Top

Journal of Orthopaedic Surgery and Research

Published in:

01-12-2020 | Bone Defect | Research article

J-bone graft with double locking plate: a symphony of mechanics and biology for atrophic distal femoral non-union with bone defect

Authors: Jian Lu, Shang-Chun Guo, Qi-Yang Wang, Jia-Gen Sheng, Shi-Cong Tao

Published in: Journal of Orthopaedic Surgery and Research | Issue 1/2020

Abstract

Objective

Atrophic distal femur non-union with bone defect (ADFNBD) has been a worldwide challenge to treat due to the associated biological and mechanical problems. The purpose of this study was to introduce a new solution involving the use of a J-shaped iliac crest bone graft (J-bone) combined with double-plate (DP) in the treatment of femoral non-union.

Methods

Clinically, 18 patients with ADFNBD were included in this retrospective study and were treated with a combination of J-bone graft and DP. The average follow-up time was 22.1 ± 5.5 months (range, 14 to 34 months). The imaging information and knee joint activity tests and scores were used to evaluate the time to weight-bearing, the time to non-union healing, and the knee joint mobility. A finite element analysis was used to evaluate the differences between the following: (1) the use of a lateral locking plate (LLP) only group (LLP-only), (2) a DP only group (DP-only), (3) a DP with a J-bone group (DP+J-bone), and (4) an LLP with a J-bone group (LLP+J-bone) in the treatment of ADFNBD. A finite element analysis ABAQUS 6.14 (Dassault systems, USA) was used to simulate the von Mises stress distribution and model displacement of the plate during standing and normal walking.

Result

All patients with non-union and bone defect in the distal femur achieved bone healing at an average of 22.1 ± 5.5 months (range, 14 to 34 months) postoperatively. The average healing time was 6.72 ± 2.80 months. The knee Lysholm score was significantly improved compared with that before surgery. Under both 750 N and 1800 N axial stress, the maximum stress with the DP+J-bone structure was less than that of the LLP+J-bone and DP-only structures, and the maximum stress of J-bone in the DP+J-bone was significantly less than that of the LLP+J-bone+on structure. The fracture displacement of the DP+J-bone structure was also smaller than that of the LLP+J-bone and DP-only structures.

Conclusion

J-bone combined with DP resulted in less maximum stress and less displacement than did a J-bone combined with an LLP or a DP-only graft for the treatment of ADFNBD. This procedure was associated with less surgical trauma, early rehabilitation exercise after surgery, a high bone healing rate, and a satisfactory rate of functional recovery. Therefore, a combination of J-bone and DP is an effective and important choice for the treatment of ADFNBD.

Koso RE, Terhoeve C, Steen RG, Zura R. Healing, nonunion, and re-operation after internal fixation of diaphyseal and distal femoral fractures: a systematic review and meta-analysis. Int Orthop. 2018;42(11):2675–83.PubMedCrossRef

Brumback RJ, Uwagie-Ero S, Lakatos RP, Poka A, Bathon GH, Burgess AR. Intramedullary nailing of femoral shaft fractures. Part II: fracture-healing with static interlocking fixation. J Bone Joint Surg Am. 1988;70(10):1453–62.PubMedCrossRef

Gardner MJ, Boraiah S, Helfet DL, Lorich DG. Indirect medial reduction and strut support of proximal humerus fractures using an endosteal implant. J Orthop Trauma. 2008;22(3):195–200.PubMedCrossRef

Meneghini RM, Keyes BJ, Reddy KK, Maar DC. Modern retrograde intramedullary nails versus periarticular locked plates for supracondylar femur fractures after total knee arthroplasty. J Arthroplasty. 2014;29(7):1478–81.PubMedCrossRef

Chen SH, Chiang MC, Hung CH, Lin SC, Chang HW. Finite element comparison of retrograde intramedullary nailing and locking plate fixation with/without an intramedullary allograft for distal femur fracture following total knee arthroplasty. Knee. 2014;21(1):224–31.PubMedCrossRef

Apel DM, Patwardhan A, Pinzur MS, Dobozi WR. Axial loading studies of unstable intertrochanteric fractures of the femur. Clin Orthop Relat Res. 1989;246:156–64.

