Application of “diamond concept” in treatment of femoral shaft fractures nonunion after intramedullary fixation_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

TANG Yanfeng , YANG Yuxia , LI Hongjun , XI Jianing , YE Ye , YUE Chen ,  LIU Youwen

Hip Injury Center, Luoyang Orthopedic-Traumatological Hospital of Henan Province (Henan Provincial Orthopedic Hospital), Luoyang Henan, 471002, P.R.China;

Corresponding author：

LIU Youwen, Email: liuyouwen534@126.com

Keywords：

Femoral fracture; intramedullary nail; nonunion; bone marrow concentration; platelet-rich plasma; diamond concept

DOI：

10.7507/1002-1892.201912028

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Objective To investigate the effectiveness of the treatment under the guidance of “diamond concept” for femoral shaft fractures nonunion after intramedullary fixation.Methods Between January 2014 and December 2016, 21 cases of femoral shaft fractures nonunion after intramedullary fixation were treated with auxiliary plate fixation combined with autogenous iliac graft, and autologous bone marrow concentrate and platelet-rich plasma (PRP) gel under the guidance of the “diamond concept”. There were 13 males and 8 females, with an average age of 32.5 years (range, 17-48 years). All fractures were closed femoral shaft fractures. Four patients underwent internal fixation with plate and resulted in nonunion, then they were fixed with intramedullary nails, but did not heal either. The rest 17 patients were fixed with intramedullary nailing. Fracture nonunion classification: 4 cases of hypertrophic nonunion, 17 cases of atrophic nonunion; the length of bone defect was 1-3 mm; the duration from the last treatment to the current treatment was 10-23 months (mean, 14.3 months). The operation time, intraoperative blood loss, the time between operation and full loading, fracture healing time, and complications were recorded. The visual analogue scale (VAS) score and the imaging system of fracture healing of the extremities (RUST) of patients before operation and at last follow-up were recorded to evaluate the fracture healing; the function of the affected limb was evaluated according to the Schatzker-Lambert efficacy score standard at last follow-up.Results The operation time was 105-160 minutes, with an average of 125.6 minutes; the intraoperative blood loss was 160-580 mL, with an average of 370.5 mL. All incisions healed by first intention, without vascular or nerve injury. All patients were followed up 22-46 months (mean, 26.5 months). All the fractures healed, with a fracture healing time of 3-7 months (mean, 4.8 months). During the follow-up, there was no infection, loosening, implant breakage, re-fracture, and other complications. The VAS score at last follow-up was 0.8±0.3, showing significant difference (t=7.235, P=0.000) when compared with preoperative score (5.2±3.7); the RUST score was 3.4±0.3, which was significantly higher than the preoperative score (1.5±0.7) (t=8.336, P=0.000). According to the Schatzker-Lambert effectiveness evaluation standard, the limb function was excellent in 16 cases, good in 4 cases, fair in 1 case, and the excellent and good rate was 95.42%.Conclusion Nonunion after intramedullary fixation of femoral fracture treated with auxiliary plate combined with autogenous iliac graft, autogenous bone marrow concentration and PRP gel in accordance with the “diamond concept” can not only restore the stability of the fracture ends, but also improves the biological environment of the fracture site, and can improve the rate of fracture healing.

Citation： TANG Yanfeng, YANG Yuxia, LI Hongjun, XI Jianing, YE Ye, YUE Chen, LIU Youwen. Application of “diamond concept” in treatment of femoral shaft fractures nonunion after intramedullary fixation. Chinese Journal of Reparative and Reconstructive Surgery, 2020, 34(8): 1012-1017. doi: 10.7507/1002-1892.201912028 Copy

