You are on page 1of 29

Bone Plating in Patients with Type III Osteogenesis Imperfecta: Results and Complications

William J Enright, MD and Kenneth J Noonan, MD
Author information ► Copyright and License information ►

This article has been cited by other articles in PMC.

Go to:

The results of bone plating in four children (6 femurs, 2 tibias) with osteogenesis imperfecta type III were analyzed. Average age at time of operation was 44 months. In three of the femurs, multiple platings were performed for a total of 13 bone platings in the eight bones studied. Average time to revision following plating was 27 months. Indications for revision included fracture (6), deformity (3), hardware failure (3), and nonunion (1). Other complications included one case of compartment syndrome. All eight bones were ultimately revised to elongating intramedullary Bailey-Dubow rods. Bone plating in skeletally immature patients with osteogenesis imperfecta does not provide better outcome than elongating rods. Complications from bone plating leading to revision, such as refracture or hardware failure, are higher than in those children managed with elongating rods, as previously reported in the literature.
Go to:

INTRODUCTION Osteogenesis imperfecta (OI) is a group of inherited disorders caused by defective type I collagen synthesis. Using the Sillence classification, one can determine the type of OI based on clinical, radiographic, and genetic findings.13 Patients with OI can suffer from frequent fractures and deformity of the long bones during development, resulting in impaired ambulation. The goal of orthopedic surgery for OI is twofold: Reduce the incidence of fractures and correct long bone deformity. Contemporary surgical options for deformed bones in OI include osteotomy and stabilization with non-elongating nails (Rush rods, flexible nails), elongating nails (Bailey- Dubow, Frasier-Duval), and bone plating.1–4,7,8,10,14,15 Elongating rods allow for growth of the bone, thereby decreasing the number of repeat operations. The advantages of elongating rods over fixed intramedullary rods include benefit to growing bones, lower incidence of re-fracture, and longer time to reoperation.4,5,11,12 There is also evidence that suggests that elongating rods used in the femur do not require revision as often as those placed in the tibia.16
At our institution, we have utilized plate fixation for stabilization of osteotomies in young patients with severe OI. Plate fixation was initially appealing in this group of patients given the age of the individuals and the difficulty of placing expandable rods in small bones. In addition, the treating surgeon felt that these rods were too large for the smallest children, thus resulting in stress shielding and bone atrophy. The purpose of this study is to review our experience in this small but select group of patients.
Go to:

This study is a retrospective review of all patients with osteogenesis type III treated with bone plating for correction of deformity or treatment of fracture. All operations were performed by the same pediatric

orthopedic surgeon between 1994 and 2001. Inclusion criteria for this study were a diagnosis of type III osteogenesis imperfecta, history of bone plating, and recent clinical follow-up. After review of the medical files of all patients treated for osteogenesis imperfecta at the University of Wisconsin Hospital and Clinics, we were able to find four patients who had undergone at least one bone plating as treatment for fracture or deformity. Clinical records and imaging studies were reviewed. We recorded the indications for initial plating, types of plates and screws used, time to evidence of healing on radiograph, time to revision, indications for revisions, hardware used in revision (plate or rod), number and location of fractures following each plating, complications including hardware failure, and number of revisions for each bone. Regarding the measurement of time to fracture and time to revision, the authors considered each plating separately. There were cases of sequential platings of the same bone in patients where initial plating was revised with further plating. Initial plating was considered as the start point for this study, and revision with expandable rods was considered the end point.
Go to:

RESULTS All four patients were diagnosed with osteogenesis type III using the Sillence classification.13 There were three males and one female, ranging in age from 14 to 82 months (44.7 months mean age) at the time of surgery. Ages ranged from five to eight years (7.7 years mean age) at last follow-up. The average time from initial plating to final follow-up period was four years.
Thirteen bone platings were performed on eight bones. The eight bones included six femurs and two tibias. Three of the femurs underwent multiple platings before being ultimately revised to Bailey-Dubow rods. Of these three femurs, two were plated twice, and one femur was plated four times for a total of 13 platings. All platings were separate operations. No two bones were plated at the same time. The indications for initial plating of the eight bones included fracture and deformity. Of the six femurs, four were plated because of fracture, and two were plated for correction of deformity. Of the two tibias, one was plated for correction of deformity and the other because of fracture. All eight bones ultimately required revision. Three of the femurs underwent further plating for revision, while the two tibias and three other femurs were revised to Bailey-Dubow rods. Indications for revision included fracture (6), deformity (3), hardware failure (3), and nonunion (1). Rate of fracture following plating was 46% (six fractures). Location of fracture was distal to the plate in two cases, under the plate in two cases, and through the plate in two cases. In the two cases of fracture through the plate, fracture of bone with broken plate was considered the reason for revision and also considered a complication (Figures 1 and and2).2). The average time to revision was 27 months (range 4 to 71 months). The average time from initial plating to final revision with Bailey-Dubow rods was 42 months (range 9 to 89 months) for all bones.

Two fractures through the plate were seen. The most common complication following plating was screw pull-out.2% (9 plates). One case involved multiple screws and required revision for stabilization. The complication rate in these patients was 69. Note the proximal and distal cancellous screws have pulled out. TABLE 1 .Figure 2 Radiograph showing screw pull-out. Complications are listed in Table 1. allowing the plate to displace from the bone and leading to hardware prominence. Bending of two of the plates was observed. Of these nine complications. and these underwent revision. three instances of hardware failure led to revision: Screw pull-out required revision in one case. Screw pull-out was seen following plating in five cases. and two fractures went through the plate as mentioned above.

Screw pull-out was not a clinical problem in this series unless it was associated with increasing deformity or fracture. both fixed and elongating.9 It compares more favorably with the average time to revision of 2. but the diameter of the rod is small enough not to affect growth. shorter length of time to revision.5% complication rate previously reported by Jerosch et al. The most common complication of Bailey-Dubow rods has been reported to be rod migration. The complication rate of plating was 69. examining the results of bone plating in comparison to the results obtained with elongating intramedullary rods. This seems intuitive given the quality of bone in patients with osteogenesis imperfecta.2Bone plating does not disturb the physis in most cases.10 Jerosch et al. Higher revision and failure rates in the bone adjacent to the plate are also most likely due to the sharp disparity in construct rigidity and osteopenic metaphyseal bone. The advantage of the elongating rod is that it allows for longitudinal bone growth. Go to: DISCUSSION Bone plating is an option in the treatment of fracture and deformity in children with osteogenesis imperfecta. which required fasciotomy. thus leaving unsupported bone. The purpose of this study was to examine the results of bone plating in patients with osteogenesis imperfecta. the bowing of bones may act to further any screw pull-out. There were three instances of prominent hardware.5. Go to: Footnotes Study conducted at University of Wisconsin Hospital and Clinics.12 There are no studies. and significantly higher than the 27% complication rate reported by Marafioti and Westin in their treatment of patients with OI. Considering the higher complication rates.2%. The rod does cross the physis. There was one case of nonunion in a femur. Madison. The benefits of elongating rods over fixed rods have been demonstrated in regard to reduction in the number of operations performed and facilitation of growth. one of which was symptomatic. This compares quite unfavorably with the five years to revision following placement of Bailey-Dubow rods reported by Luhmann et al. This rate was slightly higher than the 63. The treatment plan for skeletally immature patients with osteogenesis imperfecta must include consideration of growth.6. the Kirschner wires were implemented because of small bone diameter.6 In their study.5 years following placement of non-elongating rods reported by Marafioti and Westin. WI Go to: References . implanted Bailey-Dubow rods in 107 bones and Kirschner wires in eight bones.6.There was one case of compartment syndrome following plating of a tibia.7 The most common complication seen after plating was screw pull-out. Not only does the bone quality not allow for purchase of the screws. but it does not migrate with growth.10 The most common indication for revision following plating was fracture (6). however. bone plating does not compare favorably to elongating rods in patients with osteogenesis imperfecta. followed by deformity (3) and hardware failure (3). Average time to revision following plating was 27 months. This nonunion was noted five months after the initial plating and was revised with bone plating seven months after the initial operation. Previous studies in the orthopedic literature report treatment of these patients with intramedullary rods. and unknown effect on longitudinal growth.4. We recommend elongating rods when considering treatment of deformity or fracture in patients with osteogenesis imperfecta.

Zionts LE. Tomasevic M.82-B(1):11–16. Sharrard WJ. Clin Orthop. Mazzotti I. 1989. Sillence D. Lang-Stevenson AI. Bailey RW. Marafioti RL. 6. 10. Strudwick WJ. 1998. J Bone Joint Surg Br.66-B(2):227– 232. [PubMed] 8.1988. Sofield HA. 1982. Millar EA. Harrison WJ.159:171–176. Dubow HI. 7. Westin GW. Fragmentation. 1984. Schoenecker PL. J Pediatric Ortho.18(1):88–94. Chow W. [PubMed] 16. Clin Orthop. Stott NS. Complications after treatment of patients with osteogenesis imperfecta with a Bailey-Dubow rod. Bailey RW. Complications of intramedullary rods in osteogenesis imperfecta: Bailey-Dubow rods versus nonelongating rods. and intramedullary rod fixation of deformities of the long bones in children. 1998. Li YH. realignment.159:11– 25. 1981.117(4-5):240–245. J Bone Joint Surg.59A(4):467–472.348:186–195. Complications in the use of the Bailey-Dubow extensible nail.[PubMed] 3. J Bone Joint Surg Br. Osteogenesis imperfecta in Zimbabwe: a comparison between treatment with intramedullary rods of fixed-length and self-expanding rods. 12.14:455– 458. [PubMed] 2. Further clinical experience with the extensible nail.1963. Jerosch J. Heller E.71-B(3):422–427.1998. Clin Orthop. Leong JC.[PubMed] 4.20(2):267–273. Intramedullary rodding in osteogenesis imperfecta. Seidman DS. Archives Ortho & Trauma Surg.43(5):328– 332. 1959. J Pediatric Ortho. 1981. Meyer S. Sharrard WJ.1. Gamble JG. Osteogenesis imperfecta: an expanding panorama of variants. 15. Capelli AM. The role of expanding intramedullary rods in osteogenesis imperfecta. [PubMed] 14. J Bone Joint Surg Am. Intramedullary rodding with Bailey-Dubow extensible rods in osteogenesis imperfecta: an interim report of results and complications. [PubMed] 11. Bailey RW. 1998. [PubMed] . 5.159:157–170. J Pediatric Ortho. Management of lower extremity deformities in osteogenesis imperfecta with extensible intramedullary rod technique: a 20-year experience. Bleck EE. Rankin KC.8(6):645–649. Bell MJ. Stockley I. Mulpuri K. Surg Forum. The Sofield-Millar operation in osteogenesis imperfecta: a modified technique. Joseph B. 2000. Elongating intramedullary rods in the treatment of osteogenesis imperfecta. [PubMed] 9. Studies of longitudinal bone growth resulting in an extensible nail. Sheridan JJ. 1977. Porat S. the concept of an extensible nail accommodating to normal longitudinal bone growth: clinical considerations and implications. Rinsky LA. Functional results of operation in osteogenesis imperfecta: elongating and nonelongating rods.11(2):200–203.41A:1371.2000. Luhmann SJ. J Bone Joint Surg Br. Ebramzadeh E. J Pediatric Ortho. Evolution of. J Royal College Surg Edinburgh. 13. 1991.Clin Orthop.