Koval KJ, Seligson D, Rosen H, Fee K. Distal femoral nonunion: treatment with a retrograde inserted locked intramedullary nail. J Orthop Trauma. 1995;9(4):285–91.PubMedCrossRef

Bellabarba C, Ricci WM, Bolhofner BR. Indirect reduction and plating of distal femoral nonunions. J Orthop Trauma. 2002;16(5):287–96.PubMedCrossRef

Moroder P, Blocher M, Auffarth A, Hoffelner T, Hitzl W, Tauber M, Resch H. Clinical and computed tomography-radiologic outcome after bony glenoid augmentation in recurrent anterior shoulder instability without significant glenoid bone loss. J Shoulder Elbow Surg. 2014;23(3):420–6.PubMedCrossRef

10.

Tauber M, Resch H, Forstner R, Raffl M, Schauer J. Reasons for failure after surgical repair of anterior shoulder instability. J Shoulder Elbow Surg. 13(3):279–85.

11.

Anderl W, Pauzenberger L, Laky B, Kriegleder B, Heuberer PR. Arthroscopic implant-free bone grafting for shoulder instability with glenoid bone loss: clinical and radiological outcome at a minimum 2-year follow-up. Am J Sports Med. 2016;44(5):1137–45.PubMedCrossRef

12.

Lu J, Wang QY, Sheng JG. Exosomes in the repair of bone defects: next-generation therapeutic tools for the treatment of nonunion. Biomed Res Int. 2019;2019:1983131.PubMedPubMedCentral

13.

Moroder P, Hirzinger C, Lederer S, Matis N, Hitzl W, Tauber M, Resch H, Auffarth A. Restoration of anterior glenoid bone defects in posttraumatic recurrent anterior shoulder instability using the J-bone graft shows anatomic graft remodeling. Am J Sports Med. 2012;40(7):1544–50.PubMedCrossRef

14.

Moroder P, Plachel F, Becker J, Schulz E, Abdic S, Haas M, Resch H, Auffarth A. Clinical and radiological long-term results after implant-free, autologous, iliac crest bone graft Procedure for the treatment of anterior shoulder instability. Am J Sports Med. 2018;46(12):2975–80.PubMedCrossRef

15.

Hantes M, Fyllos A, Papageorgiou F, Alexiou K, Antoniou I. Long-term clinical and radiological outcomes after multiligament knee injury using a delayed ligament reconstruction approach: A single-center experience. Knee. 2019;26(6):1271–7.PubMedCrossRef

16.

Reina-Romo E, Rodríguez-Vallés J, Sanz-Herrera JA. In silico dynamic characterization of the femur: Physiological versus mechanical boundary conditions. Med Eng Phys. 2018.

17.

Zhang W, Li J, Zhang H, Wang M, Li L, Zhou J, Guo H, Li Y, Tang P. Biomechanical assessment of single LISS versus double-plate osteosynthesis in the AO type 33-C2 fractures: a finite element analysis. Injury. 2018;49(12):2142–6.PubMedCrossRef

18.

El Haj M, Khoury A, Mosheiff R, Liebergall M, Weil YA. Orthogonal double plate fixation for long bone fracture nonunion. Acta Chir Orthop Traumatol Cech. 2013;80(2):131–7.PubMed

19.

Zhang H, Li J, Zhou J, Li L, Hao M, Wang K, Xu G, Li C, Zhang W, Tang P. Finite element analysis of different double-plate angles in the treatment of the femoral shaft nonunion with no cortical support opposite the primary lateral plate. Biomed Res Int. 2018;2018:3267107.PubMedPubMedCentral

20.

Grassi L, Väänänen SP, Amin Yavari S, Weinans H, Jurvelin JS, Zadpoor AA, Isaksson H. Experimental validation of finite element model for proximal composite femur using optical measurements. J Mech Behav Biomed Mater. 2013;21:86–94.PubMedCrossRef

21.

