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Z Orthop Unfall 2015; 153(06): 659-676
DOI: 10.1055/s-0035-1558259
Refresher Orthopädie und Unfallchirurgie
Georg Thieme Verlag KG Stuttgart · New York

Pseudarthrosen langer Röhrenknochen

Long Bone Nonunion
G. Schmidmaier
Unfall- und Wiederherstellungschirurgie, Zentrum für Orthopädie, Unfallchirurgie und Paraplegiologie, Universitätsklinik Heidelberg
,
A. Moghaddam
Unfall- und Wiederherstellungschirurgie, Zentrum für Orthopädie, Unfallchirurgie und Paraplegiologie, Universitätsklinik Heidelberg
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Publication History

Publication Date:
15 December 2015 (online)

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Zusammenfassung

Der Anteil von verzögerter oder ausbleibender Knochenbruchheilung bei Frakturen der langen Röhrenknochen liegt, je nach Risikoprofil des Patienten, bei ca. 10 %. Dies führt bei den Patienten häufig zu einer erheblichen Einschränkung der Lebensqualität und ist mit einer verlängerten Krankheitsdauer vergesellschaftet. Nach der aktuellen Definition ist eine Pseudarthrose eine Fraktur, die ohne weitere Intervention nicht mehr zur Ausheilung kommt – unabhängig von der bisherigen Behandlungsdauer. In der Frühphase ist bei ausreichender Stabilität eine konservative Therapie möglich. In der operativen Behandlung zielt die Therapie, angelehnt an das „Diamond Concept“, zunächst auf eine Analyse der Pseudarthrose nach festen Kriterien ab. Anschließend erfolgt die Optimierung der einzelnen Faktoren, wie der mechanischen Stabilität, z. B. durch Reosteosynthese, der Verbesserung der Vaskularisation, der Bereitstellung von osteokonduktivem Material wie z. B. Trikalziumphosphat sowie vitalen Zellen durch Spongiosaplastiken und der Applikation von Wachstumsfaktoren wie Bone morphogenetic Proteins (BMP-2 oder BMP-7). Diese Maßnahmen sind, je nach Analyse der Pseudarthrose, einzeln oder kombiniert möglich. Weiterhin besteht die Möglichkeit eines zweizeitigen Verfahrens in der Masquelet-Technik, vor allem bei atrophen und Defekt- bzw. Infektpseudarthrosen. Dabei wird nach Infektsanierung und Induktion einer „Neo-Knochenhaut“ der Knochenaufbau nach den gleichen Prinzipien in einer 2. Operation vorgenommen.

Abstract

The percentage of delayed or non-unions after fractures of long bones depends on the individual risk profile at approximately 10 %. The current definition states that a non-union is a fracture that will not consolidate without any further intervention – independent from the treatment time. At the early stage of a non-union a conservative treatment is possible in case of an adequately stable situation. The operative treatment depends on the type of the non-union. There are one-step or two-step procedures, all according to the principles of the “diamond concept”. This means improvement of the mechanical situation – in most cases by means of a reosteosynthesis – and vascularization, local application of osteoconductive carriers e.g. tricalciumphosphate, vital cells from autologous bone and osteoinductive substances like bone morphogenetic proteins (BMP-2 or BMP-7). Hypertrophic and atrophic non-unions without large defect gaps or signs of infection can be treated with a one-step procedure. For treating infected non-unions or non-unions with large defect gaps the Masquelet technique is recommended.

Key words

ausbleibende Frakturheilung - verzögerte Frakturheilung - Röhrenknochen - Diamond Concept - Masquelet-Technik

