r e v b r a s o r t o p . 2 0 1 8;5 3(6):668–673 SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA www.rbo.org.br Original Article Percutaneous autogenous bone marrow injection for delayed union or non-union of long bone ଝ fractures after internal fixation Ramji Lal Sahu Department of Orthopaedics, Sharda University, Greater Noida, India a r a t b i c l e i n f o s t r a c t Article history: Objectives: The aim of this study was to assess the results of percutaneous injection of Received 3 June 2017 autologous bone marrow in the treatment of fractures presenting with delayed union or Accepted 5 September 2017 non-union after internal fixation. Available online 29 December 2017 Methods: This prospective study was carried out at the Orthopeedics Department from June 2005 to June 2010. A total of 93 patients with delayed union and non-union (56 delayed Keywords: unions and 37 non-unions) of the long bone were recruited from the Emergency and Outpa- tient Departments and treated with percutaneous autologous bone marrow injections. The Bone nails Femoral fractures clinical results of this study were rated on the basis of the criteria of union. All patients were Fracture fixation, internal followed for 24 months. Fractures, ununited Results: All the fractures (delayed union and non-union) were united within 12 weeks. Most of the patients had discomfort at the donor site for few days; none had problems of persistent pain. The results were excellent in 68.81% (64/93) of cases, good in 19.35% (18/93) of cases, and poor in 11.82% (11/93) of cases. Conclusion: Percutaneous autologous bone marrow injection is an effective and safe method for the treatment of diaphyseal non-union and delayed union. Thus, it is concluded that with an adequate amount of autologous bone marrow injection, successful union in delayed union and non-union of fractures of long bones can be achieved. © 2017 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/). ଝ Study conducted at Department of Orthopaedics, Sharda University, Greater Noida, India. E-mail: [email protected] https://doi.org/10.1016/j.rboe.2017.09.004 2255-4971/© 2017 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). r e v b r a s o r t o p . 2 0 1 8;5 3(6):668–673 669 Injec¸ão percutânea de medula óssea autóloga para tratamento de retardo de consolidac¸ão ou pseudoartrose de fraturas de ossos longos após fixac¸ão interna r e s u m o Palavras-chave: Objetivos: O objetivo deste estudo foi avaliar os resultados da injec¸ão percutânea de medula Hastes ósseas óssea autóloga no tratamento de fraturas com retardo de consolidac¸ão ou pseudoartrose Fraturas femorais após fixac¸ão interna. Fixac¸ão interna de fratura Métodos: Esse estudo prospectivo foi realizado no Departamento de Ortopedia de junho de Fraturas com pseudoartrose 2005 a junho de 2010. Um total de 93 pacientes com retardo de consolidac¸ãoe pseudoartrose (56 retardos de consolidac¸ãoe 37 pseudoartroses) de osso longo foram recrutados dos Depar- tamentos de Emergência e Ambulatórios e tratados com injec¸ões de medula óssea autóloga percutânea. Os resultados clínicos desse estudo foram avaliados com base em critérios de consolidac¸ão. Todos os pacientes foram seguidos durante 24 meses. Resultados: Todas as fraturas (retardo de consolidac¸ão e pseudoartrose) apresentaram consolidac¸ão dentro de 12 semanas. A maioria dos pacientes apresentava desconforto na região doadora por alguns dias; nenhum caso de dor persistente foi observado. Os resulta- dos foram excelentes em 68,81% (64/93), bons em 19,35% (18/93) e ruins em 11,82% (11/93) dos casos. Conclusão: A injec¸ão de medula óssea autóloga percutânea é um método efetivo e seguro para o tratamento da pseudoartrose e do retardo de consolidac¸ãodiafisários. Assim, conclui- se que uma quantidade adequada de injec¸ão autóloga de medula óssea pode levar a uma consolidac¸ão bem sucedida em casos de retardo de consolidac¸ãoe pseudoartrose de fraturas de ossos longos. © 2017 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Este e´ um artigo Open Access sob uma licenc¸a CC BY-NC-ND (http:// creativecommons.org/licenses/by-nc-nd/4.0/). marrow injections. Written informed consent was taken from Introduction each patients and study was conducted according to world medical association declaration of Helsinki. The mean age Nonunion and delayed union are common problem seen in of the patients was 46 years (range: 16–86 years) and sex fracture healing and may be caused by several factors with distribution was 67 males and 26 females. or