Qiu TX, Teo EC, Yan YB, Lei W. Finite element modeling of a 3D coupled foot-boot model. Med Eng Phys. 2011;33(10):1228–33.PubMedCrossRef

22.

Eberle S, Gerber C, von Oldenburg G, Hogel F, Augat P. A biomechanical evaluation of orthopaedic implants for hip fractures by finite element analysis and in-vitro tests. Proc Inst Mech Eng H. 2010;224(10):1141–52.PubMedCrossRef

23.

Luo CA, Lin SC, Hwa SY, Chen CM, Tseng CS. Biomechanical effects of plate area and locking screw on medial open tibial osteotomy. Comput Methods Biomech Biomed Engin. 2015;18(12):1263–71.PubMedCrossRef

24.

Luo CA, Hua SY, Lin SC, Chen CM, Tseng CS. Stress and stability comparison between different systems for high tibial osteotomies. BMC Musculoskelet Disord. 2013;14:110.PubMedPubMedCentralCrossRef

25.

Nuño N, Amabili M, Groppetti R, Rossi A. Static coefficient of friction between Ti-6Al-4V and PMMA for cemented hip and knee implants. J Biomed Mater Res. 2002;59(1):191–200.PubMedCrossRef

26.

Goffin JM, Pankaj P, Simpson AH. The importance of lag screw position for the stabilization of trochanteric fractures with a sliding hip screw: a subject-specific finite element study. J Orthop Res. 2013;31(4):596–600.PubMedCrossRef

27.

Fu J, Ni M, Chen J, Li X, Chai W, Hao L, Zhang G, Zhou Y. Reconstruction of severe acetabular bone defect with 3d printed Ti6Al4V augment: a finite element study. Biomed Res Int. 2018;2018:6367203.PubMedPubMedCentral

28.

Radcliffe IA, Taylor M. Investigation into the affect of cementing techniques on load transfer in the resurfaced femoral head: a multi-femur finite element analysis. Clin Biomech (Bristol, Avon). 2007;22(4):422–30.CrossRef

29.

Jones CB, Mayo KA. Nonunion treatment: iliac crest bone graft techniques. J Orthop Trauma. 2005;19(10 Suppl):S11–3.PubMedCrossRef

30.

Weber BG, Cech O: Pseudoarthrosis: pathology biomechanics therapy results berne 1976.

31.

Calori GM, Mazza EL, Mazzola S, Colombo A, Giardina F, Romano F, Colombo M. Non-unions. Clin Cases Miner Bone Metab. 2017;14(2):186–8.PubMedPubMedCentralCrossRef

32.

Griffin XL, Costa ML, Phelps E, Parsons N, Dritsaki M, Achten J, Tutton E, Lerner RG, McGibbon A, Baird J. Intramedullary nails versus distal locking plates for fracture of the distal femur: results from the Trial of Acute Femoral Fracture Fixation (TrAFFix) randomised feasibility study and process evaluation. BMJ open. 2019;9(5):e026810.PubMedPubMedCentralCrossRef

33.

Pekmezci M, McDonald E, Buckley J, Kandemir U. Retrograde intramedullary nails with distal screws locked to the nail have higher fatigue strength than locking plates in the treatment of supracondylar femoral fractures: a cadaver-based laboratory investigation. Bone Joint J. 2014;(1):96-b, 114–121.

34.

Kempf I, Grosse A, Rigaut P. The treatment of noninfected pseudarthrosis of the femur and tibia with locked intramedullary nailing. Clin Orthop Relat Res. 1986;212:142–54.

35.

McLaren AC, Blokker CP. Locked intramedullary fixation for metaphyseal malunion and nonunion. Clin Orthop Relat Res. 1991;265:253–60.

36.

Abdel-Aal AM. Ilizarov bone transport for massive tibial bone defects. Orthopedics. 2006;29(1):70–4.PubMedCrossRef

37.