steel bone plating. Ghosh1. India. Sarani. SUMMARY This is a retrospective study of 24 femur diaphyseal transverse fractures stabilized with intra-medullar pinning. Kolkata. and depending upon their placement resist bending forces. the use of intra-medullar interlocking nail may result in preservation of more periosteal vascularity (Heitemeyer et al. D.Management Of Femur Fractures With Self-Made Polymethylmethacrylate Plates. Key Words: Bone Plating. 2 Department of Veterinary Gynaecology and Obstetrics. as well as easy affordability. Serum calcium and phosphorus showed no significant change. it is a more traumatic procedure (Stiffler. biologic and clinical parameters associated with each patient and fracture. Department of Veterinary Surgery & Radiology. Therefore. † Corresponding author Dr. and demands extreme professional skills to achieve dynamic compression. used for decades as . polymethylmethacrylate (PMMA). 2003). fabricated polymethylmethacrylate (PMMA) plates and intra-medullar interlocking nailing (ILN).87%) (Gahold et al. India. 1. INTRODUCTION Among the long bones. 2004). steel bone plating and intra-medullar pinning. 1995). Femur Fracture. B. Prasenjit Mukherjee Senior Research Fellow Department of Veterinary Surgery and Radiology West Bengal University of Animal and Fishery Sciences. Kolkata-700 037. Full limb function was obtained quicker using fabricated PMMA plates. Intra-medullar pinning is most widely used because provides axial alignment and resists bending forces but not the shear and rotational forces (Vasseur et al. allowing weight bearing. Routine physical examinations assessed limb function. S. The selection of internal fixation is based on mechanical. Mukherjee1†. promoting biological osteosynthesis (Reems et al. Four groups. Basu2 West Bengal University of Animal and Fishery Sciences. The present study was carried out to assess the feasibility of using bone plates which contributes to dynamic compression but devoid of some complications like accurate proficiency in contouring plate with bone interface. each including 6 animals. shearing and rotational forces. Intra-Medullar Pinning. compression. joint involvement and condition of the operative site. However. 37. 2005). not just the fracture pattern itself (Aron et al. Roy1 and S. 1984). Less surgical exposure and dissection is needed to place intra-medullar interlocking nails compared to placement of bone plates. Canine. 2002) mostly seen in diaphysis and distal metaphysis (Roy et al. K. by ILN. were followed-up for 9 weeks in the perspective of postoperative complications and fracture healing. early use of the limb and rapid healing. Bone plating resists tension. firstly introduced by Charnley (1960). Fabricated PMMA and steel bone plates showed earlier radiographic disappearance of fracture lines and earlier formation of direct bridging callus. Intra-Medullar Interlocking Nailing. 1990). in the order. The use of fabricated PMMA plates showed promising results for the management of the femur transverse fracture in dogs considering the advantages of lower cost. Internal fixation provides mechanical stability to a fractured bone. the incidence of femur fractures is highest (45. To this purpose we adopted an extremely versatile thermoplastic polymeric material. followed.700 037. Intra-Medullar Pins And Interlocking Nails In Dogs P. easy fabrication and actual adaptation to the specific contour of the bone. Stainless Steel Plates. Polymethylmethacrylate Plate.

5 mg/ kg body weight intravenously for maintenance of anaesthesia. After proper sedation.Intramedullary Interlocking nailing) comprising six animals in each group. 50Kvp and 90 cm FFD) throughout the study period. 1973) (Table I) and radiological examinations (14 mAs."filler" material in total-hip insertion and recently for internal fracture-fixation plates. Study design The study was conducted on twenty four (24) clinical cases of femur diaphyseal transverse fractures in dogs between the age group 2-5 years of either sex. . Different sizes of femur from canine cadaver of different body weights were taken as negative cast. C. partial weight bearing. Each animal of different groups were subjected to physical (condition of the operative site. 1999 and Raghunath and Singh. Functional use of limb. running. to more evenly distribute forces over the plate-bone interface. carries the limb most of the time. Some functional use. The plates then were removed and grounded with sand paper into desired shape and finish and drilled with 3. Conzemius and Swainson. 1985. affection of joint as per the method described by Branden and Brinker.5 mm drill bit to make six hole plates of different sizes (Fig. MATERIAL AND METHODS Aims To evaluate the efficacy of fabricated polymethylmethacrylate (PMMA) plating as a method of internal fixation in canine diaphyseal femur fractures and to compare it with ILN. Full function for standing. walking. the dogs were placed to the operation table and operation was performed with intraoperative administration of injection ketamine hydrochloride @10 mg/ kg body weight and injection diazepam @ 0. assessment of full limb function. does not bear weight on limb. The cases were randomly divided in to four groups and treated with four internal fixation devices (Gr. The decision for adopting any one of the internal fixation technique following the standard procedures (DeYoung and Probst. 2002).Bone Plating. 1). At the time of surgical intervention. will set limb down to stand or walk. Table: I. Fabrication of polymethylmethacrylate (PMMA) bone plate For fabrication of PMMA plates of appropriate thickness. Gr. AIntramedullary pinning. full weight bearing. different plates were taken corresponding to the size and body weight similar to patient under the study. intra-medullar pinning and steel plating in view of bone healing and complications.04 mg/kg body weight 15 minutes before the administration of injection xylazine hydrochloride @ 1 mg/kg body weight intramuscularly. Gr. Then the PMMA was applied over the lateral side of the femur to achieve 6-8 mm thickness and kept till drying as a cast. two parts polymer of methylmethacrylate powder was mixed with one part of liquid monomer methylmethacrylate . D. carries limb when running. B. Sterilization of fabricated plate was achieved by autoclaving. II Slight use III Limp IV Normal Anaesthesia preoperative preparation and surgical procedure The dogs were pre-anaesthetized with subcutaneous injection of atropine sulphate @ 0. 2002) was randomly adopted. thereby combating premature plate failure (Moursi et al. Clinical evaluation of functional limb usage Grade Limb use description Nonuse Definition I No functional use of the limb.Bone plating with fabricated PMMA plates and Gr.

Table: II.Preoperatively. xylazine hydrochloride (1 mg/kg). B (n= 6) Grade. scrubbing and painting. The clinical evaluation of functional limb usage showed a remarkable difference amongst the study groups being earliest in Gr. C (n= 6) Grade. 1985. Removal of cutaneous sutures was done after complete healing of the wound in 10th postoperative day. Postoperative care Robert-Jone’s bandage was applied in all the cases postoperatively for 3 days to alleviate movement and the soft tissue swelling.II: (n=2) III: (n=4) Grade.III: (n=4) IV: (n=2) Grade. Results of limb function and Range of Motion of the Stifle Joint (ROMSJ) 1st week Gr. The movements of the animals were restricted over the post operative period for 7-10 days. The postoperative results of limb function viz. operative site was aseptically prepared with routine application of antiseptic solution.II: (n=1) III: (n=5) Grade.II: (n=6) 5th week Grade.3 mg/kg body weight for 3 days.0 version for windows.IV: (n=6) Grade. Physical examination Postoperative physical examination showed marked soft tissue swelling mostly up to 1st week of operation and in some cases extent of swelling persisted little bit more i. Statistical analysis The data were analyzed statistically by general linear model with univariate data by Tukey HSD multiple comparison test (Tukey. Animals were intramuscularly administered with injection ceftriaxone @ 10 mg/ kg body weight for 7 days and injection meloxicam @ 0. 2002) was randomly adopted.IV: (n=6) N Gr. Anesthesia was performed using atropine sulphate (0. range of motion of stifle joint and full functional limb usage have been shown in Table II and III. RESULTS The anaesthetic regimen provided adequate anaesthesia. None of the animals showed untoward complication due to anesthesia and operative procedures. The decision for adopting any one of the internal fixation technique following the standard procedures (DeYoung and Probst.II: (n=1) IV: (n=5) Grade.II: (n= 1) IV: (n= 5) A7 week: (n=1) A9 week: (n=2 A= ankylosis.e. up to 2nd week in the animals of all four groups.III: (n=4) IV: (n=2) Grade. N=normal. A (n= 6) Grade.I: (n=5) II: (n=1) Grade. C.II: (n=4) III: (n=2) Grade. 5th and 7th day and as and when required. Conzemius and Swainson. D (n= 6) Grade.04 mg/kg).II: (n= 1) IV: (n= 5) ROMSJ A5 week: (n=6) Gr. Implants were kept in situ over the entire study period. ketamine hydrochloride (10 mg/ kg) and diazepam (0. 1999 and Raghunath and Singh. Post operative dressing was carried out on 3rd. ROMSJ= range of motion of stifle join .II: (n=1) III: (n=5) 7th week Grade.I: (n=6) Grade.III: (n=6) 9th week Grade.I: (n=6) Grade.II: (n=1) IV: (n=5) A7 week: (n=1) Gr.II: (n=1) III: (n= 5) Grade.II: (n=1) III: (n=4) IV: (n=1) Grade. 1953) using SPSS 10.5 mg/ kg).I: (n=6) 3rd week Grade.

