Treatment of nonunions in fractures of the humeral shaft according to the Diamond Concept

Abstract

MethodsBetween 2005 and 2012, 50 patients (23 female, 27 male) with nonunion of the humeral shaft were included in this retrospective study. The mean age was 51.3 years (14 to 88). The patients had a mean of 1.5 prior operations (SD 1.2;1 to 8).All patients were assessed according to a specific risk score in order to devise an optimal and individual therapy plan consistent with the Diamond Concept. In 32 cases (64%), a change in the osteosynthesis to an angular stable locking compression plate was performed. According to the individual risk an additional bone graft and/or bone morphogenetic protein-7 (BMP-7) were applied. ResultsA successful consolidation of the nonunion was observed in 37 cases (80.4%) with a median healing time of six months (IQR 6). Younger patients showed significantly better consolidation. Four patients were lost to follow-up. Revision was necessary in a total of eight (16%) cases. In the initial treatment, intramedullary nailing was most common. DiscussionThe use of locking compression plates in combination with autologous cancellous bone graft has been shown to be a safe and effective treatment. In more complex cases, the use of the Masquelet technique and BMP-7 may be indicated at the first revision operation. Take home message: Our results suggest the Diamond Concept is a successful treatment strategy for nonunions of the humeral shaft. Cite this article: BoneJoint J 2016;98-B:81-7.

Treatment with recombinant human bone morphogenetic protein 7 leads to a transient induction of neutralizing autoantibodies in a subset of patients

“…Interventions according to the diamond concept involve an assessment of all of these aspects for a given patient and the attempt to optimize the therapeutic measures resulting in an individualized therapy plan. Treatment of non-unions following this concept proved to be a reasonable and successful strategy [7], [8], [9]. In early stage the therapeutic treatments in delayed union may include biophysical stimulation, e.g.…”

Low intensity pulsed ultrasound in the treatment of long bone nonunions: Evaluation of cytokine expression as a tool for objectifying nonunion therapy

“…It cannot be ruled out that the biofilm of the implant could be mobilized by ultrasound, which may lead to bacteremia or even sepsis. 26,37,38 LIPUS seems to provide osteoinductive stimulation and there is also some clinical evidence that LIPUS can accelerate the healing of fresh fractures. 39,40 But it is apparently insufficient in the treatment of nonunions.…”

“…In regards to nonunion treatment, there are a number of different surgical treatments, but most of them involve proper mechanical stabilization and debridement of nonunion tissue. 26,38,44,47,48 In future studies, it should be discussed whether there are certain specific patient groups with nonunions that could profit from LIPUS. Valid risk scores such as the PSN Score or classification systems such as the NUSS could be used to characterize differences in patients.…”

Double plating with autogenous bone grafting as a salvage procedure for recalcitrant humeral shaft nonunion

“…As the involved upper extremity often presents with pain and function loss, patients with humeral shaft nonunion often need revisions to improve their life quality. Many surgical techniques for the treatment of humeral shaft nonunion have been described, such as open reduction and internal xation (ORIF) with locking compression plate (LCP) and bone graft, double plates xation, allogeneic or autologous cortical bone graft, intramedullary nails, and Ilizarov external xators, and adding biologic augmentation (BMP) or assisted with low-intensity pulsed ultrasound [9][10][11]. However, there is currently no consensus on the optimal operative treatment strategy for nonunion of humeral shaft.…”