L. Tagliabue

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.

Risk factors contributing to fracture non-unions

Many studies have been carried out on the matter of pseudoarthrosis since the 1920s, where pseudoarthrosis is defined to occur when consolidation cannot be completed wi thout new biological or mechanical st imulation. Since then, several authors have contr ibuted their knowledge of osteogenetic mechanisms, placing the emphasis on the risk factors of a non-union. In genera[ terms the risk factors contr ibut ing to non-union can be separated into genera[ and local factors (Table 1 ). The purpose of this study is to ident i fy and report on the di f ferent factors which have been implicated in the pathogenesis of non-union of fractures.

Classification of non-union: Need for a new scoring system?

SUMMARY A new scoring system is proposed in order to assist surgeons with the complex analysis associated with non-union surgery. Patients with non-union are rarely easily compared with one another and this has frustrated research in this field. We have therefore attributed values to clinical features based on clinical experience and research evidence, so that patients of similar complexity can be compared with one another. When greater experience with this scoring system has been gained it will be further refined and validated. We propose that surgeons with a sub specialist interest in non-union surgery use this system in reporting results, and that non- specialist surgeons use it to inform their decision to treat the fracture themselves, or refer to a sub specialist.

Bone morphogenetic proteins and tissue engineering: future directions.

As long as bone repair and regeneration is considered as a complex clinical condition, the administration of more than one factor involved in fracture healing might be necessary. The effectiveness or not of bone morphogenetic proteins (BMPs) in association with other growth factors and with mesenchymal stem cells in bone regeneration for fracture healing and bone allograft integration is of great interest to the scientific community. In this study we point out possible future developments in BMPs, concerning research and clinical applications.

Treatment of long bone non-unions with polytherapy: Indications and clinical results

The incidence of long bone non-unions has been estimated to range between 5 and 10%. Autologous bone graft usually harvested from the iliac crest continues to be the gold standard for biological enhancement of atrophic non-unions. However, its use has been hampered by minor and major donor site complications. Moreover despite possessing the properties of osteogenecity, osteoconductivity and some osteoinductivity the overall results of treatment have not been consistent with disappointing success rates at times. The concept of polytherapy for the treatment of non-unions, namely the simultaneous application of the three fundamental elements of the diamond concept, osteoprogenitor cells, growth factor and osteoconductive scaffold, appears to be an attractive alternative but more studies are desirable to validate this strategy.

Tibial pilon fractures: Which method of treatment?

A comprehensive review of the existing literature, related to treatment options and management principles of pilon fractures was performed, and its results are presented. The identified series advocate in favour of a number of different treatment strategies and fixation methods. Decision making was mostly dependent on the severity of the local injury, the fracture pattern, the condition of the soft tissues, patients profile and surgical expertise. External fixation and conservative treatment did not provide sufficient articular congruence in many cases. Internal fixation allowed excellent restoration of joint congruity in Rüedi type I and II fractures. A staged approach, consisting of fibular plating and temporary bridging external fixation, later substituted by an internal minimal invasive osteosynthesis or by a definitive external fixation, was favourable for Rüedi type III fractures. Closed pilon fractures with bad soft tissue conditions (Tscherne ≥ 3) or open pilon fractures are regarded as contraindication of open reduction plate fixation. Anatomic reduction of the fracture, restoration of joints congruence, reconstruction of the posterior column, with minimal soft tissue insult, were all highlighted as of paramount importance.

Acetabular both-column fractures: Essentials of operative management

Acetabular both-column fractures are challenging articular injuries. They usually require operative treatment. We report on fundamental elements of pathoanatomy and radiology that are reviewed as far as they may influence treatment planning and surgical intervention. Surgical strategy, choice of the most suitable approach, reduction manoeuvres and fixation techniques are presented, together with some tips and tricks that are worth knowing in the surgical reconstruction of these difficult fractures.