Key words

non-union - delayed union - Masquelet technique - diamond concept - long bone
 

  • Literatur

  • 1 Einhorn TA. The cell and molecular biology of fracture healing. Clin Orthop Relat Res 1998; 355 (Suppl.) S7-S21
    PubMedSearch in Google Scholar
  • 2 Ring D, Allende C, Jafarnia K et al. Ununited diaphyseal forearm fractures with segmental defects: plate fixation and autogenous cancellous bone-grafting. J Bone Joint Surg Am 2004; 86: 2440-2445
    CrossrefPubMedSearch in Google Scholar
  • 3 Rothman RH, Klemek JS, Toton JJl. The effect of iron deficiency anemia on fracture healing. Clin Orthop Relat Res 1971; 77: 276-283
    PubMedSearch in Google Scholar
  • 4 Schmidmaier G, Schwabe P, Wildemann B et al. Use of bone morphogenetic proteins for treatment of non-unions and future perspectives. Injury 2007; 38 (Suppl. 04) S35-S41
    CrossrefPubMedSearch in Google Scholar
  • 5 Giannoudis PV, Einhorn TA, Schmidmaier G et al. The diamond concept – open questions. Injury 2008; 39 (Suppl. 02) S5-S8
    CrossrefPubMedSearch in Google Scholar
  • 6 Moghaddam A, Zimmermann G, Hammer K et al. Cigarette smoking influences the clinical and occupational outcome of patients with tibial shaft fractures. Injury 2011; 42: 1435-1442
    CrossrefPubMedSearch in Google Scholar
  • 7 Moghaddam A, Zietzschmann S, Bruckner T et al. Treatment of atrophic tibia non-unions according to ‘diamond concept’: Results of one- and two-step treatment. Injury 2015; 46 (Suppl. 04) S39-S50
    CrossrefPubMedSearch in Google Scholar
  • 8 Ruedi TP, Luscher JN. Results after internal fixation of comminuted fractures of the femoral shaft with DC plates. Clin Orthop Relat Res 1979; 138: 74-76
    PubMedSearch in Google Scholar
  • 9 Wolinsky PR, McCarty E, Shyr Y et al. Reamed intramedullary nailing of the femur: 551 cases. J Trauma 1999; 46: 392-399
    CrossrefPubMedSearch in Google Scholar
  • 10 Wright RR, Schmeling GJ, Schwab JP. The necessity of acute bone grafting in diaphyseal forearm fractures: a retrospective review. J Orthop Trauma 1997; 11: 288-294
    CrossrefPubMedSearch in Google Scholar
  • 11 Wei SY, Born CT, Abene A. Diaphyseal forearm fractures treated with and without bone graft. J Trauma 1999; 46: 1045-1048
    CrossrefPubMedSearch in Google Scholar
  • 12 Ricci WM, Bellabarba C, Evanoff B. Retrograde versus antegrade nailing of femoral shaft fractures. J Orthop Trauma 2001; 15: 161-169
    CrossrefPubMedSearch in Google Scholar
  • 13 Kontakis GM, Papadokostakis GM, Alpantaki K et al. Intramedullary nailing for non-union of the humeral diaphysis: a review. Injury 2006; 37: 953-960
    CrossrefPubMedSearch in Google Scholar
  • 14 Krzykawski R, Król R, Kamiński A. The results of locked intramedullary nailing for non-union of forearm bones. Ortop Traumatol Rehabil 2008; 10: 35-43
    PubMedSearch in Google Scholar
  • 15 Richard MJ, Ruch DS, Aldridge 3rd JM. Malunions and nonunions of the forearm. Hand Clin 2007; 23: 235-243
    CrossrefPubMedSearch in Google Scholar
  • 16 Rommens PM, Kuechle R, Bord T et al. Humeral nailing revisited. Injury 2004; 39: 1319-1328
    PubMedSearch in Google Scholar
  • 17 Moghaddam-Alvandi A, Zimmermann G, Büchler A et al. [Results of nonunion treatment with bone morphogenetic protein 7 (BMP-7)]. Unfallchirurg 2012; 115: 518-526
    CrossrefPubMedSearch in Google Scholar
  • 18 Gaston MS, Simpson AH. Inhibition of fracture healing. J Bone Joint Surg Br 2007; 89: 1553-1560
    CrossrefPubMedSearch in Google Scholar
  • 19 Giannoudis PV, Jones E, Einhorn TA. Fracture healing and bone repair. Injury 2011; 42: 549-550
    CrossrefPubMedSearch in Google Scholar
  • 20 Moghaddam A, Weiss S, Wölfl CG et al. Cigarette smoking decreases TGF-b1 serum concentrations after long bone fracture. Injury 2010; 41: 1020-1025
    CrossrefPubMedSearch in Google Scholar
  • 21 Bender D, Haubruck P, Boxriker S et al. Validity of subjective smoking status in orthopedic patients. Ther Clin Risk Manag 2015; 11: 1297-1303
    PubMedSearch in Google Scholar
  • 22 McKibbin B. The biology of fracture healing in long bones. J Bone Joint Surg Br 1978; 60: 150-162
    PubMedSearch in Google Scholar
  • 23 Macey LR, Kana SM, Jingushi S et al. Defects of early fracture-healing in experimental diabetes. J Bone Joint Surg Am 1989; 71: 722-733