1.	Zhang YZ. Clinical epidemiology of orthopedic tramuar. New York: Thieme, 2012: 177-192.
2.	田野, 鞠林林, 金霖, 等. 2010 年至 2011 年中国东部地区和西部地区成人股骨干骨折流行病学对比分析. 中华创伤骨科杂志, 2016, 18(12): 1087-1091.
3.	徐小东, 朱前丞, 王立强, 等. 髓内钉固定股骨干骨折患者围手术期失血量的分析. 中华创伤骨科杂志, 2016, 18(11): 961-964.
4.	全宸良, 娄盛涵, 刘勃, 等. 股骨骨折术后骨不连相关危险因素分析. 解放军医学院学报, 2017, 38(5): 430-432.
5.	Vicenti G, Carrozzo M, Caiaffa V, et al. The impact of the third fragment features on the healing of femoral shaft fractures managed with intramedullary nailing: a radiological study. Int Orthop, 2019, 43(1): 193-200.
6.	Schlundt C, Bucher CH, Tsitsilonis S, et al. Clinical and research approaches to treat non-union fracture. Curr Osteoporos Rep, 2018, 16(2): 155-168.
7.	Giannoudis PV, Einhorn TA, Marsh D. Fracture healing: the diamond concept. Injury, 2007, 38 Suppl 4: S3-6.
8.	Giannoudis PV, Gudipati S, Harwood P, et al. Long bone non-unions treated with the diamond concept: a case series of 64 patients. Injury, 2015, 46 Suppl 8: S48-S54.
9.	Olivier M, Gay AM, Cerlier A, et al. Can we achieve bone healing using the diamong concept without bone grafting for recalcitrant tibial nonunions? Injury, 2015, 46(7): 1383-1388.
10.	Giannoudis PV, Einhorn TA, Schmidmaier G, et al. The diamond concept—open questions. Injury, 2008, 39 Suppl 2: S5-S8.
11.	Park J, Kim SG, Yoon HK, et al. The treatment of nonisthmal femoral shaft nonunions with im nail exchange versus augmentation plating. J Orthop Trauma, 2010, 24(2): 89-94.
12.	Lin CJ, Chiang CC, Wu PK, et al. Effectiveness of plate augmentation for femoral shaft nonunion after nailing. J Chin Med Assoc, 2012, 75(8): 396-401.
13.	吴永伟, 芮永军, 殷渠东, 等. 附加钢板技术治疗股骨骨折和骨不连. 中华创伤骨科杂志, 2017, 19(8): 718-722.
14.	Stucken C, Olszewski DC, Creevy WR, et al. Preoperative diagnosis of infection in patients with nonunions. J Bone Joint Surg (Am), 2013, 95(15): 1409-1412.
15.	中华医学会骨科学分会创伤骨科学组, 中华医学会骨科学分会外固定与肢体重建学组, 中国医师协会创伤外科医师分会创伤感染专家委员会, 等. 中国骨折内固定术后感染诊断与治疗专家共识(2018 版). 中华创伤骨科杂志, 2018, 20(11): 929-936.
16.	倘艳锋, 李无阴, 李建明, 等. 自体生物活性浓集物局部注射治疗骨折延迟愈合的疗效分析. 中国现代医学杂志, 2015, 25(32): 105-109.
17.	倘艳锋, 杨玉霞, 李红军, 等. 经皮骨折断端骨皮质“刺削”并局部注射自体浓缩骨髓液和富血小板血浆混合物治疗骨折延迟愈合. 中华创伤骨科杂志, 2018, 20(11): 999-1002.
18.	Hernigou P, Mathieu G, Poignard A, et al. Percutaneous autologous bone-marrow grafting for nonunions. Surgical technique. J Bone Joint Surg (Am), 2006, 88 Suppl 1 Pt 2: 322-327.
19.	Litrenta J, Tornetta P 3rd, Mehta S, et al. Determination of radiographic healing: an assessment of consistency using RUST and modified RUST in metadiaphyseal fractures. J Orthop Trauma, 2015, 29(11): 516-520.
20.	Schatzker J, Lambert DC. Supracondylar fractures of the femur. Clin Orthop Relat Res, 1979, (138): 77-83.
21.	潘林华, 汪金华, 廖英. 交锁髓内钉延迟动力化固定治疗股骨干骨折不愈合. 中国修复重建外科杂志, 2014, 28(4): 419-422.
22.	Brinker MR, O’Connor DP. Exchange nailing of ununited fractures. J Bone Joint Surg (Am), 2007, 89(1): 177-188.
23.	Banaszkiewicz PA, Sabboubeh A, McLeod I, et al. Femoral exchange nailing for aseptic non-union: not the end to all problems. Injury, 2003, 34(5): 349-356.
24.	Weresh MJ, Hakanson R, Stover MD, et al. Failure of exchange reamed intramedullary nails for ununited femoral shaft fractures. J Orthop Trauma, 2000, 14(5): 335-338.
25.	Yang KH, Kim JR, Park J. Nonisthmal femoral shaft nonunion as a risk factor for exchange nailing failure. J Trauma Acute Care Surg, 2012, 72(2): E60-E64.
26.	Ueng SW, Chao EK, Lee SS, et al. Augmentative plate fixation for the management of femoral nonunion after intramedullary nailing. J Trauma, 1995, 43(4): 640-644.
27.	孙亮, 李忠, 薛汉中, 等. 股骨干髓内钉术后骨不连的个性化治疗. 中华创伤骨科杂志, 2018, 20(10): 843-848.
28.	Schottel PC, Warner SJ. Role of bone marrow aspirate in orthopedic trauma. Orthop Clin North Am, 2017, 48(3): 311-321.
29.	Sanghani-Kerai A, McCreary D, Lancashire H, et al. Stem cell interventions for bone healing: fractures and osteoporosis. Curr Stem Cell Res Ther, 2018, 13(5): 369-377.
30.	El-Jawhari JJ, Kleftouris G, El-Sherbiny Y, et al. Defective proliferation and osteogenic potential with altered immunoregulatory phenotype of native bone marrow-multipotential stromal cells in atrophic fracture non-union. Sci Rep, 2019, 9(1): 17340.
31.	Sahu RL. Percutaneous autogenous bone marrow injection for delayed union or non-union of long bone fractures after internal fixation. Rev Bras Ortop, 2017, 53(6): 668-673.
32.	方家刘, 尹宗生, 王伟, 等. 富白细胞和血小板血浆对 BMSCs 在兔股骨头缺血性坏死中成骨作用的影响. 中国修复重建外科杂志, 2015, 29(2): 227-233.
33.	Gómez-Barrena E, Rosset P, Lozano D, et al. Bone fracture healing: cell therapy in delayed unions and nonunions. Bone, 2015, 70: 93-101.
34.	Andrzejowski P, Giannoudis PV. The ‘diamond concept’ for long bone non-union management. J Orthop Traumatol, 2019, 20(1): 21.
35.	Douras P, Tosounidis T, Giannoudis PV. Application of the ‘diamond concept’ with fast bone marrow aspirate concentration for the treatment of medial malleous non-union. Injury, 2018, 49(1): 2326-2330.

