Article

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

ABSTRACT

Background
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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    • "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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    • "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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