- Email: [email protected]
Healing of a clavicle fracture nonunion with bone marrow injection
Healing of a clavicle fracture nonunion with bone marrow injection Patrice Tétreault, MD,a and Hugue A. Ouellette, MD,b Montreal, Quebec, Canada, and Boston, MA
N
onunion of the clavicle can be a debilitating condition by limiting shoulder range of motion and endurance for physical work. Pain can also be the primary symptom. Current treatment for clavicle nonunion consists of plate-and-screw osteosynthesis with iliac crest bone graft1,7,10,13,16 or intramedullary screw fixation.9,15 Surgical treatment has possible complications, such as intolerance to metal, scarring, or persistence of nonunion.6 Bone marrow injection has been used to treat humeral nonunion,11 femoral nonunion,14 and other long bones.2-4,8,17 We present a patient who had a clavicle nonunion that was successfully treated with only bone marrow injection. To our knowledge, this technique has never been reported.
Figure 1 Anteroposterior view of left clavicle 12 months before intervention.
CASE REPORT A 39-year-old right hand– dominant man broke his left clavicle after a bicycle accident. There was minor displacement at the fracture site on the initial radiographic evaluation (Figure 1). Conservative management with a figure-of-8 sling for 6 weeks was chosen for treatment. The patient only came to a follow-up visit 9 months later complaining of poor endurance when performing physical labor, as well as persistent pain at the clavicle. Clinically, the range of motion was normal, but pain was present at the nonunion site. The neurovascular status was unremarkable. Plain radiographs of the clavicle revealed the presence of a nonunion (Figure 2). The patient was reluctant to undergo stabilization of his clavicle with a plate and screws. As a treatment option, we offered an injection of bone marrow into the site of the nonunion without the plate and screws. He agreed to the injection, knowing that this treatment was not the gold standard. The patient was brought to the operating room, and general anesthesia was induced. The iliac crest and clavicle were prepped and draped in a sterile fashion. A 3-cm incision was made over the iliac crest, and the soft tissues were dissected From the aDepartment of Orthopaedic Surgery, Montreal University, Hôpital Notre-Dame du Centre Hospitalier de l’Université de Montréal, Montreal, and bDepartment of Radiology, Harvard University, Massachusetts General Hospital, Boston. Reprint requests: Patrice Tétreault, MD, Department of Orthopaedic Surgery, Hôpital Notre-Dame du Centre Hospitalier de l’Université de Montréal, 1560 Rue Sherbrooke Est, Montreal, Quebec, H2L 4M1 Canada (E-mail: [email protected]). J Shoulder Elbow Surg 2007;16:e23-e24. Copyright © 2007 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2007/$32.00 doi:10.1016/j.jse.2006.05.001
Figure 2 Anteroposterior view of left clavicle 3 months before intervention.
down to bone. A 1-cm-wide cortical window was made on the crest, and bone marrow was aspirated. Small fragments of cancellous bone were collected and put in the syringe. With the use of fluoroscopy, approximately 10 mL of bone marrow was injected with an 18-gauge needle within and around the nonunion pseudocapsule through 5 puncture sites. We noticed that small fragments of cancellous bone were left in the syringe because they could not fit through the needle. These fragments appeared to be white because the blood was squeezed out by the syringe piston. The injection caused mild swelling at the nonunion site. We decided not to add more marrow to avoid possible discomfort from a hematoma. The ends of the clavicle fragments were also scratched with the needle with the intent of stimulating the periosteum. Care was taken to not pass beyond the nonunion site to prevent puncture into the subclavian vessels or the lung. The wounds were dressed with sterile dressing, and the patient went home on the same
e23
e24
Tétreault and Ouellette
Figure 3 Anteroposterior view of left clavicle showing solid union.
day. He was instructed to wear a sling for 6 weeks and to return for clinical and radiographic follow-up. The patient was seen 1 week postoperatively for removal of the suture over the iliac crest. Unfortunately, he only came to his next follow-up visit 1 year later. He mentioned that the pain was gone and that he returned to work with no physical restriction. Clinical examination showed symmetric motion and strength of the upper extremities. There was no scar at the site of injection of the bone marrow. The clavicle appeared slightly deformed and shortened. No motion was detected at the previous nonunion site. Plain radiographs clearly revealed healing of the nonunion site (Figure 3).