suggesting maturation and remodeling. Marked soft tissue swelling during 1st postoperative week.E.80 Radiographic findings Radiographically.Table: III. Mean ± S. more number of screw tips which crossed the transcortex might had also resulted more sustained trauma to the muscle mass in comparison to other two groups. 1969). which still represented the presence of dense callus packing the medullary canal. After the 9th week of fracture treatment with PMMA plate the radiograph showed presence of plate and all screws in situ without any materialistic abnormalities.33 ± 2. The end stage radiograph at the 9th week of fracture immobilization in group -B. The radiodensity of the callus at the fracture side was uniform to that of cortical bone. The remodeling was completed which was evidenced by absence of extra callus in the exterior or interior of the cortex at the junctional zone (Figure 4).00 ± 0. where either no screw or less numbers of screws were used. In group C and B the more duration of perceptible soft tissue swelling was due to more injury inflicted upon the tissue at the time of surgery. After 9 weeks of fracture immobilization with ILN in the radiograph. The fracture gap was completely obliterated and remodeled imparting uniformity in radiographic features to that of proximal and distal bone fragments. A 63. fracture was found completely obliterated with organized callus. The nail and screws were found intact without any distortion. B (steel plate) and A (intramedullary pinning) were also suggestive of quality of healing in those group in a same order as. The thickness of cortex at the union site was similar to that of normal in transcortical site (Figure 3). showed intact radiodense stainless steel plate and screws. C 44. B 49. In intramedullary interlocking nailing. The animals of group A treated with intramedullary pinning showed nonuse of limb for a longer duration (table-II). The more duration of nonuse of the limb by the same animals might be due to incomplete neutralization of the forces as the rotational forces never are neutralized as a result of which slight rotational instability persisted in early phase of fracture healing. of achievement of Grade IV (full functional) limb usage in days Groups Days Gr. D 46. 1982). process found to be in advance stage as evidenced by irregularly arranged hypo dense callus at the periphery of the union site (Figure 2). whereas in intramedullary pinning. though did not show appreciably noticeable excess external callus formation. The early ambulation of the affected limbs in the animals treated with PMMA plate in group C. The observation of grade-II and grade-III limb use on 3rd week as well as full functional limb use on 7th week of fracture immobilization indicated the positive correlation of better fracture immobilization and fracture . Moreover. weight bearing is considered to be one of the most important gross observable parameter for assessing the quality of fracture healing (Hutzschenreuter et al. The medullary cavity was established with uniformity of diameter throughout the length of bone. The 9th week post operative diagram of femur fracture of dog managed with intramedullary pin showed no radiographic signs of soft tissue swelling. pin migration or distortion. was due either to the preoperative trauma by the bone fragments and severity of the soft tissue injury during surgery. The medullary canal looked uniform in diameter even at the junctional site to that of proximal and distal fragments (Figure 5). they took more remodeling time than steel bone plating and fabricated polymethylmethacrylate plating but lesser than intramedullary pinning. fabricated polymethylmethacrylate plated animals showed early disappearance of fracture line and formation of direct bridging callus. irrespective of the groups. The remodeling was yet to be completed though. animals exhibited formation of excess external callus and more remodeling time.00 ± 0. bending or breakage. Similar to the animals of group A.00 Gr.00 Gr. DISCUSSION Formation of pre-molded PMMA concave plate was very convenient without much difficulty due to its some inherent biomechanical properties like noncorrosiveness and nonabsorption or degradation of the material within the system (Vécsei and Starlinger. followed by group D (ILN).95 Gr. The medullary cavity was noticed reestablished in proximal and distal fragments of the fracture except at the site of union. might have resulted due to the painful swelling of the operated limb which improved in course of time.20 ± 2. the femur fracture of dogs immobilized with steel bone plate in group B also showed nonuse of the affected limb during the 1st week of operation which might be due to the inflammatory reaction of tissue at the site.

. Anchorage of the femoral head prosthesis to the shaft of the femur.. retained without any remarkable anomalies in group B and C. Vet. the exuberant callus formation was not observed which has also been reported by many workers (Wiss et al. shearing and compressive forces at the fracture site. 1973. Educ. 1986 and Brumback et al. Pract. 29 . M. 17: 35-49. In group B. where direct osteon to osteon union of fragments occured (Stiffler.. type of periosteal reaction and formation of callus are in conformity of normal bore healing (Dambacher and Ruegsegger. G. Palmer. Radiographically. Vet. Conzemius.I limb function in first week which suggested the similar grade of tissue trauma to other groups while the surgical intervention was undertaken for fixing the internal fixation device. Brumback. Am. Vet. Charnley. the minimum external callus formation was observed with quickest symptoms of remodeling. W. 1960. Am. minimum is callus formed (Beale. The early and full limb ambulation is one of the criteria on the basis of which apparently quality of callus formation and fracture healing can be assessed. when used for immobilization of the bone with convex surface.. 1995. Branden. Med.. due to rigid fixation. compression. J. 2004. 1999). Vasseur et al. At all stages of radiography in both the groups .. weight bearing and uneventful recovery which obviously might had resulted from optimum rigid fixation and qualitative fracture healing. Intramedullary pinning in long bone in animals undoubtedly results to better fixation stability barring its incapability for resisting the rotational force which can be overcome by using the ILN (Dueland et al.. Subsequently. Assoc. R. S. R. 1988). Femur fractures were treated with interlocking nail as internal fixation device also showed grade. REFERENCES Aron. such treated dog showed early ambulation. Intramedullary interlocking nailing does not require perfect anatomic fracture reduction of fracture for stability as such fracture with intramedullary interlocking nail undergoes indirect bone healing as interfragmentary load sharing is not usually obtained (Stiffler. J. the dogs showed better grades of limb ambulation which reached to its best i. fracture healed by primary union.. Effect of certain internal fixation devices on functional limb usages in dogs. 2004. 1988. T. Pract. and Swainson. S.D..healing with limb use. coupled perfectly covering almost 1/3rd of the circumference. Beale. fabrication and facilities for imparting the specific contour of the questioned bone to be repaired. was satisfactorily observed in the animals of the Group D treated with ILN. which provide the efficacy of using dynamic compression of fracture healing..e.. A. 42: 28.L. The use of PMMA plate for internal fixation of fracture is comparatively a newer concept with variable success (Kallmes and Jensen.. 162: 642-646. The addition of screws or bolts increases the ability of the pin to resist the rotational. D. The prefabricated concave plate. and Johnson. is indicative of secondary bone healing with stability of fracture. the fracture fragments were found perfectly aligned. 2004). Small Anim. Small Anim. Fracture fixation with screws and bone plates. 1999. In the instant study. 2003). earliest at 5th to 7th postoperative weeks. The quality and quantity of fracture callus formation mostly depends on type and accuracy of fracture fixation. Clin. R. 1984). Biologic strategies and a balanced concept for repair of highly comminuted long bone fractures.. The use of bone plate for internal immobilization results to rigid fixation. which provided very good gripping when fixed with cortical screws in the present study that might be attributed to the reasons for good alignment . Bone Joint Surg. Bathon.. 19: 134-150.. Pract. B.H. more the rigidity and stability in the fixation. In the present study. presence of moderate quantities of external bridging callus in group A and D. and Brinker. A. Uwagie-Ero. 2004). A. CONCLUSIONS Based on the above findings it may be concluded that bone plating is considered to be best option than any other immobilization devices but. Orthopedic Clinical Techniques Femur Fracture Repair. resisting tension. 1994). self fabricated PMMA plate seems promising result in veterinary orthopedic surgery considering its cost. 70 (10):1453-62..D.N. 2004). J. and Burgess.R. Intramedullary nailing of femoral shaft fractures. Comp. Clin.P. shearing and rotational forces (Stiffler. Part II: Fracture-healing with static interlocking fixation. Tech.H. Bone Joint Surg. As compression fixation was not attained by interlocking nailing as well as due to prevention of rotational stability of pin by screwing. Poka. The postoperative physical finding after using PMMA plates for management of femur fracture in the present study should be graded as promising as. J. gradeIV. Lakatos.. Contin. North Am. retention of fracture fragments in postoperative observation period.J.

H. Trauma.. C. 214 (1): 59-66.. Hutzschenreuter.. 99 (4): 259-263. L. and Kamble. 1982. D.B.. B. S.. J. Comminuted and rotationally unstable fractures of the femur treated with an interlocking nail.. Pract. and Körber.N. M.. Ghosh.. Surg. K. and Crumley. A. K. Orthop. Paul..V.J. L. Methods of fracture fixation. S. J.. D.. and Seghi. Biomaterials. and Jensen..A. 45: 1504-1507.. Perren. Engen.W.. 2002.. 2004. and Hulse. and De. In: XXIX Annual Congress of Indian Society for Veterinary Surgery and National Symposium. Gahold. 2003. Assoc. A.. Heitemeyer. Vet.R. Vet. Occurrence of fracture in dogs in and around Kolkata: A review of 150 cases.S. p 30. Slatter.. Med. 1969. Winnard. S.S. Arch..E. Moursi. Res.. 2005.A.. 1990. Stiffler. J.. Internal fixation. J. D. M. Injury.M. Interlocking nail treatment of diaphyseal long-bone fractures in dogs. S.. P.S.. D.. V. Vet.... Johnson. M. G. D. 212: 35-47. Winnard. D. Matta. P. Samanta. Vet. Beale. 109 (3): 144-149.A. Kallmes. 1953. P.. M. Use of a plate-rod construct and principles of biologic osteosynthesis for repair of diaphyseal fractures in dogs and cats: 47 cases (1994-2001).F. Med. S. Indian J.. Arch. and Probst. Dhakate. Roy.R. Patil. In: Textbook of Small Animal Surgery.. Assoc. 2003. Dueland. Trauma Surg. 1.. V..M.A. DeYoung. Clin. A. D.H. Retrospective study of fractures in canines – A report of 109 cases. Percutaneous vertebroplasty. Steinemann. p 1949-1988. Surg.T. Claes. Intramedullary interlocking nailing (ILN) for long bone fracture fixation in dogs using indigenously designed equipment.B. Evaluation of fixation devices for prevention of rotation in transverse fractures of the canine femoral shaft: An in vitro study. Wiss.S.. 2002. R. 19: 105-113. M. 1986.H. M. Vécsei. Geret. The problem of multiple comparisons. U. and Singh. Am.. Copyright Priory Lodge Eduation Limited 2008 First Published November 2008 . Hierholzer. Enhanced osteoblast response to a polymethylmethacrylate-hydroxyapatite composite. Raghunath. Am. 23 (2): 129.. C. and Lesser.M.J. 23 (2): 89-91.. Small Anim. 23 (1): 133-144. R. H..M. 223: 330-335. R. Gawande.C. M. Res. Significance of postoperative stability of bony reparation of comminuted fractures. Gentamicin-PMMA bead chains in the treatment of posttraumatic osseous and tissue infections. Am.S. J.S.(5): 1117-1133. Orthop. Rel. 229:27–36.. Fleming. Surg. 1999. Mukherjee.. Department of Statistics. and Klebl. P. Orthop.. W. and Starlinger. J. G. Edn.W. Saunders. Indian J. 1: 77-81.V. Roe. Tech. 2002. and Clark. Philadelphia.. Some effects of rigidity of internal fixation on the healing pattern of osteotomies. 1984. 1985. S. Radiology. Princeton University.. Dittoed Manuscript of 396 pages. D. Lannutti.. Tukey. M. M.. Reems. Vasseur.. Vet. B.L. Clin.

