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. 2022 Aug 27;15(2):106-115.
doi: 10.1055/s-0042-1748783. eCollection 2023 Apr.

Multifactorial Analysis of Treatment of Long-Bone Nonunion with Vascularized and Nonvascularized Bone Grafts

Marco Guidi  1 , Matteo Guzzini  2 , Carolina Civitenga  2 , Riccardo Maria Lanzetti  3 , Bong-Sung Kim  1 , Inga Swantje Besmens  1 , Martin Riegger  4 , Stefano Lucchina  5 , Maurizio Calcagni  1 , Dario Perugia  2
Affiliations

Multifactorial Analysis of Treatment of Long-Bone Nonunion with Vascularized and Nonvascularized Bone Grafts

Marco Guidi et al. J Hand Microsurg. .

Abstract

Introduction The purpose of the study was to evaluate the results of treatment of the nonunion of long bones using nonvascularized iliac crest grafts (ICGs) or vascularized bone grafts (VBGs), such as medial femoral condyle corticoperiosteal flaps (MFCFs) and fibula flaps (FFs). Although some studies have examined the results of these techniques, there are no reports that compare these treatments and perform a multifactorial analysis. Methods The study retrospectively examined 28 patients comprising 9 women and 19 men with an average age of 49.8 years (range: 16-72 years) who were treated for nonunion of long bones between April 2007 and November 2018. The patients were divided into two cohorts: group A had 17 patients treated with VBGs (9 patients treated with MFCF and 8 with FF), while group B had 11 patients treated with ICG. The following parameters were analyzed: radiographic patterns of nonunion, trauma energy, fracture exposure, associated fractures, previous surgeries, diabetes, smoking, age, and donor-site morbidity. Results VBGs improved the healing rate (HR) by 9.42 times more than the nonvascularized grafts. Treatment with VBGs showed a 25% decrease in healing time. Diabetes increased the infection rate by 4.25 times. Upper limbs showed 70% lower infection rate. Smoking among VBG patients was associated with a 75% decrease in the HR, and diabetes was associated with an 80% decrease. Conclusion This study reports the highest success rates in VBGs. The MFCFs seem to allow better clinical and radiological outcomes with less donor-site morbidity than FFs.

Keywords: iliac crest bone graft; medial femoral condyle; nonunion of long bone; vascularized bone grafts; vascularized fibular graft.

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Conflict of interest statement

Conflict of Interest The authors declared no potential conflict of interest with respect to the research, authorship, and/or publication of this article. Dr. Calcagni reports nonfinancial support from Sobi, nonfinancial support from Medartis, nonfinancial support from Silk Biomaterials, nonfinancial support from DyCare, outside the submitted work.

Figures

Fig. 1
Fig. 1
Boxplot of the results of the regression analysis as a function of the type of treatment (vascularized bone grafts vs. nonvascularized bone grafts).
Fig. 2
Fig. 2
Boxplot of the results of the regression analysis as a function of the type of vascularized bone graft (VBG) (fibula flap [FF] vs. medial femoral condyle corticoperiosteal flap [MFCF]).
Fig. 3
Fig. 3
A 19-year-old patient with and atrophic nonunion of the tibia treated with wide resection, fibula flap and external fixator ( A, B ). Removal of the external fixator at 8 months with a complete healing of the flap ( C ).
Fig. 4
Fig. 4
A 38-year-old patient with oligotrophic nonunion of the radius and ulna after open forearm fracture with recoplate breakage ( A , white arrow ), treated with plate removal, new osteosynthesis with LCP with medial femoral condyle corticoperiosteal flap ( B , white asterisk ). ( C, D ) Follow-up at 6 months with healing of the radius fracture ( black asterisk ).
Fig. 5
Fig. 5
A 43-year-old patient. Open forearm fracture treated with K wires ( A, B ). Because of the bone defect of the radius with an oligotrophic fracture, after 5 months, we decided to use a nonvascularized bone graft (iliac crest graft [ICG]). ( C, D ) Follow-up at 6 months postoperatively after reosteosynthesis and ICG with a complete healing of the site.
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