DISCUSSION Bone marrow injection for the treatment of fracture nonunions has been reported on many occasions4,8,11,14,17 and is also the subject of intense fundamental research.2,5,12 Connolly et al3 reported their extensive experience with injectable bone marrow preparations to stimulate osteogenic repair. They described the successful use of a centrifugation technique to concentrate marrow for injection in small bones, as well as the possibility of mixing the bone marrow with demineralized bone matrix composite. For this case, only the bone marrow collected was used for injection of our patient’s clavicle nonunion. The nonunion was present and symptomatic for at least 12 months before the injection and healed within the 12 months after the intervention. Unfortunately, the patient had poor compliance with our follow-up visits, which were scheduled every 6 weeks, such that the precise timeframe for healing cannot be established. More cases will eventually indicate whether bone marrow injection requires a longer healing time than a classic open reduction–internal fixation. To our knowledge, it is not entirely clear which part of the technique contributed the most to the successful healing of our patient’s clavicle nonunion: Is it scratching of the periosteum of the clavicle with the needle, the bone marrow elements in the aspirated blood, or the bone marrow elements squeezed out of the cancellous bone fragments? Should we add synthetic composite? Since this successful intervention, we now offer this procedure to patients presenting with clavicle nonunion but advise them that the chances of success are unknown at this time and that failure to cure may imply another surgery. We suspect that this technique may not be suitable for all nonunion cases. Further trials will help select the best candidates for this technique (young vs old patients, atrophic nonunion versus hypertrophic nonunion, smokers vs nonsmokers, and so on). We are
J Shoulder Elbow Surg January/February 2007
also planning on performing the procedure in the operating room but with patients under local anesthesia. We will use a bone marrow biopsy needle to collect bone marrow and fragments of cancellous bone. The needle is slightly larger and will allow us to push the cancellous bone fragments into the nonunion site. No stitching over the iliac crest will be necessary. Because of potential complications such as puncture of the subclavian artery or vein and pneumothorax, we believe that the operating room remains the safest place in which to perform this technique. Bone marrow injection for the treatment of clavicle nonunion is promising. We believe that the low morbidity and preliminary success of this technique justify further trials. REFERENCES
1. Bradbury N, Hutchinson J, Hahn D, Colton CL. Clavicular nonunion. 31/32 healed after plate fixation and bone grafting. Acta Orthop Scand 1996;67:367-70. 2. Connolly JF. Injectable bone marrow preparations to stimulate osteogenic repair. Clin Orthop Relat Res 1995:8-18. 3. Connolly JF, Guse R, Tiedeman J, Dehne R. Autologous marrow injection as a substitute for operative grafting of tibial nonunions. Clin Orthop Relat Res 1991:259-70. 4. Connolly JF, Guse R, Tiedeman J, Dehne R. Autologous marrow injection for delayed unions of the tibia: a preliminary report. J Orthop Trauma 1989;3:276-82. 5. Dahir GA, Cui Q, Anderson P, Simon C, Joyner C, Triffitt JT, et al. Pluripotential mesenchymal cells repopulate bone marrow and retain osteogenic properties. Clin Orthop Relat Res 2000; (Suppl):S134-45. 6. Der Tavitian J, Davison JN, Dias JJ. Clavicular fracture non-union surgical outcome and complications. Injury 2002;33:135-43. 7. Ebraheim NA, Mekhail AO, Darwich M. Open reduction and internal fixation with bone grafting of clavicular nonunion. J Trauma 1997;42:701-4. 8. Healey JH, Zimmerman PA, McDonnell JM, Lane JM. Percutaneous bone marrow grafting of delayed union and nonunion in cancer patients. Clin Orthop Relat Res 1990:280-5. 9. Hoe-Hansen CE, Norlin R. Intramedullary cancellous screw fixation for nonunion of midshaft clavicular fractures. Acta Orthop Scand 2003;74:361-4. 10. Laursen MB, Dossing KV. Clavicular nonunions treated with compression plate fixation and cancellous bone grafting: the functional outcome. J Shoulder Elbow Surg 1999;8:410-3. 11. Li Y, Shi S, Liu Z, Li Z, Wang R, Guo Y, et al. Treatment of humeral shaft nonunion with interlocking nail and percutaneous injection of bone marrow [in Chinese]. Zhonghua Wai Ke Za Zhi 2000; 38:732-5, 42. 12. Ma HL, Chen TH, Hung SC. Development of a new method in promoting fracture healing: multiple cryopreserved bone marrow injections using a rabbit model. Arch Orthop Trauma Surg 2004; 124:448-54. 13. Marti RK, Nolte PA, Kerkhoffs GM, Besselaar PP, Schaap GR. Operative treatment of mid-shaft clavicular non-union. Int Orthop 2003;27:131-5. 14. Matsuda Y, Sakayama K, Okumura H, Kawatani Y, Mashima N, Shibata T. Percutaneous autologous bone marrow transplantation for nonunion of the femur. Nippon Geka Hokan 1998;67:10-7. 15. Neviaser RJ, Neviaser JS, Neviaser TJ, Neviaser JS. A simple technique for internal fixation of the clavicle. A long term evaluation. Clin Orthop Relat Res 1975:103-7. 16. Olsen BS, Vaesel MT, Sojbjerg JO. Treatment of midshaft clavicular nonunion with plate fixation and autologous bone grafting. J Shoulder Elbow Surg 1995;4:337-44. 17. Sim R, Liang TS, Tay BK. Autologous marrow injection in the treatment of delayed and non-union in long bones. Singapore Med J 1993;34:412-7.