    CrossrefPubMedSearch in Google Scholar
  • 24 Schoierer O, Bloess K, Bender D et al. Dynamic contrast-enhanced magnetic resonance imaging can assess vascularity within fracture non-unions and predicts good outcome. Eur Radiol 2014; 24: 449-459
    CrossrefPubMedSearch in Google Scholar
  • 25 Bode G, Strohm PC, Südkamp NP et al. Tibial shaft fractures – management and treatment options. A review of the current literature. Acta Chir Orthop Traumatol Cech 2012; 79: 499-505
    PubMedSearch in Google Scholar
  • 26 Stannard JP, Schmidt A, Kregor P et al., Hrsg. Spezielle Unfallchirurgie. Stuttgart: Thieme; 2012
    Thieme ConnectSearch in Google Scholar
  • 27 Calori GM, Phillips M, Jeetle S et al. Classification of non-union: need for a new scoring system?. Injury 2008; 39 (Suppl. 02) S59-S63
    CrossrefPubMedSearch in Google Scholar
  • 28 Abumunaser LA, Al-Sayyad MJ. Evaluation of the calori et Al nonunion scoring system in a retrospective case series. Orthopedics 2011; 34: 359
    PubMedSearch in Google Scholar
  • 29 Calori GM, Colombo M, Mazza EL et al. Validation of the Non-Union Scoring System in 300 long bone non-unions. Injury 2014; 45 (Suppl. 06) S93-S97
    PubMedSearch in Google Scholar
  • 30 Pneumaticos SG, Panteli M, Triantafyllopoulos GK et al. Management and outcome of diaphyseal aseptic non-unions of the lower limb: a systematic review. Surgeon 2014; 12: 166-175
    CrossrefPubMedSearch in Google Scholar
  • 31 Roussignol X, Currey C, Duparc F et al. Indications and results for the Exogen ultrasound system in the management of non-union: a 59-case pilot study. Orthop Traumatol Surg Res 2012; 98: 206-213
    CrossrefPubMedSearch in Google Scholar
  • 32 Giannoudis PV, Einhorn TA, Marsh D. Fracture healing: the diamond concept. Injury 2007; 38 (Suppl. 04) S3-S6
    PubMedSearch in Google Scholar
  • 33 Tonna EA. Histologic and histochemical studies on the periosteum of male and female rats at different ages. J Gerontol 1958; 13: 14-19
    CrossrefPubMedSearch in Google Scholar
  • 34 Calori GM, Colombo M, Ripamonti C et al. Polytherapy in bone regeneration: clinical applications and preliminary considerations. Int J Immunopathol Pharmacol 2011; 24 (1 Suppl. 2) 85-90
    PubMedSearch in Google Scholar
  • 35 Calori GM, Giannoudis PV. Enhancement of fracture healing with the diamond concept: the role of the biological chamber. Injury 2011; 42: 1191-1193
    CrossrefPubMedSearch in Google Scholar
  • 36 Giannoudis PV, Ahmad MA, Mineo GV et al. Subtrochanteric fracture non-unions with implant failure managed with the Diamond concept. Injury 2013; 44 (Suppl. 01) S76-S81
    CrossrefPubMedSearch in Google Scholar
  • 37 Pountos I, Georgouli T, Pneumaticos S et al. Fracture non-union: Can biomarkers predict outcome?. Injury 2013; 44: 1725-1732
    CrossrefPubMedSearch in Google Scholar
  • 38 Schmidmaier G, Schwabe P, Strobel C et al. Carrier systems and application of growth factors in orthopaedics. Injury 2008; 39 (Suppl. 02) S37-S43
    PubMedSearch in Google Scholar
  • 39 Giannoudis PV, Chris Arts JJ, Schmidmaier G et al. What should be the characteristics of the ideal bone graft substitute?. Injury 2011; 42 (Suppl. 02) S1-S2
    PubMedSearch in Google Scholar
  • 40 Cox G, McGonagle D, Boxall SA et al. The use of the reamer-irrigator-aspirator to harvest mesenchymal stem cells. J Bone Joint Surg Br 2011; 93: 517-524
    PubMedSearch in Google Scholar
  • 41 Giannoudis PV, Calori GM, Begue T et al. Bone regeneration strategies: current trends but what the future holds?. Injury 2013; 44 (Suppl. 01) S1-S2
    PubMedSearch in Google Scholar
  • 42 Kanakaris NK, Morell D, Gudipati S et al. Reaming Irrigator Aspirator system: early experience of its multipurpose use. Injury 2011; 42 (Suppl. 04) S28-S34
    PubMedSearch in Google Scholar
  • 43 Dinopoulos C. Re: The article Dinopoulos H, Dimitriou R, Giannoudis PV. Bone graft substitutes: what are the options? Surgeon 2012; 10: 230–239. Surgeon 2013; 11: 293
    PubMedSearch in Google Scholar
  • 44 Schmidmaier G, Moghaddam-Alvandi A. Was gibt es Neues 2014 in der Pseudarthrosen-Therapie? (2014).. Im Internet: http://www.ecme-center.org/WebObjects/ECMECenter.woa/cms/1001057/Kurssuche.html?courseDetails=1003662 Stand: 10.06.2015
