Diaphyseal and metaphyseal nonunions treated with bone morphogenetic protein BMP-7 and autologous bone-marrow concentrate

Introduction Although a better understanding of and improved surgical techniques for the treatment of fractures, progression to nonunion is a possible occurrence whose incidence is rather increasing due to the raise of high-energy trauma (motor-vehicle and working accidents, open fractures, bone loss and/or comminution, soft tissue impairment), resulting in reduced biological capabilities. Materials and methods From May 2002 to December 2008, we treated 74 cases of aseptic stabilized nonunion in the meta-diaphyseal region of a long bones of the limbs. Eighteen cases involved the upper limb (1 clavicle, 12 humeri, 5 ulnae, 1 radius) and 56 cases involved the lower limb (27 femora, 29 tibiae). We modified the osteosynthesis in 14 and 53 cases in the upper and lower limb, respectively. In the upper limb we always used a locking plate system, while in the lower limb an intramedullary nail was used in 40 cases, plate and screws in 9 cases and a cast immobilization in one case. Results In 6 cases, nonunion was treated with percutaneous infiltration of bone marrow concentrate (BMC), resulting in bone healing in 4 cases (67%) to an average interval of 6 months. In 17 cases, nonunion was treated with a composite graft made of homologous bone chips, BMC and platelet-rich plasma; 87.5% of these patients healed at an average time of 5 months. In the remaining 57 cases, we employed the recombinant human bone morphogenetic protein 7 (rhBMP-7; Osigraft, Stryker, Limerick, Ireland) alone (44 cases) or in combination with BMC and homologous bone graft (13 cases); 89.4% of these patients healed at an average time of 4 months. The use of Osigraft increased over the years and it replaced other growth factors, because of its high success rate and simple surgical technique. Discussion The addition of other growth factors or autologous bone graft did not show superior results, and therefore our recommendation is to use autologous grafts only in massive defects ([4 cm), while in minor defects an allograft may be used to obtain mechanical stability and as a scaffold for osteogenic proteins, with similar results. Conclusions The use of BMP-7 is a simple and effective method to treat simple and difficult nonunions, provided you obtain mechanical stability. On the other hand, Osigraft is very expensive but is likely to lower; in addition, studies have shown the total economic benefit of this therapeutic approach, and patient satisfaction is definitely superior to other conventional approaches.