J-bone graft with double locking plate: a symphony of mechanics and biology for atrophic distal femoral non-union with bone defect

Abstract

Objective: Atrophic distal femur non-union with bone defect (ADFNBD) has been a worldwide challenge to treat due to the associated biological and mechanical problems. The purpose of this study was to introduce a new solution involving the use of a J-shaped iliac crest bone graft (J-bone) combined with double-plate (DP) in the treatment of femoral non-union. Methods: Clinically, 18 patients with ADFNBD were included in this retrospective study and were treated with a combination of J-bone graft and DP. The average follow-up time was 22.1 ± 5.5 months (range, 14 to 34 months). The imaging information and knee joint activity tests and scores were used to evaluate the time to weight-bearing, the time to non-union healing, and the knee joint mobility. A finite element analysis was used to evaluate the differences between the following: (1) the use of a lateral locking plate (LLP) only group (LLP-only), (2) a DP only group (DP-only), (3) a DP with a J-bone group (DP+J-bone), and (4) an LLP with a J-bone group (LLP+J-bone) in the treatment of ADFNBD. A finite element analysis ABAQUS 6.14 (Dassault systems, USA) was used to simulate the von Mises stress distribution and model displacement of the plate during standing and normal walking. Result: All patients with non-union and bone defect in the distal femur achieved bone healing at an average of 22.1 ± 5.5 months (range, 14 to 34 months) postoperatively. The average healing time was 6.72 ± 2.80 months. The knee Lysholm score was significantly improved compared with that before surgery. Under both 750 N and 1800 N axial stress, the maximum stress with the DP+J-bone structure was less than that of the LLP+J-bone and DP-only structures, and the maximum stress of J-bone in the DP+J-bone was significantly less than that of the LLP+J-bone+on structure. The fracture displacement of the DP+J-bone structure was also smaller than that of the LLP+J-bone and DP-only structures. Conclusion: J-bone combined with DP resulted in less maximum stress and less displacement than did a J-bone combined with an LLP or a DP-only graft for the treatment of ADFNBD. This procedure was associated with less surgical trauma, early rehabilitation exercise after surgery, a high bone healing rate, and a satisfactory rate of functional recovery. Therefore, a combination of J-bone and DP is an effective and important choice for the treatment of ADFNBD.Keywords: Distal femur non-union with bone defect, J-shaped iliac crest bone graft, Finite element analysis

Union rates and functional outcome of double plating of the femur: systematic review of the literature

“…Both, Lu et al . [ 43 ] and Mardani-Kivi et al . [ 44 ] reported that double plating and bone grafting achieved a healing rate of 100% for the treatment of atrophic distal femur non-union with bone defect and non-union of femoral supracondylar, subtrochanteric, and shaft fractures, respectively.…”

“…Nine studies reported outcomes of case series with double plating of femoral non-unions including the proximal femur, femoral shaft and distal femur [4,24,[39][40][41][42][43][44][45]. Pydisetty et al [42] analysed 10 patients with revision surgery for non-union of bisphosphonate-related subtrochanteric fractures.…”

“…However, one patient was lost to follow-up and complication rate was high in these complex fracture patterns [42]. Both, Lu et al [43] and Mardani-Kivi et al [44] reported that double plating and bone grafting achieved a healing rate of 100% for the treatment of atrophic distal femur non-union with bone defect and non-union of femoral supracondylar, subtrochanteric, and shaft fractures, respectively. There were no differences between double plating, single plate and interfragmentary screw in the only study comparing different fixation techniques [39].…”

Infected Non-Union of the Distal Femur

“…For the treatment of atrophic distal femur non-union with bone defect, J shaped iliac crest bone graft combined with double plate resulted in less maximal tension and less displacement than a J shaped iliac crest bone combined with lateral locking plate or double plate only graft. Less surgical trauma, early rehabilitation exercise after surgery, a high rate of bone healing and a satisfactory rate of functional recovery were associated with this procedure [ 12 ]. An attractive alternative seems to be the idea of polytherapy for the treatment of non-union, namely the simultaneous application of the three fundamental elements of the diamond concept, osteoprogenitor cells, growth factor and osteoconductive scaffold; however, it is desirable to verify this technique with further research [ 13 ].…”

The comparison of clinical effect, knee function, prognosis of double plate fixation and locking plate internal fixation for tibial plateau fractures

“…14 Therefore, for tibial plateau fractures, internal fixation methods such as double plate fixation and locking plate fixation are often adopted. 15 While double plate internal fixation can provide local stability and continuous fixation force to the knee joint in order to prevent fracture displacement and force line change, the technique is associated with a long healing time, which negatively impacts prognosis by delaying the return to normal activity. 16,17 Medical technology developments have led to the gradual implementation of locking plate internal fixation in clinical practice.…”