This stability makes it easier for elderly patients to resume activities of daily living earlier than is the case after treatment with use of the traditional. physician specialty. however. Traditionally.10-12. there has been an increase in the use of internal fixation and a concurrent decrease in the rate of closed treatment of distal radial fractures in the elderly in the United States. more conservative approaches that require a longer period of immobilization14. Birkmeyer. and external fixation) was extracted from the dataset. The introduction of the volar locking plating system in 2000 has spurred this interest. percutaneous pin fixation. internal fixation. Other available data were diagnosis. Information on four treatment methods (closed treatment. MPH. even in the elderly14. Approximately 10% of sixty-five-year-old white women in the United States will sustain a distal radial fracture during the remainder of their lifetime1. many elderly patients function relatively well. from 3% in 1996 to 16% in 2005. whereas hand surgeons were significantly more likely to use internal fixation than orthopaedic surgeons were. remained the predominant method (used for 82% of the fractures in 1996 and 70% in 2005). but the majority of studies showing acceptable function involved elderly patients who were frail or had low functional demands5-9. there has been an interest in the use of more aggressive treatment methods. . Distal radial fracture is a public health concern. MD2 Author information ► Copyright and License information ► This article has been cited by other articles in PMC. who often experience fragility fractures. Methods: We evaluated a 5% sample of Medicare data from 1996 to 1997 and a 20% sample from 1998 to 2005. Shauver. Fractures in patients with an age of eighty-five years or more were significantly more likely to be treated in a closed fashion (p < 0. However. Results: Over the ten-year time period examined. and patient age. particularly among the elderly. The purpose of the present study was to assess changing trends in the treatment of distal radial fractures in elderly patients in the United States. Go to: Abstract Background: Traditionally. these fractures in the elderly have been treated nonoperatively with use of casting alone2. despite the development of a malunion. however. The volar locking plating system imparts sufficiently stable fixation to maintain good anatomic reduction. Recently.Trends in the United States in the Treatment of Distal Radial Fractures in the Elderly Kevin C.1 Melissa J. the rate of internal fixation of distal radial fractures in the elderly increased fivefold. although the majority of distal radial fractures are still treated nonoperatively. Orthopaedic surgeons were significantly more likely to use closed treatment than hand surgeons were. sex.0001). The use of nonoperative treatment has been based on the perceived low functional demands in the elderly population. MD. it has been shown that casting alone for the treatment of unstable osteoporotic distal radial fractures can result in collapse of the fracture fragments and the development of a malunion3.1 and John D. Chung. MS. since the introduction of the volar locking plating system in 2000. Interestingly. There was a large variation among physician specialties with regard to the fixation methods that were used. A recent prospective study evaluating the rate of functional improvement after treatment with the volar locking plating system demonstrated similar rates of recovery between patients in two age groups (twenty to forty years and more than sixty years)13. Conclusions: Since 2000.4. We calculated frequencies and rates to compare the utilization of different treatments over time. Closed treatment. distal radial fractures in the elderly have been treated nonoperatively with casting. and race. there has been an interest in more aggressive fracture fixation in the elderly in the hopes of speeding the rate of recovery in order to preserve the ability of patients to live independently2.

obtained by means of a formal request. In addition. percutaneous pin fixation. Both samples were of Medicare Part B claims. the year in which the claim was filed. which cover physicians' services and were randomly selected on the basis of the last two digits of the Health Insurance Claim number15. The United States Centers for Medicare and Medicaid Services draws the samples from the claims data for fee-for-service Medicare patients who are sixty-five to ninety-nine years of age. The dataset has undergone extensive ―cleaning‖ to allow ease of analysis and is most relevant for studying distal radial fractures. We obtained this dataset from The Dartmouth Institute for Health Policy and Clinical Practice. seventy-five to seventy-nine years. The specific purpose of the present investigation was to study a random sample of United States Medicare claims from a ten-year period (1996 to 2005) in order (1) to examine the changing trend in the treatment of distal radial fractures in the Medicare population and (2) to evaluate physician specialty experiences in the treatment of these fractures. Clinical Modification) code indicating a closed distal radial fracture. However. Because of the coding terminology. a surgeon may identify himself or herself as an orthopaedic surgeon primarily and as a hand surgeon secondarily. Likewise. eighty to eighty-four years. This is a standard and often-used method to . Using this smaller group of claims. Ninth Revision. the sex of the patient. Frequencies were calculated for 1996 to 1997 by multiplying the 5% sample by 20. we first extracted claims including an ICD-9-CM (International Classification of Diseases. frequencies for 1998 to 2005 were calculated by multiplying the 20% sample by 5. the age group of the patient (sixty-five to sixty-nine years. The United States Centers for Medicare and Medicaid Services allows the physician to designate as many as three specialties in the order that he or she chooses. TABLE I ICD-9-CM and CPT Codes Used for Filtering Medicare Datasets* Each claim contained the Current Procedural Terminology code of the procedure (treatment method) performed. it is rare that open treatment is pursued without internal fixation. For instance. Alternatively. we will refer to open treatment as internal fixation throughout the present report. seventy to seventy-four years. For these reasons. we used a 5% sample of claims data from 1996 and 1997 and a 20% sample of claims data from 1998 to 2005 from the United States Centers for Medicare and Medicaid Services. Go to: Materials and Methods For the present study. It is quite possible that an orthopaedic hand surgeon may identify himself or herself as an orthopaedic surgeon primarily and as a hand surgeon secondarily. and open treatment (Table I). the epidemiology of distal radial fractures is not well-characterized and the treatment of these fractures in the elderly population remains ill-defined. the same surgeon could identify himself or herself as a hand surgeon primarily and as an orthopaedic surgeon secondarily. From this sample. external fixation (uniplane or multiplane). and eighty-five years or more). investigators at that institution have previously used this particular dataset to track practice variations for a variety of diseases. each claim contained the self-designated primary specialty of the treating physician. The dataset that we obtained contained only the primary specialty designation. we were unable to determine if fixation took place during open treatment.Despite their high prevalence. and the racial category of the patient (white or nonwhite). we then filtered for claims with Current Procedural Terminology codes for closed treatment (with or without manipulation).

a Clinical Trial Planning Grant (R34 AR055992-01).008 Medicare claims (range.C. with little change occurring over the study period. The rate of external fixation use was very low. which corresponded with a decrease in the use of closed treatment (from 82% to 70%). 1 Line graph illustrating the rate of each fixation method according to year. There was no difference between the sexes with regard to the use of internal or external fixation. the second-most-frequently used method of treatment. whereas nonwhite patients were 1% more likely to be managed with both closed reduction and internal fixation. There was an increasing trend in the use of internal fixation (from 3% to 16%). Closed treatment was the predominant method of distal radial fracture fixation in these patients (Fig. the rate of nonoperative treatment increased (Table III). There was very little variation in fixation method according to sex. and female patients were 2% more likely to be managed with percutaneous pinning. White patients were 1% more likely to be managed with percutaneous pinning.9% of all patients who were sixty-five to sixty-nine years of age to 87. Go to: Results The 5% dataset (1996 to 1997) and the 20% dataset (1998 to 2005) represented an average of 81. There was also no notable difference in the utilization of fixation techniques according to racial group. 76. 70% of the Medicare claims were for closed treatment.080 to 87. Male patients were 1% more likely to be managed with closed reduction. and a Midcareer Investigator Award in Patient-Oriented Research (K24AR053120) to one of the authors (K. The significance of differences between groups was analyzed with use of the Student t test and odds ratios.315 claims) for distal radial fracture treatment per year.C. TABLE II Estimated Frequency and Percentage of Fractures Treated Each Year According to Physician Specialty* Fig. As with sex.determine overall frequencies from small samples16-18. remained flat before decreasing slightly between 2004 and 2005. 1). the National Institute of Arthritis and Musculoskeletal and Skin Diseases Exploratory/Developmental Research Grant Award (R21 AG030526). In 2005.0% in patients who were more than eighty-five years of age (p < . Funds were used to purchase the dataset and for salary support. The rate of percutaneous pin fixation.). As patients aged. the rate of closed reduction increased from 70. The tabulation of this tenyear dataset is presented in Table II. Overall. Source of Funding The present study was supported in part by a grant from the American Foundation for Surgery of the Hand. there were no racial differences in terms of the percentage of patients who received external fixation.

the rapid increase in the use of internal fixation corresponded with the earliest report on the volar locking plating system. Furthermore. Because of the general nature of the Current Procedural Terminology coding. p < 0. through 2005.0. specifically. Similarly. Orthopaedic surgeons were significantly more likely to use closed reduction than hand surgeons were. which was published in 200019. closed reduction requires four to six weeks of wrist immobilization.7 times greater for an orthopaedic surgeon as compared with a hand surgeon (95% confidence interval. The present study also demonstrates that despite the common use of closed treatment. It is probable that physicians in these two specialties are treating distal radial fractures in the emergency department or in outpatient clinics in the acute setting.0001).0% in the oldest age group.1% of fractures treated by hand surgeons. However.12. these individuals were physicians with the primary designation of emergency medicine and family practice. 5.1. we are unable to ascertain exactly which internal fixation technique was used. closed reduction remained the predominant method of treatment of distal radial fractures in the elderly in the United States. which can lead to stiffness. the treatment provided by these individuals was limited almost exclusively to closed reduction. There was no difference between the specialties with regard to the rate of use of percutaneous pinning. The odds of performing closed treatment as opposed to internal fixation were 5. However.3% of fractures treated by orthopaedic surgeons (p < 0.4. Ten percent of distal radial fractures were treated by nonsurgeons (Fig. TABLE III Estimated Frequency* and Percentage of Fractures by Age Group†and Fixation Method There was a considerable difference among physician specialties with regard to the fixation methods used (Fig. hand surgeons were significantly more likely to use internal fixation than orthopaedic surgeons were. .5% of fractures treated by hand surgeons (p < 0. Likewise. and both specialties seldom used external fixation. compared with 6. Disuse of the hand and wrist can result in osteopenia that may result in fracture collapse7. Fig. Go to: Discussion Changing trends in the treatment of distal radial fractures in elderly patients in the United States are evident in this ten-year review of Medicare data. 2 Bar graph illustrating the use of each fixation method according to primary self-designated physician specialty. Most commonly.0001). specifically. 2). at least 50% of the fractures that are treated in this manner lead to malunion 3. It is well known that closed reduction may not adequately restore anatomic alignment11.3 to 6. compared with 56. internal fixation was used for 27. distal radial fractures in the Medicare population are increasingly treated with internal fixation methods. 2). this finding was unexpected.0001).9% in the youngest age group to 1. the rate of internal fixation decreased from 10.2% of fractures treated by orthopaedic surgeons. However.0001). closed reduction was used for 78.

