral ossification (indirect bone formation)”. It's a paradigm shift of Stem Cell Therapy for bone regeneration. We have already reported on the healing of large femur defects in rats by transplantation of “MSCs pre-differentiated in vitro into cartilage-forming chondrocytes”. We named the cells as Mesenchymal Stem Cell-Derived Chondrocytes (MSC-DCs). The success of reconstruction of a massive 15-mm femur defect (approximately 50% of the rat femur shaft length) provides a sound foundation for potential clinical application of this technique. We believe our results may offer a new avenue of reconstruction of large bone defect, especially in view of the their high reproducibility and the excellent biomechanical strength of repaired femora.
    Preview · Article · Jan 2016 · Injury
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    • "The role of the orthopedic surgeon is to reduce the bone fragments anatomically, stabilize the fracture to allow healing without malunion, and thus restore function. The healing process is a cascade of events, mainly influenced by the mechanical fracture fixation stability and the biological environment, summarized as the " diamond concept "[1]. Depending on various factors, bony union occurs either by primary or secondary healing. "
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    Preview · Article · Jan 2016 · Injury
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    • "It often requires additional surgery to be solved. Its causes must be carefully determined and addressed, both from the biological and mechanical point of view, in order to restore the bone healing process and to give the patient a more accurate prognosis13141516171819. When a bridge plating technique is chosen for B type fractures of distal shaft of the tibia, in order to avoid healing issues, accurate reduction with cortical contact should be obtained, even at the expense of a more invasive surgery. "
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    ABSTRACT: A fit 42-year-old woman presented to our department with a closed isolated distal tibial and fibular shaft fracture (AO 42-B1.3), which was addressed with a minimally invasive plate osteosynthesis (MIPO) with a bridging technique for both the tibia and the fibula. No risk factors for healing issues were known at the time of surgery. At the 6-month follow-up, the leg was still painful during walking and the fracture site was still evident on the radiographs. Bone and CT-scans confirmed the diagnosis of oligotrophic non-union. A revision surgery was then successfully performed with a reamed IM tibial nail and a fibular osteotomy taking into consideration both biological and mechanical factors. Surgeons must treat tibial shaft fractures avoiding unnecessary damage to soft tissue, restoring an appropriate reduction of the bony segment and providing an adequate fixation; however, other factors may play a role in the development of “unexpected non-union”.
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