Session III - Reconstruction

Thurs., 10/5/06 Reconstruction, Paper #13, 4:30 pm

Percutaneous Injection of Iliac Crest Aspirate for the Treatment of Long Bone Delayed Union and Nonunion

J. Tracy Watson, MD (n); Kevin J. Quigley, MD (n); Christopher D. Mudd, MD (n);
Division of Orthopaedic Traumatology, Department of Orthopaedic Surgery,
St. Louis University School of Medicine, St. Louis, Missouri, USA

Introduction: The treatment of nonunions is multifactorial and often requires open bone graft augmentation. Percutaneous injection of centrifuged concentrated autologous bone marrow harvested from the iliac crest has been advocated for stimulating bone healing in delayed unions and nonunions. However, few studies have looked at the long-term effectiveness of this procedure.

Materials/Methods: 52 patients (29 female, 23 male, median age 41, range 16-79) underwent iliac crest aspiration and injection at our institution between 1995 and 2003. According to a standardized protocol, patients who demonstrated long bone delayed union (>3 months) or nonunion (>6 months) without active sepsis were candidates. All patients were aspirated under general anesthesia (anterior or posterior iliac crests in 4-5 cc intervals). In each procedure, the aspirate was centrifuged, the supernatant discarded, and cellular concentrate obtained. Large bore needles were directed at the site of bone deficit under fluoroscopic control, and cellular concentrates were injected. At follow-up, retrospective review of these patients' charts and radiographs was performed, evaluating multiple factors including duration of nonunion, mechanical stabilization, surgical technique, time to union, and effectiveness of the procedure.

Results: 46 patients were available for long-term follow-up (>2 years). On average, 52 cc of iliac crest aspirate was obtained during each procedure, with 27 cc injected into the site of nonunion (29 tibia, 12 femur, 5 humeri). 28 of 46 patients (61%) treated with aspiration and injection did not heal their nonunion. Only 17 (37%) went on to bony union after their first procedure (average time to union 4 months). Two patients healed a nonunion after a second procedure (one femur, one tibia), including one patient whose contralateral tibia failed to heal despite two procedures. Six of seven patients (86%) receiving multiple injections had persistent nonunion despite this treatment. Of 56 total procedures performed in this population, 37 failed (66%). No significant difference was noted between the group that healed vs. the group that did not with regard to gender, mechanical stabilization, fracture grade, smoking, or type of nonunion (atrophic vs. hypertrophic). There were no complications from the procedure itself.

Conclusion: Iliac crest aspiration and injection alone is ineffective and cannot be recommended in this setting. Further studies are needed to delineate the role of this procedure in nonunion management, as well as the balance between stabilization and biologic factors in bone healing.

If noted, the author indicates something of value received. The codes are identified as a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options; e-consultant or employee; n-no conflicts disclosed, and *disclosure not available at time of printing.
· The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an "off label" use). · · FDA information not available at time of printing.