1. Zhang YZ. Clinical epidemiology of orthopedic tramuar. New York: Thieme, 2012: 177-192.
2. 田野, 鞠林林, 金霖, 等. 2010 年至 2011 年中国东部地区和西部地区成人股骨干骨折流行病学对比分析. 中华创伤骨科杂志, 2016, 18(12): 1087-1091.
3. 徐小东, 朱前丞, 王立强, 等. 髓内钉固定股骨干骨折患者围手术期失血量的分析. 中华创伤骨科杂志, 2016, 18(11): 961-964.
4. 全宸良, 娄盛涵, 刘勃, 等. 股骨骨折术后骨不连相关危险因素分析. 解放军医学院学报, 2017, 38(5): 430-432.
5. Vicenti G, Carrozzo M, Caiaffa V, et al. The impact of the third fragment features on the healing of femoral shaft fractures managed with intramedullary nailing: a radiological study. Int Orthop, 2019, 43(1): 193-200.
6. Schlundt C, Bucher CH, Tsitsilonis S, et al. Clinical and research approaches to treat non-union fracture. Curr Osteoporos Rep, 2018, 16(2): 155-168.
7. Giannoudis PV, Einhorn TA, Marsh D. Fracture healing: the diamond concept. Injury, 2007, 38 Suppl 4: S3-6.
8. Giannoudis PV, Gudipati S, Harwood P, et al. Long bone non-unions treated with the diamond concept: a case series of 64 patients. Injury, 2015, 46 Suppl 8: S48-S54.
9. Olivier M, Gay AM, Cerlier A, et al. Can we achieve bone healing using the diamong concept without bone grafting for recalcitrant tibial nonunions? Injury, 2015, 46(7): 1383-1388.
10. Giannoudis PV, Einhorn TA, Schmidmaier G, et al. The diamond concept—open questions. Injury, 2008, 39 Suppl 2: S5-S8.
11. Park J, Kim SG, Yoon HK, et al. The treatment of nonisthmal femoral shaft nonunions with im nail exchange versus augmentation plating. J Orthop Trauma, 2010, 24(2): 89-94.
12. Lin CJ, Chiang CC, Wu PK, et al. Effectiveness of plate augmentation for femoral shaft nonunion after nailing. J Chin Med Assoc, 2012, 75(8): 396-401.
13. 吴永伟, 芮永军, 殷渠东, 等. 附加钢板技术治疗股骨骨折和骨不连. 中华创伤骨科杂志, 2017, 19(8): 718-722.
14. Stucken C, Olszewski DC, Creevy WR, et al. Preoperative diagnosis of infection in patients with nonunions. J Bone Joint Surg (Am), 2013, 95(15): 1409-1412.
15. 中华医学会骨科学分会创伤骨科学组, 中华医学会骨科学分会外固定与肢体重建学组, 中国医师协会创伤外科医师分会创伤感染专家委员会, 等. 中国骨折内固定术后感染诊断与治疗专家共识(2018 版). 中华创伤骨科杂志, 2018, 20(11): 929-936.
16. 倘艳锋, 李无阴, 李建明, 等. 自体生物活性浓集物局部注射治疗骨折延迟愈合的疗效分析. 中国现代医学杂志, 2015, 25(32): 105-109.
17. 倘艳锋, 杨玉霞, 李红军, 等. 经皮骨折断端骨皮质“刺削”并局部注射自体浓缩骨髓液和富血小板血浆混合物治疗骨折延迟愈合. 中华创伤骨科杂志, 2018, 20(11): 999-1002.
18. Hernigou P, Mathieu G, Poignard A, et al. Percutaneous autologous bone-marrow grafting for nonunions. Surgical technique. J Bone Joint Surg (Am), 2006, 88 Suppl 1 Pt 2: 322-327.
19. Litrenta J, Tornetta P 3rd, Mehta S, et al. Determination of radiographic healing: an assessment of consistency using RUST and modified RUST in metadiaphyseal fractures. J Orthop Trauma, 2015, 29(11): 516-520.
