|Year : 2019 | Volume
| Issue : 2 | Page : 51-53
Diamonds are expensive, rings are not: Mastering The Paradoxical Evolution Of Nonunion Treatment
Milind M Chaudhary
Centre for Ilizarov Techniques, Chaudhary Hospital, Akola, Maharashtra, India
|Date of Submission||27-Dec-2019|
|Date of Acceptance||27-Dec-2019|
|Date of Web Publication||31-Dec-2019|
Prof. Milind M Chaudhary
Director, Centre for Ilizarov Techniques, Chaudhary Hospital, Akola - 444 001, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Chaudhary MM. Diamonds are expensive, rings are not: Mastering The Paradoxical Evolution Of Nonunion Treatment. J Limb Lengthen Reconstr 2019;5:51-3
Welcome to the tenth issue of JLLR. We have now completed 5 years of steady progress and are inching slowly toward our goal of being the repository of knowledge for the science and practice of limb reconstruction.
Including this editorial, we have devoted 80% of this issue to “Nonunions.” Nonunions are common where neglected and inadequate initial treatment is prevalent. It is also high in countries with ideal fracture care.
Nonunions present with a bewildering laundry list of problems; each needing specialized treatment. Failure of union causes reduced mobility, suspended employment, economic hardships, and social isolation. No wonder, that a nonunion ranks as high as chronic renal disease and other serious medical ailments as a cause of morbidity.
With infection, the problem becomes formidable, needing a multipronged attack with expensive, often repeated surgeries, antibiotics, and adjuncts. Bone loss and shortening ensure that treatment is unlikely to end with excellent results using either simple or sophisticated treatment. Deformities, poor bone quality, joint contractures and stiffness, soft tissue injuries, and defects aggravate problems and necessitate multilevel and multispecialty treatment.
The advent of the Ilizarov techniques and their spread approximately 30 years ago brought optimism and confidence. Certainly, the Ilizarov techniques do work well with simple and possibly inexpensive equipment. Sustained compression ensures reliable union in a majority. Ability to lengthen, fill bone gaps, and correct deformities with regenerate bone justified a global wave of acceptance and adoption. For some surgeons, it came close to a panacea. It could handle the baggage accompanying nonunions, often with elegance and certainty, even for those without deep pockets.
There was enough literature on the use of different modalities of Ilizarov method on nonunions. Monofocal compression, bone transport, bifocal simultaneous compression and distraction, monofocal distraction, trifocal transport, horizontal transport, skin transport to solve docking site skin invagination, and docking site problems were all reported. High rates of success in some hands enthused many to give it a go. However, many did not prepare for hidden or obvious difficulties.
Prolonged duration, restrictions because of bulky femoral frames, pin infections, difficulties in controlling pain, or movement of bone fragments had brought quick disillusionment for many.
Work to improve on drawbacks started on various fronts: from the all-wire frames to hybrid frames with half pins and smaller profile arches, reduced pain and joint stiffness in the femur. Acute compression and then lengthening reduced duration needed for bone transport. Acute compression with intentional angular deformities at nonunion site helped skin wounds heal without flaps, to be gradually straightened. Efforts at reducing healing time at docking sites or nonunion started with acceptance of bone grafting as helpful in reducing time rather than unnecessary.
The low profile LRS system  is definitely more convenient for the patient and the surgeon especially for nonunions in the femur.
Exhaustion of bone grafting donor sites in recalcitrant nonunions leads the search for alternatives. Use of bone marrow aspirate injections, either without processing, as a concentrate  or after culturing to increase the colony-forming count of precursor cells, became popular. The use of bone graft substitutes such as demineralized bone matrix (DBM), calcium phosphate, beta-tricalcium phosphates, or hydroxyapatites saw widespread use. Authors did manage to prove shortened healing times, albeit at increased costs and an additional trip to the operating room.
After a brief honeymoon period of believing the apocryphal “infection burns in the fire of the regenerate,” most surgeons resigned to the reality of debridement as the real solution for infection. Debridement, the oldest of surgeries, saw revival. Debridement as a forerunner to internal or fixator application became compulsory. Antibiotic-impregnated cement beads or rods became a popular way to deliver high concentrations of local antibiotics. The need to remove these beads or rods in a second surgery leads to the growth of antibiotic cement impregnated in soluble calcium phosphate cements. While these changes in infection control did work, the issues of prolonged duration of external fixation with its inconvenience left many searching for more.
Masquelet et al. described the role of debridement and cement blocks to create a pseudo-membrane. This was filled with bone grafts to successfully heal bone defects and gaps. Many abandoned external fixation and used internal fixation despite infection. The pseudo-membrane formed well in 3–6 weeks and purportedly secreted the secret sauce which helped the bone gaps to heal. However, the need was for a plenty of bone graft to occupy the cylinder of the membrane. For gaps larger than 4 cm, iliac crest grafts were not enough. Hence, the search was on for alternate sources of graft.
The reamer irrigator aspirator (RIA) allows reaming in polytraumatized patients without raising pulmonary pressures. A large number of workers adopted this to harvest graft from the opposite femoral canal. Surgeons can harvest 80 g of graft, fill larger gaps in the pseudo-membrane, and hence rise the popularity of Masquelet technique. It was, however, not without problems. The effective reaming and suction results in much blood loss in a short time, leading at times to a precipitous fall in blood pressure on the table. Most patients would end with a decrease of at least 2 g of hemoglobin. This seemingly small drop could be a large price to pay in anemic patients who have negative nitrogen balance from prolonged infection. Expensive disposables make the RIA unaffordable to some. Excessive reaming can weaken and break the anterior cortex of distal femur.