N
onunion of the clavicle can be a debilitating condition by limiting shoulder range of motion and endurance for physical work. Pain can also be the primary symptom. Current treatment for clavicle nonunion consists of plate-and-screw osteosynthesis with iliac crest bone graft1,7,10,13,16 or intramedullary screw fixation.9,15 Surgical treatment has possible complications, such as intolerance to metal, scarring, or persistence of nonunion.6 Bone marrow injection has been used to treat humeral nonunion,11 femoral nonunion,14 and other long bones.2-4,8,17 We present a patient who had a clavicle nonunion that was successfully treated with only bone marrow injection. To our knowledge, this technique has never been reported.
Figure 1 Anteroposterior view of left clavicle 12 months before intervention.
CASE REPORT A 39-year-old right hand– dominant man broke his left clavicle after a bicycle accident. There was minor displacement at the fracture site on the initial radiographic evaluation (Figure 1). Conservative management with a figure-of-8 sling for 6 weeks was chosen for treatment. The patient only came to a follow-up visit 9 months later complaining of poor endurance when performing physical labor, as well as persistent pain at the clavicle. Clinically, the range of motion was normal, but pain was present at the nonunion site. The neurovascular status was unremarkable. Plain radiographs of the clavicle revealed the presence of a nonunion (Figure 2). The patient was reluctant to undergo stabilization of his clavicle with a plate and screws. As a treatment option, we offered an injection of bone marrow into the site of the nonunion without the plate and screws. He agreed to the injection, knowing that this treatment was not the gold standard. The patient was brought to the operating room, and general anesthesia was induced. The iliac crest and clavicle were prepped and draped in a sterile fashion. A 3-cm incision was made over the iliac crest, and the soft tissues were dissected From the aDepartment of Orthopaedic Surgery, Montreal University, Hôpital Notre-Dame du Centre Hospitalier de l’Université de Montréal, Montreal, and bDepartment of Radiology, Harvard University, Massachusetts General Hospital, Boston. Reprint requests: Patrice Tétreault, MD, Department of Orthopaedic Surgery, Hôpital Notre-Dame du Centre Hospitalier de l’Université de Montréal, 1560 Rue Sherbrooke Est, Montreal, Quebec, H2L 4M1 Canada (E-mail: [email protected]). J Shoulder Elbow Surg 2007;16:e23-e24. Copyright © 2007 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2007/$32.00 doi:10.1016/j.jse.2006.05.001
Figure 2 Anteroposterior view of left clavicle 3 months before intervention.
down to bone. A 1-cm-wide cortical window was made on the crest, and bone marrow was aspirated. Small fragments of cancellous bone were collected and put in the syringe. With the use of fluoroscopy, approximately 10 mL of bone marrow was injected with an 18-gauge needle within and around the nonunion pseudocapsule through 5 puncture sites. We noticed that small fragments of cancellous bone were left in the syringe because they could not fit through the needle. These fragments appeared to be white because the blood was squeezed out by the syringe piston. The injection caused mild swelling at the nonunion site. We decided not to add more marrow to avoid possible discomfort from a hematoma. The ends of the clavicle fragments were also scratched with the needle with the intent of stimulating the periosteum. Care was taken to not pass beyond the nonunion site to prevent puncture into the subclavian vessels or the lung. The wounds were dressed with sterile dressing, and the patient went home on the same
e23
e24
Tétreault and Ouellette
Figure 3 Anteroposterior view of left clavicle showing solid union.