The present study has several limitations. which today is viewed less favorably because of complications related to implant loosening. Furthermore.12. The Dartmouth Atlas of Musculoskeletal Health Care explored geographic variations in the incidence and surgical treatment of various musculoskeletal injuries (including distal radial fractures) in the United States by examining the Medicare database from 1996 to 199728.24 demonstrated that patients managed with plate fixation had significantly better outcomes than patients managed with external fixation and pin fixation. found that internal fixation of distal radial fractures increased dramatically over this eight-year period. The present study confirms the increasing popularity of this fixation method. As noted. the investigators did not examine the change in rates over time. internal fixation was accomplished with a variety of methods. the popularity of this mode of treatment does not necessarily indicate its superiority. This means that the accuracy of the specialty designations was very dependent on how the providing physician entered the data. The most obvious limitations are the generality of coding for internal fixation and the imprecision of coding for the medical specialty of the treating physician. in which hand-fellowship-trained surgeons employed open treatment 84% of the time. one study that compared two weeks of wrist immobilization with six weeks of immobilization following fixation with the volar locking plating system demonstrated no significant difference between the two groups with regard to the final range of wrist motion27. although physicians are allowed to designate both a primary and a secondary specialty. physicians with the primary designation of hand surgeon were much more inclined to apply internal fixation methods. because there were no patient identifiers in our dataset. It would be interesting to know if the rapid increase in internal fixation from 2002 to 2005 mainly comprised fixation with the volar locking plating system. However. We examined changes in the treatment of distal . Nevertheless. as well. because our data provided no information on outcomes. some patients may have been counted more than once. It is possible that some hand surgeons identified themselves as orthopaedic surgeons primarily and that the information that their practices are predominantly composed of hand surgery was not available to us. the large difference in the rate of utilization of the surgical procedures between the self-designated orthopaedic surgeons and the self-designated hand surgeons cannot be accounted for by the specialty coding issue alone. Physicians who identified themselves as orthopaedic surgeons primarily and hand surgeons secondarily would be coded as orthopaedic surgeons in this dataset. However. and they postulated that this increase may have been due to the introduction of the volar locking plating system25. The investigators reported evidence of marked geographic variations and found that surgical intervention rates varied as much as tenfold. A single code for all internal fixation techniques cannot discern the type of fixation procedures used. The dataset that we obtained included only the primary identifier for specialty. it is not especially likely. However. three retrospective studies supported the use of internal fixation for the treatment of distal radial fractures in the elderly. two studies supported its use in general2. These results are corroborated by an examination of American Board of Orthopaedic Surgery Part II oral examination data from 1999 to 2007. elderly patients require less immobilization time and may be able to return to normal activities sooner. whereas physicians who reported hand surgery first and orthopaedic surgery second would be coded as hand surgeons. Conversely.26. whereas those without hand-fellowship training used open treatment only 57% of the time25. including dorsal plating. and one supported the use of the volar locking plating system specifically11. tendon rupture. a randomized controlled trial by Leung et al. Internal fixation techniques require more operative dissection and may be technically challenging. Finally. Koval et al. emergency medicine physicians accounted for only 6% of the closed treatment cases.Before the introduction of the volar locking plating system. and wrist stiffness20-24. The present study revealed that most physicians with the primary designation of orthopaedic surgeon still predominantly employed closed methods for the treatment of distal radial fractures. The invasiveness of the operation also may be associated with more complications. This may have occurred if a patient received closed treatment in an emergency department and was later referred for surgical intervention. This finding was observed in the study by Koval et al. We believe that although this is possible. However. With internal fixation.

or agreed to pay or direct. J Hand Surg [Am]. Michigan Go to: References 1. [PubMed] 5. Rayan GM. Functional outcomes after open reduction and internal fixation for treatment of displaced distal radius fractures in patients over 60 years of age. J Hand Surg [Am]. Outcome following nonoperative treatment of displaced distal radius fractures in lowdemand patients older than 60 years. 6. [PubMed] 4. They often prefer medical treatments that do not hamper their activities. Cummings SR. foundation. Strange-Vognsen HH. Fractures of the distal radius in low-demand elderly patients: closed reduction of no value in 53 of 60 wrists. Acta Orthop Scand.88:1944-51. Lifetime risks of hip. are affiliated or associated. [PubMed] 8. These factors all point to a shift toward the increased use of more aggressive treatments of distal radial fractures in elderly patients. Colles'. in any one year. 2004. McQueen MM. Acta Orthop Scand. Mackenney PJ. J Orthop Trauma. one or more of the authors received. Anzarut A. Radiologic and patient-reported functional outcomes in an elderly cohort with conservatively treated fractures. and a Midcareer Investigator Award in Patient-Oriented Research (K24 AR053120).radial fractures in the elderly population in the United States over time. . 1989. Lambert RGW. or other charitable or nonprofit organization with which the authors.29:1121-7. 2006. the National Institute of Arthritis and Musculoskeletal and Skin Diseases Exploratory/Developmental Research Grant Award (R21 AG030526). Beharrie AW. 2003. Investigation performed at the University of Michigan.18:680-6. or a member of their immediate families. No commercial entity paid or directed. 7. center. MacDermid JC. The risk of adverse outcomes in extra-articular distal radius fractures is increased with malalignment in patients of all ages but mitigated in older patients. Elton R. Grewal R. J Bone Joint Surg Am. division.74:98-100. which had previously been reserved for younger patients. any benefits to any research fund. Ann Arbor. 1991. [PubMed] 2. outside funding or grants in excess of $10.000 from the American Foundation for Surgery of the Hand. McQueen MM. Bozentka DJ. a Clinical Trial Planning Grant (R34 AR055992-01). Intraarticular fractures of the distal end of the radius in young adults. including internal fixation. Prediction of instability in distal radial fractures. and elderly individuals are now more active than ever30. The elderly population is growing at an ever-increasing rate29. Johnson JA. clinical practice. 2000. Rubin SM. 2004. Blitz S. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. or vertebral fracture and coronary heart disease among white postmenopausal women. J Hand Surg [Am].149:2445-8. Young BT. Majumdar SR. Black DM. A 16 (2-26) year follow-up of 42 patients.2007.62:527-30. Go to: Notes Disclosure: In support of their research for or preparation of this work.32:962-70. Beredjiklian PK. [PubMed] 3. Arch Intern Med. Rowe BH.25:19-28. Beumer A.

J Hand Surg [Am]. Kreder HJ.[PubMed] 23. 24. J Hand Surg [Am]. Fernandez DL. Surgical treatment of redisplaced fractures of the distal radius in patients older than 60 years.asp. Leung F. 2005. External fixation for unstable intra-articular distal radial fractures in women older than 55 years.2008. Rajamani S. Arch Orthop Trauma Surg. [PubMed] 15.27:205-15. Westphal T. Winckler S. Osteoporos Int. A randomized study.183:561-8. 2004. Vierhout PAM. 2005. Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. Kim HM.33:809-19. 1996-2000.http://www. Comparative outcomes study using the volar locking plating system for distal radius fractures in both young adults and adults older than 60 years. [PubMed] . Jupiter JB. 2004. [PubMed] 18. 2005. 2002. 22.9. 13. Tu YK.27:714-23. Centers for Medicare and Medicaid Services.125:507-14. Hand Surg. 16. ten Duis HJ. Jupiter JB.[PubMed] 21. Accessed 2008 Nov 7. Injury. 1986-1997.29:96-102. controlled trial. Axelrod TS. J Bone Joint Surg Br.90:1622. 1998. 2005. J Hand Surg [Am]. Grewal R. Ring D. Piatek S. Kambouroglou GK. 14. McBean M. Complications of the AO/ASIF titanium distal radius plate system (pi plate) in internal fixation of the distal radius: a brief report. Chow SP. Chew WY.umn. [PubMed] 19. Kim M.asp.30:764-72. J Bone Joint Surg Am. J Infect Dis.resdac. percutaneous fixation. Orbay JL. Wilmink M. [PubMed] 10. McKee M. Perey B. Research Data Assistance Fernandez DL. 2005. and external fixation. Treatment of osteoporotic distal radius fractures. J Hand Surg [Am]. Schubert S. Increasing rates of hospitalization due to septicemia in the US elderly population. 17. Standard analytical files. The treatment of unstable distal radius fractures with volar fixation. Hanel DP. University of Minnesota. 2001. Weitzel PP.23:737-41. Volar fixed-angle plate fixation for unstable distal radius fractures in the elderly patient. 11. Hegeman JH. AJR Am J Roentgenol. Increase in utilization of percutaneous renal artery interventions by Medicare beneficiaries. Stephen D.2008. [PubMed] 20. Soares G. Department of Health and Human Services. Ring D. Orbay JL. Comparison of external and percutaneous pin fixation with plate fixation for intra-articular distal radial fractures. http://www.hhs.183:596-603. Chung KC. Squitieri L.36:339-44.2000. Murphy TP. Indirect reduction and percutaneous fixation versus open reduction and internal fixation for displaced intra-articular fractures of the distal radius: a randomised. J Hand Surg [Am]. Agel Suppl 2:S804. 2002. Outcome after surgery of distal radius fractures: no differences between external fixation and ORIF. A randomized prospective study on the treatment of intraarticular distal radius fractures: open reduction and internal fixation with dorsal plating verses mini open reduction. J Hand Surg [Am].5:10312. Schemitsch EH. Acceptable functional end results in the majority of the patients despite significant secondary displacement.87:829-36. Trumble TE. Orbay JL. Accessed 2008 Nov 3. 12. Oskam J. Stothers K.