    PubMed
  • 45 Fayaz HC, Giannoudis PV, Vrahas MS et al. The role of stem cells in fracture healing and nonunion. Int Orthop 2011; 35: 1587-1597
    CrossrefPubMedSearch in Google Scholar
  • 46 Cruess RL, Sakai T. Effect of cortisone upon synthesis rates of some components of rat bone matrix. Clin Orthop Relat Res 1972; 86: 253-259
    CrossrefPubMedSearch in Google Scholar
  • 47 Cuthbert R, Boxall SA, Tan HB et al. Single-platform quality control assay to quantify multipotential stromal cells in bone marrow aspirates prior to bulk manufacture or direct therapeutic use. Cytotherapy 2012; 14: 431-440
    CrossrefPubMedSearch in Google Scholar
  • 48 Kouroupis D, Baboolal TG, Jones E et al. Native multipotential stromal cell colonization and graft expander potential of a bovine natural bone scaffold. J Orthop Res 2013; 31: 1950-1958
    CrossrefPubMedSearch in Google Scholar
  • 49 Schmidmaier G, Herrmann S, Green J et al. Quantitative assessment of growth factors in reaming aspirate, iliac crest, and platelet preparation. Bone 2006; 39: 1156-1163
    CrossrefPubMedSearch in Google Scholar
  • 50 Blokhuis TJ, Calori GM, Schmidmaier G. Autograft versus BMPs for the treatment of non-unions: what is the evidence?. Injury 2013; 44 (Suppl. 01) S40-S42
    PubMedSearch in Google Scholar
  • 51 Calori GM, Colombo M, Mazza E et al. Monotherapy vs. polytherapy in the treatment of forearm non-unions and bone defects. Injury 2013; 44 (Suppl. 01) S63-S69
    CrossrefPubMedSearch in Google Scholar
  • 52 Calori GM, Colombo M, Mazza EL et al. Incidence of donor site morbidity following harvesting from iliac crest or RIA graft. Injury 2014; 45 (Suppl. 06) S116-S120
    CrossrefPubMedSearch in Google Scholar
  • 53 Schmidmaier G, Lucke M, Wildemann B et al. Prophylaxis and treatment of implant-related infections by antibiotic-coated implants: a review. Injury 2006; 37 (Suppl. 02) S105-S112
    CrossrefPubMedSearch in Google Scholar
  • 54 Schmidmaier G, Wildemann B. The role of BMPs in current orthopedic practice. IBMS BoneKEy 2009; 6: 244-253
    CrossrefPubMedSearch in Google Scholar
  • 55 Giannoudis PV, Kanakaris NK, Dimitriou R et al. The synergistic effect of autograft and BMP-7 in the treatment of atrophic nonunions. Clin Orthop Relat Res 2009; 467: 3239-3248
    CrossrefPubMedSearch in Google Scholar
  • 56 Ewerbeck V, Wentzensen A, Grützner PA, Holz F, Krämer K-L, Pfeil J, Sabo D Hrsg. Standardverfahren in der operativen Orthopädie und Unfallchirurgie. Stuttgart: Thieme; 2014
    Thieme ConnectSearch in Google Scholar
  • 57 Westhauser F, Zimmermann G, Moghaddam S et al. Reaming in treatment of non-unions in long bones: cytokine expression course as a tool for evaluation of non-union therapy. Arch Orthop Trauma Surg 2015; 135: 1107-1116
    CrossrefPubMedSearch in Google Scholar
  • 58 Janicki P, Schmidmaier G. What should be the characteristics of the ideal bone graft substitute? Combining scaffolds with growth factors and/or stem cells. Injury 2011; 42 (Suppl. 02) S77-S81
    CrossrefPubMedSearch in Google Scholar
  • 59 Zimmermann G, Moghaddam A. Allograft bone matrix versus synthetic bone graft substitutes. Injury 2011; 42 (Suppl. 02) S16-S21
    PubMedSearch in Google Scholar
  • 60 Schmidmaier G, Capanna R, Wildemann B et al. Bone morphogenetic proteins in critical-size bone defects: what are the options?. Injury 2009; 40 (Suppl. 03) S39-S43
    CrossrefPubMedSearch in Google Scholar
  • 61 Fuchs T, Schmidmaier G, Raschke MJ et al. Bioactive-coated implants in trauma surgery. Eur J Trauma Emerg Surg 2008; 1: 60-68
    PubMedSearch in Google Scholar
  • 62 Fuchs T, Stange R, Schmidmaier G et al. The use of gentamicin-coated nails in the tibia: preliminary results of a prospective study. Arch Orthop Trauma Surg 2011; 131: 1419-1425
    CrossrefPubMedSearch in Google Scholar
  • 63 Claes L, Grass R, Schmickal T et al. Monitoring and healing analysis of 100 tibial shaft fractures. Langenbecks Arch Surg 2002; 387: 146-152
    CrossrefPubMedSearch in Google Scholar
  • 64 Schmickal T, von Recum J, Wentzensen A et al. Stiffness measurement of the neocallus with the Fraktometer FM 100. Arch Orthop Trauma Surg 2005; 125: 653-659
    CrossrefPubMedSearch in Google Scholar