Locking Compression Plate Combined With Autologous Bone Grafting And Red Marrow Injection Treatment Of Long Bone Aseptic Nonunion

Background:With the development of modern agriculture and transportation, more accidental disasters, including the limbs long bone fracture、comminuted and segmental fracture、especially open fracture incidence, the treatment is difficult.Since the principle of treatment from1960the anatomical reduction, rigid internal fixation and early painless muscle and joint active fracture, long bone fracture treatment technology continues to improve,90%～95%of the fracture can be healed, but nonunion occurred from time to time, failure rate is higher,which has become a major problem in the Department of orthopedics in the face of doctors.Although the exact causes of delayed union and nonunion are unknown, systemic and local factors are thought to contribute to their development. Systemic factors include the patient’s metabolic and nutritional status, general health, and activity level. The use of tobacco has been implicated in the development of nonunions. Local factors were defined in a review at this clinic of842patients with nonunions of long bones. Boyd, Lipinski, and Wiley found that nonunion was more common when the fractures were (1) open;(2) infected;(3) segmental, with impaired blood supply, usually to the middle fragment;(4) comminuted by severe trauma;(5) insecurely fixed;(6) immobilized for an insufficient time;(7) treated by ill-advised open reduction;(8) distracted either by traction or by a plate and screws; or (9) of irradiated bone.For the treatment of bone nonunion can be divided into operation therapy, biological and physical therapy, including:(1) bone graftingor internal fixation with bone grafting;(2) external fixation;(3) physical therapy:A, low intensity pulsed ultrasound therapy; B, electric stimulation therapy; C, hyperbaric oxygen therapy; D, extracorporeal shock wave therapy;(4) the bone induction therapy;(5) red marrow injection;(6) gene therapy.The common treatment of nonunion is internal fixation with bone grafting.The essence of bone regeneration is the biological and biomechanical role.In promoting wound healing and treatment of bone nonunion, biomechanics therapy is widely used. The important of mechanical environment has been generally accepted by the doctors of orthopedic surgery.but the use of biological resources has not been paid enough attention.Evidence shows that many factors can stimulate new bone formation and the formation of vessels to reconstruct bone and soft tissue defect.Effective treatment measures include the biomaterial scaffold, growth factors, optimizing the mechanical environment and appropriate surgical intervention.Reliable fracture healing is an important factor of functional rehabilitation.It is very important for bone healing to combine mechanics,mechanical and biological together.In1869Goujon demonstrated that bone marrow had osteogenetic capabilityin rabbit experiments.Red marrow can effectively promote the healing of fractures, which has been demonstrated by many scholars in cytological basic research, animal experiment and clinical application.Containing osteoprogenitor cells and stromal cells, red marrow can be induced cartilage and osteoblast.Red marrow can be injected into the bone stump,which contains lots of bone morphogenetic protein (BMP), stromal cells, bone lining cells and bone progenitor cells, stromal cells. It can differentiate into osteoblasts, promote bone healing and stimulate fracture other tissue cells into bone cells.Autologous bone marrow source is rich in human body. Percutaneous transplantation in delayed fracture healing site is safe and convenients for taking,with few complications and no immune response problems.Objective:Bone healing needscombining mechanics, biomechanics well with biological factors.To summarize the current factors causing bone nonunion and the existing advantages and disadvantages of various methods of nonunion treatment, wetreat nonunion by the locking compression plate autogenous bone graft combined with red bone marrow injection.This method not only pays attention to the biomechanical principles, but also attaches importances to biological factors in bone healing. A detailed analysis of the mechanics, the biomechanical and biological reasons of nonunion is provided in this paper.Bycomparing bone healing procedure under different conditions, we take it seriously in order to find the exact therapy for treatment of bone nonunion, to providing the clinical information for the treatment of long bone shaft aseptic nonunion.Methods:All patients underwent complete preoperative examination, treatingmedicine disease, than do operation treatment. operation including:The control group (locking plate+autologous bone graft)①Iliac bone grafting:along the ipsilateral iliac crest do oblique incision about6cm, divide skin,subcutaneous and deep fascia, As the deep fascia is incised, divede the periosteum of iliac, with wide ostectriteto cut bone slices, curette scrape enoughcancellous bone, after saline flushing raw surface coate the bone wound with amount of bone wax, layer by layer suture.Bone grafting method:transplant bone360°aroundthe nonunion ends, this bone grafting method increases the contact area of cell and bone graft with the nonunion ends, playsaimportant role of bone induction and bone conduction, stimulating bone connection occurs.In addition, cancellous bone in the humoral nutrition broken ends can have more survival bone cells, which increase the possibility of bone connection.