Accessed 2008 July 17. Harrast JJ.2006.27:1-6. [PubMed] 27. . April 1. Souer S. Kutscha-Lissberg Drobetz H.90:1297-1304. US Census Bureau. Wrist mobilization following volar plate fixation of fractures of the distal part of the radius. Weinstein JN. Lamb VL. elderly population. National sex and age.25. Weinstein JN. J Bone Joint Surg Am. 2006. 2008. National population estimates—characteristics. The evolution of practice over time. 2000.90:1855-61. 2003.html.census.[PubMed] 26. to 2004/2005 as measured by longterm changes in function and health in the U.103:18374-9.S. Gu X. Proc Natl Acad Sci U S A. Fractures of the distal part of the radius. Change in chronic disability from 1982. Where's the evidence? J Bone Joint Surg Am. 30. Koval KJ. Anglen JO. to July 1. http://www. Chicago.[PubMed] 28. Mudgal C. Osteosynthesis of distal radius fractures with a volar locking screw plate system. Ring D. Birkmeyer JD. Int Orthop. Lozano-Calderon SA. 2000. IL: American Hospital Association. 29. Jupiter JB. 2008. Manton KG. The Dartmouth atlas of musculoskeletal health care.

with a persistent nonunion and did not wish any further treatment. Seven patients were smokers. The other had hardware failure. Level of Evidence: IV. Three had a persistent painful nonunion. Grant L. Two proceeded to union after revision fixation. iliac crest bone graft. Riggenbach. However. Results: For the 19 patients included and treated with ORIF and allograft. clinical follow-up averaged 15 months. clavicle nonunion. Although complete radiographic healing was achieved in only 68% of patients. which was removed. No literature exists clearly demonstrating this in the clavicle. Smokers were identified to have a trend toward higher failure rates with ORIF augmented with allograft and therefore these patients may be better served by augmenting fixation with autograft. Bishop Author information ► Copyright and License information ► Go to: Abstract Background: Biologic augmentation with allograft has shown equivalent healing rates to autograft in several nonunion models. The three patients who did not demonstrate full radiographic healing were completely pain free. open reduction and internal fixation Go to: INTRODUCTION . Conclusion: ORIF with allograft bone substitute is an acceptable treatment alternative to iliac crest bone graft for clavicle nonunions. Materials and Methods: Nineteen clavicle nonunions treated with ORIF and allograft were evaluated retrospectively to assess healing rates and complications based on clinical symptoms and radiographic findings. retrospective comparative study. we did not demonstrate equivalent healing rates to published results utilizing autograft. and Julie Y. Jones. Five patients experienced complications (26%). Keywords: Allograft bone substitute. Each of these three patients was a smoker (P=0.Open reduction and internal fixation of clavicular nonunions with allograft bone substitute Michael D. clinical success occurred in 16 (84%) patients who demonstrated full range of motion and strength without pain. The purpose of this study was to evaluate the healing and complication rates of clavicle nonunions treated solely with open reduction and internal fixation (ORIF) and allograft. Two underwent hardware removal due to persistent irritation after union.08).

Thus. prolonged pain.[12–19] Hip pain has been shown to persist as long as six months postoperatively in 37. the study was not just evaluating the use of allograft alternatives. Major complications such as pelvic fracture.8% were treated with local autogenous graft—thus. The purpose of this investigation was to evaluate the clinical outcomes. infection. The records of two shoulder surgeons at a tertiary referral center over the previous five years (2004-2009) were retrospectively reviewed to identify all clavicle nonunions requiring operative intervention. These patients presented for operative fixation due to their persistent symptoms and failure of conservative management.7] Patients may present with mechanical symptoms. Based on these criteria. only 29.[1–4. active males. minimally comminuted shaft fractures are treated nonoperatively and heal without complication.[1–3] Most nondisplaced.11] Although ICBG is very effective for fracture healing.[18. Inclusion criteria consisted of any patient between the ages of 18 to 89 years with a symptomatic clavicular nonunion. and minor complications such as persistent drainage. Most stable lateral clavicle fractures heal without event as well. reportedly ranging from less than 1 to 4. sensory disturbances. mechanical symptoms.9] These persistent symptoms may limit functional capacity and often necessitate surgical intervention. complications from graft harvest can potentially cause significant morbidity. one due to suture fixation of a distal clavicle fracture. respectively. preventing postoperative evaluation.6] However. performed a retrospective analysis of superior plate fixation in the treatment of clavicular nonunions citing a 93% healing rate.[4] Overall. Open reduction and internal fixation (ORIF) with autologous iliac crest bone graft (ICBG) has been the gold standard to address clavicular shaft nonunions. although unstable distal clavicle fractures have a higher nonunion rate of up to 30%. and complication rate of clavicle nonunions treated with ORIF and allograft bone substitute. age.[5.[21] However. and one due to death unrelated to the surgery. the nonunion rate after nonoperative treatment of clavicle fractures is rare. In addition. the potential for graftsite complications and their associated morbidity remains and continues to be a substantial concern for the treating surgeon. motion restriction. the literature incorporating graft alternatives in clavicle nonunions is sparse.[20] However. A nonunion diagnosis was based on radiographic [Figures [Figures11 and and2]2] as well as clinical exam findings consistent with a symptomatic nonunion (continued pain.9% of patients. Five patients were excluded. and even thoracic outlet syndrome. and temporary pain range from 0.[13. and comminution have been shown to increase this nonunion risk in some studies to between 33 and 47%.Clavicle fractures account for up to 10% of all fractures and are typically sustained by young. In an effort to minimize graft-site complications.19] and variable enhancement of fusion rates in the spine without the associated morbidity of graft harvest. tenderness. fracture stability. 24 patients with a clavicular nonunion were identified.8. and/or crepitus on exam). .14] Even with meticulous technique. female gender.8% of these patients were treated with DBM and the other 63. no series exists demonstrating the efficacy of ORIF with allograft bone substitute alone when treating clavicular nonunion. they did not differentiate healing rates in those with DBM vs those with autogenous graft. two months postoperatively. radiographic healing.[8. Endrizzi et al. intractable pain. one due to incarceration. two due to segmental defects requiring iliac crest corticocancellous graft. fracture displacement. ORIF with demineralized bone matrix (DBM) rather than ICBG has shown equal efficacy in treating nonunions of the humerus and tibia. alternative methods to augment healing have emerged. Go to: MATERIALS AND METHODS Institutional Review Board Approval was obtained prior to investigation.7 to 25% and 9. A review of the literature demonstrates healing rates ranging from 89 to 100%.4 to 24%.10.5%.[5.

and 12-month visits and evaluated for bridging callus in two views. duration. another with calcium phosphate cement. Union demonstrated after fixation (b). All plate fixation constructs achieved a minimum of three screws medial and lateral to the nonunion site. length of postoperative follow-up. debrided of fibrous tissue and/or attempted callus to expose bleeding bone edges. Go to: . patient had radiographic and clinical evidence of union after fixation Figure 2 Clavicle nonunion (a). In one case. subdermal and dermal layers were closed in succession. and strength at the shoulder. They were placed supine on the operating table with a scapular bump. and return of full pain-free strength. The debrided nonunion site was then reduced and fixed on the superior surface of the clavicle with a precontoured locking clavicle plate. No radiographic evidence of complete union (b) despite full strength. The deltotrapezial fascia. subdermal and dermal layers were closed in succession. and any complications. comparable with the contralateral side. range of motion. type. and in a second case. Strengthening was allowed when the patients had no clinical signs of pain. six-. One of the following healing adjuncts was placed at the nonunion site: 12 received platelet-rich plasma (PRP) with DBM and the other seven received allograft corticocancellous chips. the investigators examined patients for tenderness to palpation over the nonunion site. clinical and radiographic evidence of healing. the allograft chip was supplemented with rhBMP-2. Fracture line still visible eight months postoperatively (arrow) We recorded information about the subject's age. clavicular nonunion location. An oblique incision was made in line with the clavicle over the nonunion site. active and passive range of motion. The nonunion site was identified. The deltotrapezial fascia. Patients were allowed to return to full activity when they had radiographic evidence of healing. Postoperative care Patients were discharged home the same day of surgery with a sling for the first six weeks.Figure 1 Clavicle nonunion (a). At each postoperative visit. range of motion and no pain on clinical exam. no clinical tenderness. Surgical technique Patients were given a preoperative interscalene block and administered general anesthesia. Radiographs were taken at the six-week and three-. tobacco use. Patients then progressed to active shoulder range of motion over the next six weeks as their symptoms allowed. strength.