20. Schatzker J, Lambert DC. Supracondylar fractures of the femur. Clin Orthop Relat Res, 1979, (138): 77-83.
21. 潘林华, 汪金华, 廖英. 交锁髓内钉延迟动力化固定治疗股骨干骨折不愈合. 中国修复重建外科杂志, 2014, 28(4): 419-422.
22. Brinker MR, O’Connor DP. Exchange nailing of ununited fractures. J Bone Joint Surg (Am), 2007, 89(1): 177-188.
23. Banaszkiewicz PA, Sabboubeh A, McLeod I, et al. Femoral exchange nailing for aseptic non-union: not the end to all problems. Injury, 2003, 34(5): 349-356.
24. Weresh MJ, Hakanson R, Stover MD, et al. Failure of exchange reamed intramedullary nails for ununited femoral shaft fractures. J Orthop Trauma, 2000, 14(5): 335-338.
25. Yang KH, Kim JR, Park J. Nonisthmal femoral shaft nonunion as a risk factor for exchange nailing failure. J Trauma Acute Care Surg, 2012, 72(2): E60-E64.
26. Ueng SW, Chao EK, Lee SS, et al. Augmentative plate fixation for the management of femoral nonunion after intramedullary nailing. J Trauma, 1995, 43(4): 640-644.
27. 孙亮, 李忠, 薛汉中, 等. 股骨干髓内钉术后骨不连的个性化治疗. 中华创伤骨科杂志, 2018, 20(10): 843-848.
28. Schottel PC, Warner SJ. Role of bone marrow aspirate in orthopedic trauma. Orthop Clin North Am, 2017, 48(3): 311-321.
29. Sanghani-Kerai A, McCreary D, Lancashire H, et al. Stem cell interventions for bone healing: fractures and osteoporosis. Curr Stem Cell Res Ther, 2018, 13(5): 369-377.
30. El-Jawhari JJ, Kleftouris G, El-Sherbiny Y, et al. Defective proliferation and osteogenic potential with altered immunoregulatory phenotype of native bone marrow-multipotential stromal cells in atrophic fracture non-union. Sci Rep, 2019, 9(1): 17340.
31. Sahu RL. Percutaneous autogenous bone marrow injection for delayed union or non-union of long bone fractures after internal fixation. Rev Bras Ortop, 2017, 53(6): 668-673.
32. 方家刘, 尹宗生, 王伟, 等. 富白细胞和血小板血浆对 BMSCs 在兔股骨头缺血性坏死中成骨作用的影响. 中国修复重建外科杂志, 2015, 29(2): 227-233.
33. Gómez-Barrena E, Rosset P, Lozano D, et al. Bone fracture healing: cell therapy in delayed unions and nonunions. Bone, 2015, 70: 93-101.
34. Andrzejowski P, Giannoudis PV. The ‘diamond concept’ for long bone non-union management. J Orthop Traumatol, 2019, 20(1): 21.
35. Douras P, Tosounidis T, Giannoudis PV. Application of the ‘diamond concept’ with fast bone marrow aspirate concentration for the treatment of medial malleous non-union. Injury, 2018, 49(1): 2326-2330.

Chinese Journal of Reparative and Reconstructive Surgery

Application of “diamond concept” in treatment of femoral shaft fractures nonunion after intramedullary fixation

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