Copyright © 2006 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
David Ring, MD*,
Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
The authors present an extensive experience with operative treatment of ununited diaphyseal fractures of the humerus. The opportunity to compare the use of autologous iliac crest bone graft and demineralized bone matrix allograft to treat these nonunions in such a large series is unique; however, as a result of several problems with the methodology, alternative conclusions can be drawn. The ununited fractures in the demineralized bone matrix allograft group were more often delayed unions (45% vs 29%), occurred more frequently after nonoperative treatment (70% vs 38%), and were usually treated through an extended deltopectoral approach (64% vs 24%). These differences suggest that the fractures in the demineralized bone matrix group were much more straightforward to repair. A delayed union after nonoperative treatment is very different from an established nonunion after one or more operative procedures with consequent devitalized bone and debris, inflammation, and diminished bone quality from failed implants. Furthermore, the authors state that a "protocol" was used, but the paper reveals that a variety of fixation constructs were used, due in part to evolution in implants during the time period of the study.
I would argue that the key to interpreting these data is that all of the operations were performed by a single surgeon with expertise, experience, and wisdom regarding the treatment of diaphyseal nonunions of the humerus—a fact that is obvious from the number of patients in the series. It is safe to assume that not all of us can expect to achieve these results.
The results do suggest that the use of autologous cancellous bone graft may not be critical in achieving osseous union when treating humeral diaphyseal nonunions with plate and screw fixation. In my opinion, demineralized bone matrix is a relatively poor substitute for bone graft, raising the possibility that no graft is needed whatsoever. In any case, this study certainly places a burden of proof on those who promote very expensive recombinant-growth-factor technology for treatment of humeral nonunions, as it suggests that the preparation of the nonunion site and the techniques of internal fixation are more important than the adjunctive bone graft or graft substitute. In fact, given that nonunion was so uncommon with demineralized bone matrix alone, it may be very difficult if not impossible, given the rarity of this problem, to demonstrate an advantage with use of a more sophisticated graft substitute in a clinical trial.
*The author did not receive grants or outside funding in support of his research for or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. A commercial entity (AO Foundation) paid or directed, or agreed to pay or direct, benefits to a research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.
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