5-120 months).8 pks/day) and continued to smoke during treatment despite advice to the contrary. Three major complications occurred. Table 1 Patient demographics Go to: . were not smokers. and the remaining three had an oligotrophic nonunion. He subsequently developed a hematoma requiring irrigation and debridement. 2 of the 3 persistent nonunions did go on to eventual union. Overall. Seven patients (37%) were smokers. Each of the three patients with a persistent nonunion were smokers (average 0. Eleven patients (58%) had an atrophic nonunion on preoperative X-rays. Patient 15 had a persistent nonunion with painful instability at the nonunion site. while the other two were in patients with atrophic nonunions. One of these occurred in a patient with hypertrophic nonunions. initial radiographic evidence of healing was obtained in 13/19 (68%) patients[Figure 1b]. He then underwent two subsequent irrigation and debridement procedures for persistent hematoma and then removal of hardware after a stress fracture developed medial to his plate. Five had a hypertrophic nonunion. The two patients with clinical evidence of healing. and two of these were catastrophic failures. Table 1 lists data regarding each patient and his/her respective outcome. These patients had no pain. but not radiographic evidence of healing.08) compared with those who went on to clinical union. He underwent revision fixation with DBM. Two patients without radiographic evidence of healing exhibited clinical signs of union by examination[Figure 2b].5 months after their surgery due to clinical and radiographic evidence of healing and demonstration of full function at that time. A mean of 19 months elapsed between initial injury and presentation (range. Three patients had failures requiring revision fixation. This patient eventually healed without any further complications. Two were minor (hardware removal due to persistent irritation). 2. A total of 16 patients exhibited clinical signs of healing (84%). Patient 10 had four total surgeries. Patients averaged 41. This rate of persistent nonunion in smokers approached statistical significance (P=0. They did not have any hardware complications. which healed without any further issues. had no further interventions. including revision ORIF after the initial plate fixation pulled out. and achieved range of motion equal to the contralateral side and were satisfied with their result. Average follow-up was 15 months (range.5-48 months). requiring revision fixation with ICBG. The other three patients are discussed below in the complication section. 2.1 years in age (range. Overall. One patient could not afford final radiographs but had eight months of clinical follow-up and is clinically healed. and returned to full function. Patient 19 had the plate catastrophically fail. There was no difference in complication rate in those with allograft corticocancellous chips vsthose with PRP and DBM. 18-57 years). This patient's nonunion persisted. achieved full strength in resisted forward elevation and external rotation.RESULTS The 19 patients included in this study were treated with ORIF and allograft bone substitute. and he did not wish any further attempts at fixation. All 19 patients underwent plate fixation. bringing the final radiographic union rate up to 80% and final clinical healing rate up to 95%. Patient 11 was only followed up for 2. Complications There were five total complications (26%). Eighteen patients demonstrated midshaft nonunion and one had a medial shaft nonunion.

based on procedure. including growth factors. they reported no graft-site complications. In their study evaluating external fixation of clavicle fractures and nonunions.[17] However. and the morbidity associated with obtaining it has been well studied. Ahlmann et al.[24. load sharing with intramedullary fixation. Younger and Chapman reported major and minor complication rates of 5. respectively. the pin does not provide rotational control. for anterior ICBG sites and 11. utilized DBM alone in 29. drill reamings in 63.3 and 25%. the carrier. and designation of major and minor complications. Schiund et al. pain >6 months) to be 8% and 2% for anterior and posterior ICBG.[27] Their only failure was due to a postoperative wound infection and subsequent persistent nonunion.[26] Subsequently. for posterior grafting sites. this step would add significant time and complexity to the operation.25] Fifty-three to 66% of these complications are from skin irritation or persistent pain. and ICBG. and ease of hardware removal as benefits to intramedullary fixation.4% to yield a 93% rate of union. unlike a plate and screw construct. Vascularized corticoperiosteal bone grafts from the medial femoral condyle and vascularized fibula strut grafts demonstrate excellent healing capabilities.[19] Augmentation with DBM yielded a 97% healing rate with no donor site morbidity. Like the vascularized bone grafts.8%. alternative graft sources are becoming more frequently studied to determine if healing rates are acceptable given the decreased morbidity.6%. yet.29] The authors caution that these vascularized grafts should be used for refractory nonunions or in adverse healing environments such as an irradiated tissue bed. Ahlmannet al. extensive literature exist exploring alternative fixation constructs and biologic adjuncts in an attempt to minimize potential graft-site morbidity. respectively. Tashjian and Horwitz infused tricalcium phosphate with iliac crest aspirate during open reduction and plate fixation in ten clavicle nonunions and reported a 90% healing rate with no graft-site complications. reported major complications (hernia.[21] Despite their usage of DBM in nearly a third of their patients. ICBG remains the gold standard. DBM is created from allograft bone demineralized with acid extraction. graft site.[18] When treating 47 clavicular nonunions. the nonunion rate when using this construct in the acute setting is only 8.[28. This led the authors to restrict forward elevation above 90 degrees in the early stages of rehabilitation.[24. with 100% healing rates. respectively. corticoperiosteal first rib. DBM demonstrated statistically equivalent clinical and radiographic healing rates at nine months and two years (81% vs 85%). Endrizzi et al. healed 30/31 (97%) distal femoral nonunions in which 30% were treated with DBM.[17] Similarly. has limited their overall use.[17] The minor complication rate (superficial hematomas. leaving collagen and non-collagenous proteins.25] In examining graft choices.[30–32] Hierholzer et al. There was a significant rate of hardware irritation as pin removal occurred in 17 patients (81%) due to a painful bursa forming at the lateral end of the clavicle.[19] Similarly.[23] They cited incisional cosmesis with Langer's lines.3 and 18. respectively. DBM has shown success with bone healing in other clinical trials. Therefore.8% of patients. although most surgeons do not have a comfort level with obtaining corticoperiosteal first rib grafts. they are an unlikely source of graft for the first-time treatment of a clavicle nonunion. the complication rate with the use of the Hagie pin has ranged 25.4%. However. Complication rates for harvesting ICBG vary significantly in the literature. However. when positioning a patient for fixation of a clavicle nonunion. compared DBM with ICBG in their series of humeral nonunions treated with plate fixation.DISCUSSION Despite the success of ORIF with ICBG in treating clavicular nonunions. the total amount and ratios of bone morphogenetic protein (BMP) present. Because of this complication rate. achieved 95% healing rates with Hagie pin fixation. and ICBG in 6. temporary pain/sensory disturbances) was 15% and 0% for anterior and posterior grafting. while 44% of patients augmented with autologous ICBG had donor-site morbidity.[33] In a multicenter randomized controlled trial of tibial nonunions treated with intramedullary (IM) nailing and either autologous ICBG or OP1 (BMP-7) implanted in a bovine collagen carrier (DBM).8 to 50% and to some degree. Gardner et al. However.[22] Boehmeet al. healed all five nonunions treated with a Hoffmann external fixator with no re-fractures. two pins broke during removal. The osteoinductive potential of the graft is influenced by a number of factors: The sterilization process. recommended posterior grafting whenever possible. their reoperation rate only approximated 7%. Despite this. they did not differentiate between .

also refrained from DBM in segmental defects. This trend is supported by Ziran et al. this is a limitation of the study. showed no difference in bone formation for periodontal bone defects treated with either PRP or PRP and allograft. humeral. Thus. Although it did not reach statistical significance (P=0. in a variety of forms. demonstrated no improvements in union rates or time to union when PRP was injected into atrophic tibial. Ballmer et al. in a non-smoker. Still. Although the complication rate is slightly higher than those in the studies using ORIF with ICBG. found that Grafton putty yielded the most fusion material at eight weeks in athymic rats when comparing three brands of DBM. Ideally. despite two requiring repeated percutaneous injections. those reported rates mostly focused on graft-site morbidity—not the complications regarding the surgical procedure itself. we incorporated PRP at the nonunion site in 12 (63%) of patients to augment healing. the three patients with persistent nonunions each smoked at least one pack of cigarettes daily. respectively. and the graft sources of the treating surgeons did change throughout the years of retrospective data collection.[34] Allograft bone substitute has also been studied in combination with autograft with similar success. the best source is yet to be determined. Radiographic healing is truly the best indicator of success of the use of allograft.[21] We believe that those with segmental bony defects should receive ICBG. Han et al. Thirtyseven percent of the patients in this study were smokers and in particular.[3] Two of our complications were minor and involved painful hardware that was removed. allograft corticocancellous bone chips (37%) supplemented with rhBMP (5%) and calcium phosphate (5%) were also included. the numbers do suggest that a trend may be present and perhaps a smoking history should be the reason for pause when using allograft bone substitute. found significant increases in DBM osteoinductivity with PRP when not activated by thrombin. Endrizzi et al. reported healing of all femoral nonunions (N=15) with injection of PRP in conjunction with allograft. noted that their only reoperations were on smoking patients (N=3). However. Our study demonstrated an 84% clinical healing rate with an overall complication rate of 26%. Rather. one must exercise caution in choosing an allograft substitute.[36] Likewise. Peterson et al. as many different allograft sources are available.[39] Markou et al. In addition to the heterogeneity in graft choice. We did exclude these patients from our study and did not review their charts further (The incorporation of an autogenous graft with structural integrity in this instance theoretically appears superior and is supported in the literature). Multiple factors influence the surgeons’ choice and cannot be explored in depth in this paper. However.[21] Two issues arose when examining the graft sources chosen to augment plate fixation in this study. Although DBM was the primary graft source (68%).[9] Additionally. However.[40] We cannot draw any conclusions on PRP based on our study. they did not specify what size of defect would lead them to ICBG. the three individuals without radiographic evidence of healing cannot be considered truly ―healed‖ as the goal of using biologic enhancement is to obtain bony healing. Endrizzi et al. which range from 89 to 100%. or forearm nonunions. Sanchez et al.healing rates for those with DBM vs local grafting.[38] However. Morone and Boden demonstrated that decreased autograft volume could be supplemented with DBM gel to yield fusion rates similar to those following use of autograft alone.9% and 87. three of the complications were persistent nonunions.[37] Likewise.[35] Overall. our results demonstrate that allograft bone substitute. it was to present a series of patients supplemented with a nonautogenous graft source rather than ICBG and demonstrate its efficacy at healing clavicle nonunions. this is not a commonly seen operative problem. another study by Mariconda et al. . two of which failed catastrophically. in particular. we would have used identical graft choices in each patient. Although the authors recognize that the clinical success rate was 84%. at this point. who noted healing rates of 67. had 100% union rate at six months in patients receiving tricortical ICBG for segmental clavicular defects greater than or equal to 15 mm. has the potential to facilitate healing in a clavicular nonunion. It is unknown whether this helped stimulate healing. This study's intention was not to isolate a particular substance to prove similar efficacy to ICBG. Admittedly. however. Previous studies showed mixed results with its efficacy in stimulating bone formation. Variation in each company's bone supply and mode of preparation yields varying qualities of DBM.5% in smokers and nonsmokers receiving allograft for fractures and nonunions.08). our radiographic healing rate of 68% is certainly not equivalent to the reported healing rates in the literature for autograft. For instance.

