Abstract
Introduction
We describe a minimally invasive technique that permits intra-focal bone graft of non-union sites with minimal disturbance of soft tissues and vascularity, and present the results of this technique.
Materials and Methods
10 patients with established tibia fracture non-union were judged suitable for the technique, and were treated in our limb reconstruction unit between January 1995 to June 2007. Eight patients were male, 2 were females with a mean age of 37.4 years (27–64). Five fractures were in the distal tibia and five were diaphyseal fractures. Five fractures were as a result of high velocity and 6 fractures were open. Average number of previous operations were 3 (range 1–7). Time lapse between injury to trephine grafting procedure was mean of 34 (6–168 months)
5 patients had a sedentary job, 2 were labourers and 2 were not working. There were 5 smokers and 2 obese patients. Six cases were of infected non-unions.
Operative technique
Under general anaesthesia, the graft(s) was first obtained from the iliac crest using a guide wire centred trephine. A stab incision was made at the non-union site under image control. A core was taken across the non-union, taking care to breach both bone fragments. A trephine core was rolled in Bone Morphogenetic Protein (BMP-7). This was then introduced through the trephine in to the non-union site and pushed with the plunger into the defect created by the cylindrical plug taken from the site. After this, the trocar with the stylet in place was gradually withdrawn with small oscillating motions to fill in the path of the trocar. This was repeated about 3–4 times at the non-union site. The stab wound were closed with interrupted Nylon
Results
10 patients underwent treatment for complex non-union after initial operation (average number 3) at the referring centre. Treatment in a circular fixator ranged from 10–33 months (20.7 months) with reapplication in 2 patients. Average number of procedures were 4 (range 1–7). Trephine grafting was performed in all cases; BMP was used in 4 cases along with iliac crest bone graft.
All patients attained clinical and radiological union with CT confirmation required in 2 patients. 4 patients with sedentary job returned to work, manual workers returned to low demand occupation.
Conclusion
The technique described is a safe and effective treatment method for this complex problem with limited donor site morbidity and avoids prolonged hospital stay.