Allografts and DBM along with bone grafts can fill up the pseudo-membrane.
Giannoudis et al. created the Diamond concept to fill up the pseudo-membrane with grafts, DBM, and BMP-7. The concept has many proponents, and literature is full of articles and excitement runs high. Many believe that the Diamond concept has cut through the evil impregnable fortress of infected nonunions.
But, Diamonds are expensive and not everyone can have them.
Vascularized fibular grafts can fill up large bone gaps after controlling infection. However, surgeries may be prolonged and require specific expertise.
The Masquelet technique is attractive to most trauma surgeons as they do not need special training in either Ilizarov techniques or microvascular grafting. It is also attractive to the patient due to convenience of internal fixation and no need for repeat follow-up visits.
In recent cost analysis articles published by Calori et al., comparing bone grafting and BMP treatment, the latter turned out minimally expensive compared to Iliac Crest Bone Grafting (ICBG). However, considering the longer duration for ICBG and repeat follow-up visits, they managed to prove that BMP-7 treatment was cost-effective.
Finite element analysis (FEA) helps design titanium cages using three-dimensional (3D) printing  to insert in a pseudo-membrane. A recent addition to the Masquelet technique is the ability to print by an additive manufacturing. This will work as a scaffold, add strength, occupy volume, and help early weight-bearing walking.
A possible alternative could be use cages similar to those used in spine surgery manufactured by the less expensive subtractive manufacturing. Again, incomplete eradication of infection could lead even this addition to failure.
Hence, where does the treatment of infected nonunions stand today? Ilizarov methods are reliable, consistent, and not expensive. However, the Ilizarov method is expensive in terms of time, effort, and expertise of the surgical team and expensive due to possible down time for the patient. Chances of recrudescence of infection are less with Ilizarov, and it can fill large bone gaps reliably.
Quo Vadis? Where do we go from here? What is needed in nonunion treatment? One of the articles mentions the need for a preoperative score that takes into account the difficulties of achieving excellent results according to the ASAMI criteria. It may seem like a duplication of nonunion severity score (NUSS). It attempts to improve the infection and bone gap components of the NUSS.
The infection severity score mentioned helps helped numerically grade infection on a continuous scale, rather than a categoric binary scale as does the AO classification or the NUSS. It is not yet validated. It could help decide whom to treat with internal fixation and Masquelet technique and who would be better off with the infection-safe Ilizarov method.
Inoue et al. have helped design iodine-impregnated implants. Using these, all infected nonunions could be treated with internal fixation. Then, with the pseudo-membrane and bone graft substitutes and BMAC and BMP-7, perhaps with 3D-printed titanium cages, we could have the perfect solution which could reliably heal infected nonunions despite the extent of bone loss. This solution would not be affordable to many in less developed economies. Till then, the Ilizarov techniques, with their affordability and reliability, will continue to remain the bulwark and backbone of nonunion treatment for some time to come.
| References|| |
Hak DJ, Fitzpatrick D, Bishop JA, Marsh JL, Tilp S, Schnettler R, et al
. Delayed union and nonunions: Epidemiology, clinical issues, and financial aspects. Injury 2014;45 Suppl 2:S3-7.
Chaudhary MM. Infected nonunion of tibia. Indian J Orthop 2017;51:256-68.
] [Full text]
Paley D, Catagni MA, Argnani F, Villa A, Benedetti GB, Cattaneo R. Ilizarov treatment of tibial nonunions with bone loss. Clin Orthop Relat Res 1989;241:146-65.
Tetsworth KD, Dlaska CE. The art of tibial bone transport using the Ilizarov fixator: The suspension wire technique. Tech Orthop 2015;30:142-55.
McKee MD, Yoo DJ, Zdero R, Dupere M, Wild L, Schemitsch EH, et al
. Combined single-stage osseous and soft tissue reconstruction of the tibia with the Ilizarov method and tissue transfer. J Orthop Trauma 2008;22:183-9.
Seenappa HK, Shukla MK, Narasimhaiah M. Management of complex long bone nonunions using limb reconstruction system. Indian J Orthop 2013;47:602-7.
] [Full text]
Gianakos AL, Sun L, Patel JN, Adams DM, Liporace FA. Clinical application of concentrated bone marrow aspirate in orthopaedics: A systematic review. World J Orthop 2017;8:491-506.
Masquelet A, Kanakaris NK, Obert L, Stafford P, Giannoudis PV. Bone repair using the masquelet technique. J Bone Joint Surg Am 2019;101:1024-36.
Cox G, Jones E, McGonagle D, Giannoudis PV. Reamer-irrigator-aspirator indications and clinical results: A systematic review. Int Orthop 2011;35:951-6.
Morelli I, Drago L, George DA, Gallazzi E, Scarponi S, Romanò CL. Masquelet technique: Myth or reality? A systematic review and meta-analysis. Injury 2016;47 Suppl 6:S68-76.
Giannoudis PV, Einhorn TA, Marsh D. Fracture healing: The diamond concept. Injury 2007;38 Suppl 4:S3-6.
Calori GM, Colombo M, Mazza EL, Mazzola S, Malagoli E, Marelli N, et al
. Validation of the non-union scoring system in 300 long bone non-unions. Injury 2014;45 Suppl 6:S93-7.
Tetsworth K, Block S, Glatt V. Putting 3D modelling and 3D printing into practice: Virtual surgery and preoperative planning to reconstruct complex post-traumatic skeletal deformities and defects. SICOT J 2017;3:16.
Inoue D, Kabata T, Kajino Y, Shirai T, Tsuchiya H. Iodine-supported titanium implants have good antimicrobial attachment effects. J Orthop Sci 2019;24:548-51.