Our healing rates with allograft are lower than reported rates utilizing ICBG. We hope this will shed more light on this complicated problem.. [PubMed] 2. J Bone Joint Surg Am. Go to: Footnotes Source of Support: Nil Conflict of Interest: None declared. Go to: CONCLUSION Despite these limitations.Associated complications and surgical management. Thus. the failures can be catastrophic and difficult to revise. Colton CL. but our method does eliminate graft-site morbidity. [PubMed] 5. Szabo RM. Eighteen of the fractures were fixed with a locking clavicle plate. one was treated with a pelvic recon plate. ORIF with a bone graft substitute source is a viable alternative to ICBG when treating clavicle nonunions.31/32 healed after plate fixation and bone grafting. however. We believe our data do demonstrate acceptable healing rates without graft-site morbidity. Non-union of the clavicle. However. O’Connor DP. 2nd Nonunion of the clavicle. ORIF and ICBG may better serve patients with a smoking history. 1996. 1960. [PubMed] . A ―cleaner‖ study would employ the same type of fixation for all fractures. and as stated above. Lastly. our goal was to look at all clavicle nonunions to evaluate the efficacy of allograft as an alternative and successful treatment option when compared with ICBG.172:1006–11. When clavicle nonunions persist after surgical treatment.67:1367–71. It is a retrospective case series without randomization to a treatment group. Jupiter JB. Leffert RD. Acta Orthop Scand. Manske DJ. Bradbury N. We are currently enrolling patients in a prospective case series to re-examine the efficacy of ORIF with DBM in clavicular nonunions to standardize treatment and to formally evaluate patient's clinical progress with standardized outcomes measurements and complete radiographic analysis. The operative treatment of mid-shaft clavicular non-unions. it does have several limitations. J Bone Joint Surg Am. However. Hutchinson J. Hahn D. 1987. but it was rigidly fixed with a locking plate. follow-up was not optimally standardized with functional assessments or complete radiographic profiles to ensure healing as several patients ceased to follow-up once they had obtained clinical evidence of healing.J Bone Joint Surg Am. J Am Med Assoc.Although this study is the first to look only at clavicular nonunions treated with ORIF and bone graft substitute.69:753–60. we do recognize that our healing rates are inferior to the reported healing rates for the use of allograft. However.67:367–70. One fracture was more medial and is susceptible to different forces across the fracture site and thus perhaps a different union potential. Edwards TB. Brinker MR. 1985. has a lack of standardization to treatment when utilizing allograft source choices.87:676–7. smokers may have a higher risk for failure with allograft. Neer CS. although this was not found to be statistically significant. Go to: REFERENCES 1. Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. [PubMed] 3. [PubMed] 4. 2005. Based on our current results. this is the only series found in the literature evaluating clavicle nonunion healing rates grafted exclusively with allograft bone substitute sources. given this trend. Clavicular nonunion.

83-A(Suppl 1):S151–8.88:1442–7. Sama D. Schaap GR. J Oral Maxillofac Surg. Roper JG.1987. Osteogenic protein-1 (bone morphogenetic protein-7) in the treatment of tibial nonunions. Arrington ED. Open reduction and internal fixation with bone grafting of clavicular nonunion. 1983. Lambert SM. Smith WJ. Clin Orthop Relat Res. 1988.45:11–4. Andrianne Y.Am J Orthop (Belle Mead NJ) 1995. Mekhail AO. Iliac bone grafting: Review of 160 consecutive cases. Demineralized bone matrix and spinal arthrodesis. Rasquin C. [PubMed] 9. 1996. Muschler GF. Kerkhoffs GM. Autogenous iliac crest bone graft. [PubMed] 18. Kurz LT.6. [PubMed] 21. Olsen BS. Marti RK. Darwich M. Perry CR. Holtom P. Jr Harvesting autogenous iliac bone grafts. Senunas LE. Patzakis M.2005. Vaesel MT. McQueen MM. Schuind F. Wilkins RM. [PubMed] 16. Shepherd L. J Bone Joint Surg Am. Complications associated with harvesting autogenous iliac bone graft. Fowler BL. Garfin SR. [PubMed] 12.339:76–81. 2004. 2006. Nolte PA. Treatment of midshaft clavicular nonunion with plate fixation and autologous bone grafting. Ebraheim NA. [PubMed] 11. [PubMed] 20. Pay-Pay E.[PubMed] 8.27:131–5.84-A:716– 20. Nonunion of the clavicle treated with plate fixation: A review of forty-seven consecutive cases. Spine (Phila Pa 1976) 1989. Greenfield ML. [PubMed] 22. 1998.Complications and functional assessment. Hierholzer C. Lee KJ.4:337–44. Burny F. J Bone Joint Surg Am. Cole JD. Keller EE. 1997. Ahlmann E. [PMC free article] [PubMed] 19. Old AB.329:300–9. J Shoulder Elbow Surg.24:895–903. [PubMed] 15.. et al.5:217S– 23S. Spine J.65:773– 8.[PubMed] 7. Court-Brown CM. [PubMed] 14. Davino NA. 2003. Roidis N. Ballmer FT. DeSilva GL. 1995. Rowe DE. Ununited fractures of the clavicle. Robinson CM.86-A:1359–65. Comparison of anterior and posterior iliac crest bone grafts in terms of harvest-site morbidity and functional outcomes. Besselaar PP. Donkerwolcke M. Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. Friedlaender GE. Bucknell AL. External fixation of the clavicle for fracture or non-union in adults. [PubMed] 13.70:692–5. [PubMed] 17. Toro JB. Booth RE. J Bone Joint Surg Am. Wakefield AE.A review of complications and techniques. Cierny G. [PubMed] . Helfet DL. J Bone Joint Surg Am. Cook SD.42:701–4. 2001. Endrizzi DP. Babikian GM. White RR. J Shoulder Elbow Surg.7:581–5. Complications of iliac crest bone graft harvesting. Decortication and plate osteosynthesis for nonunion of the clavicle. Operative treatment of mid-shaft clavicular non-union. Johnston RM. Peterson M. 2008. J Bone Joint Surg Am. Triplett WW. J Bone Joint Surg Am.17:951–3.14:1324–31. J Trauma. Hertel R. [PubMed] 10. Dall BE. Clin Orthop Relat Res. Goulet JA. Plate fixation of ununited humeral shaft fractures: Effect of type of bone graft on healing. Sojbjerg JO. 1997. Int Orthop. J Shoulder Elbow Surg. Chambers HG.2002. Wang JC.

Lorich DG.86-A:2243– 50.20:86–91. France MA. et al. 2005. Peterson B. Am J Orthop (Belle Mead NJ) 2009. Whang PG. Tashjian RZ. 2002. Rockwood CA.7:19–41. Agudelo JF. 1989. [PubMed] 35. Boden SD. Hierholzer C. Shamie AN. [PubMed] 36. Iglesias R. Coleman DA. Experimental posterolateral lumbar spinal fusion with a demineralized bone matrix gel. 2011. Young DC. Azofra J. [PubMed] . Lipids closely associated with bone morphogenetic protein (BMP)–and induced heterotopic bone formation. Chang L. [PubMed] 26. Urist MR. et al.296:266–9. Kerendi F.[PubMed] 27. Jr. J Shoulder Elbow Surg. [PubMed] 37. J Shoulder Elbow Surg. Curtis RJ. Momberger NG. [PubMed] 29. Nuygen TD. Lieberman JR. Sammarco VJ. J Trauma. Osteoinductivity of commercially available demineralized bone matrix. Connolly JF. J Bone Joint Surg Am.2004. DeHaan JT. Guadilla J. Connect Tissue Res.. 2000. Seijas R.14:264–8. Healing and graft-site morbidity rates for midshaft clavicle nonunions treated with open reduction and internal fixation augmented with iliac crest aspiration. Younger EM. 2008. [PubMed] 31. Zuckerman JD.23:159–67.3:192– 5. Ziran BH. Toro-Arbelaez JB. [PubMed] 33. Vascularized fibular grafts for salvage reconstruction of clavicle nonunion.Preparations in a spine fusion model. J Orthop Trauma. Open reduction and internal fixation of distal femoral nonunions: Long-term functional outcomes following a treatment protocol. Fuchs B. [PubMed] 30. Osseous healing with a composite of allograft and demineralized bone matrix: Adverse effects of smoking.23:52–9. Modern issues in bone graft substitutes and advances in bone tissue technology. Koval KJ. J Shoulder Elbow Surg. Jr Non-union of fractures of the mid-shaft of the clavicle.73:1219–26. Am J Med Sci.64:434–8.16:280–4. 2009. Horwitz DS. Foot Ankle Clin. Gardner MJ. 1991.With preliminary observations of deficiencies in lipid and osteoinduction in lathyrism in rats. Kay SP. Helfet DL. Am J Orthop (Belle Mead NJ)2007. Morbidity at bone graft donor sites. [PubMed] 25. Smith WR. Free vascularized corticoperiosteal bone graft for the treatment of persistent nonunion of the clavicle.1997. Stock AJ. J Shoulder Elbow Surg. Horan MP. Strates BS. Egol KA. Cugat R. Nonunions treated with autologous preparation rich in growth factors. Behnam K. Steinmann SP. [PubMed] 28. [PubMed] 24. 1988. [PubMed] 34.38:133–6.9:389–94. Spine (Phila Pa 1976) 1998. Chapman MW. Bishop AT. 2007. Harrison M. Anitua E.36:207– 9. Boehme D. Complications of intramedullary Hagie pin fixation for acute midshaft clavicle fractures. Complications of clavicle fractures treated with intramedullary fixation. Skeletal repair in the aged: A preliminary study in rabbits. Hurst JM. Westerheide K. Smith J. Strauss EJ. Sanchez M. Millett PJ.Treatment with a modified Hagie intramedullary pin and autogenous bone-grafting. Hawkins RJ.36:9–20. Hendi P.23. Wang JC. [PubMed] 32. J Orthop Trauma. Raskin K. J Bone Joint Surg Am. Morone MA.

Yang Z. D’Agostino E. J Orthop Trauma. J Bone Joint Surg Am. Treatment of periodontal endosseous defects with platelet-rich plasma alone or in combination with demineralized freezedried bone allograft: A comparative clinical trial. Vavouraki H. Milano C.2009. Cozzolino A. [PubMed] .91:1459–70. et al. Markou N. Stamatakis HC. Mariconda M. Nikolopoulos G. 2009. The effect of thrombin activation of platelet-rich plasma on demineralized bone matrix osteoinductivity. 2008. Nimni M. [PubMed] 40. Han B. Platelet gel supplementation in long bone nonunions treated by external fixation. Cozzolino F.22:342–5. J Periodontol.38. Ponticiello M. Pepelassi E. Woodell-May J.80:1911–9. Vrotsos I. Bove A. [PubMed] 39.