Zhang H, Xue F, Jun Xiao H. Ilizarov method in combination with autologous mesenchymal stem cells from iliac crest shows improved outcome in tibial non-union. Saudi J Biol Sci. 2018;25(4):819–25.PubMedCrossRef

38.

Kubiak EN, Fulkerson E, Strauss E, Egol KA. The evolution of locked plates. J Bone Joint Surg Am. 2006;88(Suppl 4):189–200.PubMed

39.

Jiang Y, Guo YF, Meng YK, Zhu L, Chen AM. A report of a novel technique: the comprehensive fibular autograft with double metal locking plate fixation (cFALP) for refractory post-operative diaphyseal femur fracture non-union treatment. Injury-Int J Care Inj. 2016;47(10):2307–11.CrossRef

40.

Morlock M, Schneider E, Bluhm A, Vollmer M, Bergmann G, Muller V, Honl M. Duration and frequency of every day activities in total hip patients. J Biomech. 2001;34(7):873–81.PubMedCrossRef

41.

Yang D, Liu Z. Quantification of microstructural features and prediction of mechanical properties of a dual-phase Ti-6Al-4V alloy. Materials (Basel, Switzerland). 2016;9(8).

42.

Higgins TF. Distal femoral fractures. J Knee Surgery. 2007;20(1):56–66.CrossRef

43.

Egol KA, Kubiak EN, Fulkerson E, Kummer FJ, Koval KJ. Biomechanics of locked plates and screws. J Orthop Trauma. 2004;18(8):488–93.PubMedCrossRef

44.

Schütz M, Südkamp NP. Revolution in plate osteosynthesis: new internal fixator systems. J Orthop Sci. 2003;8(2):252–8.PubMedCrossRef

45.

Ring D, Kloen P, Kadzielski J, Helfet D, Jupiter JB. Locking compression plates for osteoporotic nonunions of the diaphyseal humerus. Clin Orthop Relat Res. 2004;425:50–4.CrossRef

46.

Khan SN, Cammisa FP Jr, Sandhu HS, Diwan AD, Girardi FP, Lane JM. The biology of bone grafting. J Am Acad Orthop Surg. 2005;13(1):77–86.PubMedCrossRef

47.

Vidyadhara S, Vamsi K, Rao SK, Gnanadoss JJ, Pandian S. Use of intramedullary fibular strut graft: a novel adjunct to plating in the treatment of osteoporotic humeral shaft nonunion. Int Orthop. 2009;33(4):1009–14.PubMedCrossRef

Title: J-bone graft with double locking plate: a symphony of mechanics and biology for atrophic distal femoral non-union with bone defect
Authors: Jian Lu
Shang-Chun Guo
Qi-Yang Wang
Jia-Gen Sheng
Shi-Cong Tao
Publication date: 01-12-2020
Publisher: BioMed Central
Keyword: Bone Defect
Published in: Journal of Orthopaedic Surgery and Research / Issue 1/2020
Electronic ISSN: 1749-799X
DOI: https://doi.org/10.1186/s13018-020-01636-3

Keynote webinar | Spotlight on medication adherence

Springer Medicine

J-bone graft with double locking plate: a symphony of mechanics and biology for atrophic distal femoral non-union with bone defect

Abstract

Objective

Methods

Result

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Objective

Methods

Result

Conclusion

Please log in to get access to this content

Other articles of this Issue 1/2020

Persistent postoperative pain and healthcare costs associated with instrumented and non-instrumented spinal surgery: a case-control study

Ultraviolet irradiation improves the hydrophilicity and osteo-conduction of hydroxyapatite

Cemented versus uncemented total hip replacement for femoral neck fractures in elderly patients: a retrospective, multicentre study with a mean 5-year follow-up

Preliminary clinical and radiographic outcomes of proximal humeral fractures: comparison of ALPS and PHILOS plating in Asian patients in Taiwan

Ipsilateral proximal and shaft femoral fractures treated with bridge-link type combined fixation system

Meta-analysis of serum and/or plasma D-dimer in the diagnosis of periprosthetic joint infection