without any obvious cause. Numerous methods have been adopted to overcome this problem such as bone graft, electri- Inclusion criteria cal stimulation, ultrasound, bone transport and bone marrow injection. The concept of bone marrow graft and the per- cutaneous grafting method were subsequently combined in 1. Patients with delayed and non-union of long bone frac- many studies, taking into account the fluid nature of the bone tures. marrow. Some studies stated that percutaneous bone mar- 2. Age between 16 and 86 years. row injection could be used with composite graft with good 3. All fractures had acceptable alignment, good bone opposi- results in the treatment of simple bone cyst congenital tib- tion and stable fixation. ial pseudoarthrosis and in the management of delayed union 4. Bone marrow aspiration was done from anterior or poste- 1–4 in difficult clinical circumstances such as cancer patients. rior iliac crest. The aim of this prospective study was to assess the results of 5. Bone marrow was injected at interval of four to six weeks percutaneous bone marrow injection in the treatment of frac- after radiological evaluation for union under image inten- tures presenting with delayed union and non-union following sifier control. internal fixation. 6. The clinical results of this study were rated on the basis of the criteria of union; Union was defined clinically by the absence of bony tenderness and abnormal mobility at the Material and methods fracture site, and no pain at the fracture site on weight bearing. Radiological fracture union was defined by the This prospective study was carried out at Orthopaedics presence of callus bridging the fracture and partial obliter- department from June 2005 to June 2010. Institutional medi- ation of the fracture line in 2 views perpendicular to each cal ethics committee approved it. A total of 93 patients with other.5 delayed and non-union (56 delayed unions and 37 non-unions) 7. Patients were followed up for 24 months. of long bone were treated with percutaneous autologous bone 670 r e v b r a s o r t o p . 2 0 1 8;5 3(6):668–673 Exclusion criteria Table 1 – Age and sex distribution in study group (n = 93). Age Male Female Total % 1. Patients with pathological fractures. 2. Malnourished patients and those with open fractures, arte- <20 7 3 10 10.75 rial injuries, nerve injuries, infected fractures. 20–40 14 5 19 20.43 40–60 18 8 26 27.95 60–80 16 6 22 23.65 A written informed consent was obtained from all the >80 12 4 16 17.20 patients; they were explained about treatment plan, cost of Total 67 26 93 100 operation, and hospital stay after surgery, and complications of anaesthesia. They were followed up after surgery, were clinically and radio logically assessed for fracture healing, joint movements and implant failure. According to the criteria Results the results are graded as excellent when the fractures unites within 16 weeks without any complication, good when union In this prospective study, 93 long bone fractures of delayed or occur within 24 weeks with treatable complications like super- nonunion were treated with percutaneous autologous bone ficial infection and knee/ankle stiffness and poor when union marrow injections and followed for a period of two years. occur before or after 24 weeks with one or more permanent 72.04% (67/93) patients were males and 27.95% (26/93) patients complications like infection (osteomyelitis), implant failure, were females. The patients were aged sixteen years to eighty- non-union, limb shortening and permanent knee/ankle stiff- six years. 60.21% (56/93) had met with a road traffic accident, ness. Delayed union was recorded when the fracture united 13.97% (13/93) had a fall from a height and 25.80% (24/93) between three to six months while nonunion was noted when patients got injured from sport injuries. There were 53.76% a minimum of nine months have elapsed since injury and the (50/93) right sided and 46.23% (43/93) left sided fractures. Out fracture shows no visible sign healing for 3 months. Out of 93 of 100% (93/93), 13.97% (13/93) patients were open fractures long bones, 6 fracture shaft of the femur were treated with (Gustilo and Anderson type I) and 86.02% (80/93) were closed interlocking nail and 15 supracondylar fracture of femur were fractures. In this study, 22.58% (21/93) patients had fracture treated with lower femoral locking plates. 19 tibial shaft frac- shaft of the femur, 20.43% (19/93) fracture shaft of the tibia, tures were treated with dynamic compression locking plates.