②Locking plate fixation:take appropriate length of incisionbeside the nonunion end, divide skin,subcutaneous and deep fascia, As the deep fascia is incised, remove the original internal fixation and bone sequestrum completely, exposure of the fracture site, clean up the granulation tissue, thril the medullary cavity, make the nonunion end with fresh wound.The locking compression plateshould be of sufficient length, combined with body weight and bone length to increasing the number of screws.Insertethe locking compression plateby MIPPO technology, we should pay attention to ensure that the force line, length of the limb be well recovered, and attach importance to check the rotation.Finally finished all of the above, transplant the iliac bone,especially the cancellous bone.In the prosedure of operation,we should minimize the periosteal stripping, do minimally invasive operation, and protectethe normal bone blood supplycarefully.The experimental group (locking plate+autologous bone graft+red marrow injection)①Iliac bone grafting:along the ipsilateral iliac crest do oblique incision about6cm, divide skin,subcutaneous and deep fascia, As the deep fascia is incised, divede the periosteum of iliac, with wide ostectrite to cut bone slices, curette scrape enough cancellous bone, after saline flushing raw surface coate the bone wound with amount of bone wax, layer by layer suture.Bone grafting method:transplant bone360°around the nonunion ends, this bone grafting method increases the contact area of cell and bone graft with the nonunion ends, plays a important role of bone induction and bone conduction, stimulating bone connection occurs.In addition, cancellous bone in the humoral nutrition broken ends can have more survival bone cells, which increase the possibility of bone connection.②Locking plate fixation:take appropriate length of incision beside the nonunion end, divide skin,subcutaneous and deep fascia, As the deep fascia is incised, remove the original internal fixation and bone sequestrum completely, exposure of the fracture site, clean up the granulation tissue, thril the medullary cavity, make the nonunion end with fresh wound.The locking compression plate should be of sufficient length, combined with body weight and bone length to increasing the number of screws.Inserte the locking compression plate by MIPPO technology, we should pay attention to ensure that the force line, length of the limb be well recovered, and attach importance to check the rotation.Finally finished all of the above, transplant the iliac bone,especially the cancellous bone.In the prosedure of operation,we should minimize the periosteal stripping, do minimally invasive operation, and protecte the normal bone blood supply carefully.③Bone marrow collection and injection:2and4weeks after operation, collect marrow with the bone marrow puncture needle and20ml plastic needle cylinder,with heparin soluting.The needle deep into the cancellous bone, plastic needle aspiration of bone marrow.In the continuous process of pumping, the puncture needle bevel graded rotated45degrees, in the same depth extraction maximum amount of bone marrow. Complete the rotating suction draw back lcm, repeat the above rotary suction.Each pumping volume is about4ml, less than10ml, in order to reduce the dilution of blood infiltration.In the same skin puncture point can have3-5puncture way, to acquire sufficient bone marrow.There must be about2cm interval between each of the2puncture path, so as to avoid the puncture point accidentally into the original point and bone marrow dilution.After extract the red marrow successfully, inject red bone marrow into the medullary cavity,fibrous scar tissue and the nonunion ends immediately under fluoroscopic guidance by epidural puncture needle. Each injection position of not less than20ml,take care of maintaining a certain pressure during injection, through more than3injection points, so as to making red bone marrow all around the nonunion end.Postoperative treatment:Observe the patient’s vital signs carefully, keep limb in the correct position, change fresh dressing for the wound and take the stitches routinely.All patients were treated with low-frequency pulsed electromagnetic therapy.Do postoperative functional training at second day, firstly with active muscle contraction exercise; than active exercise after the swelling subsided with the around joins, supplemented by modest passive activity, action should be slow, avoind rapid rocking back and forth limb joint, give resistance against the functional training after bone line vaguely.At the same time, in the same timetake steps to prevent and treat complications.Results:The two groups of patients with operation have good results, without redness, inflammation. through statistical analysis, operation time, intraoperative blood loss, length of hospital stay, healing time and wound drainage have no significant difference in two groups (p>0.05). Control group:1months after operation, bone density increased, but less than the experimental group, there is not obvious callus growth;3months, bone density continues to increase, the density of the callus growth, like the experimental group at1month after operation;6months,the implant shape is fuzzy, defection density increased, external callus growthmassively, most of the fracture line is still visible;9 months,nonunion end and defection can be seen a large number of callus, fracture line disappeared, but the cortical bone is not well reformed;12months, bone defection was completely repaired, the majority of marrow cavity recanalization, but slightly narrower than normal medullary cavity.Experimental group:1months after operation, there is a little new bone formationaround the bone defect area, density increased significantly, the nonunion ends exists visibly low density bone callus image;3months, defect area central and external callus formation further increased, autogenous bonehas been degradated and absorpted; bone defect area can be seen a large number of dense callus shadow, the vast majority of the fracture line is fuzzy;9months,the nonunion ends exists a lot of high density continuous bone callus, density is basically the sameas cortical bone, bone defect area filled by new bone, fracture line disappeared completely;12months, the bone defect was completely repaired.Two groups of patients evaluated by Fernandez-Esteve X-ray score, there was a significant difference in the postoperative,1,3,6,9months (p<0.05); and in12months after operation, there was no significant difference (p>0.05).Conclusion:1, Locking compression plate combined with Autologous bone grafting can promote fracture healing, for treatment of bone nonunion.2, Autologous bone grafting combined with red bone marrow injection promote bone healing in the treatment of nonunion more efficiently.