day. He was instructed to wear a sling for 6 weeks and to return for clinical and radiographic follow-up. The patient was seen 1 week postoperatively for removal of the suture over the iliac crest. Unfortunately, he only came to his next follow-up visit 1 year later. He mentioned that the pain was gone and that he returned to work with no physical restriction. Clinical examination showed symmetric motion and strength of the upper extremities. There was no scar at the site of injection of the bone marrow. The clavicle appeared slightly deformed and shortened. No motion was detected at the previous nonunion site. Plain radiographs clearly revealed healing of the nonunion site (Figure 3).
DISCUSSION Bone marrow injection for the treatment of fracture nonunions has been reported on many occasions4,8,11,14,17 and is also the subject of intense fundamental research.2,5,12 Connolly et al3 reported their extensive experience with injectable bone marrow preparations to stimulate osteogenic repair. They described the successful use of a centrifugation technique to concentrate marrow for injection in small bones, as well as the possibility of mixing the bone marrow with demineralized bone matrix composite. For this case, only the bone marrow collected was used for injection of our patient’s clavicle nonunion. The nonunion was present and symptomatic for at least 12 months before the injection and healed within the 12 months after the intervention. Unfortunately, the patient had poor compliance with our follow-up visits, which were scheduled every 6 weeks, such that the precise timeframe for healing cannot be established. More cases will eventually indicate whether bone marrow injection requires a longer healing time than a classic open reduction–internal fixation. To our knowledge, it is not entirely clear which part of the technique contributed the most to the successful healing of our patient’s clavicle nonunion: Is it scratching of the periosteum of the clavicle with the needle, the bone marrow elements in the aspirated blood, or the bone marrow elements squeezed out of the cancellous bone fragments? Should we add synthetic composite? Since this successful intervention, we now offer this procedure to patients presenting with clavicle nonunion but advise them that the chances of success are unknown at this time and that failure to cure may imply another surgery. We suspect that this technique may not be suitable for all nonunion cases. Further trials will help select the best candidates for this technique (young vs old patients, atrophic nonunion versus hypertrophic nonunion, smokers vs nonsmokers, and so on). We are
J Shoulder Elbow Surg January/February 2007
also planning on performing the procedure in the operating room but with patients under local anesthesia. We will use a bone marrow biopsy needle to collect bone marrow and fragments of cancellous bone. The needle is slightly larger and will allow us to push the cancellous bone fragments into the nonunion site. No stitching over the iliac crest will be necessary. Because of potential complications such as puncture of the subclavian artery or vein and pneumothorax, we believe that the operating room remains the safest place in which to perform this technique. Bone marrow injection for the treatment of clavicle nonunion is promising. We believe that the low morbidity and preliminary success of this technique justify further trials. REFERENCES
1. Bradbury N, Hutchinson J, Hahn D, Colton CL. Clavicular nonunion. 31/32 healed after plate fixation and bone grafting. Acta Orthop Scand 1996;67:367-70. 2. Connolly JF. Injectable bone marrow preparations to stimulate osteogenic repair. Clin Orthop Relat Res 1995:8-18. 3. Connolly JF, Guse R, Tiedeman J, Dehne R. Autologous marrow injection as a substitute for operative grafting of tibial nonunions. Clin Orthop Relat Res 1991:259-70. 4. Connolly JF, Guse R, Tiedeman J, Dehne R. Autologous marrow injection for delayed unions of the tibia: a preliminary report. J Orthop Trauma 1989;3:276-82. 5. Dahir GA, Cui Q, Anderson P, Simon C, Joyner C, Triffitt JT, et al. Pluripotential mesenchymal cells repopulate bone marrow and retain osteogenic properties. Clin Orthop Relat Res 2000; (Suppl):S134-45. 6. Der Tavitian J, Davison JN, Dias JJ. Clavicular fracture non-union surgical outcome and complications. Injury 2002;33:135-43. 7. Ebraheim NA, Mekhail AO, Darwich M. Open reduction and internal fixation with bone grafting of clavicular nonunion. J Trauma 1997;42:701-4. 8. Healey JH, Zimmerman PA, McDonnell JM, Lane JM. Percutaneous bone marrow grafting of delayed union and nonunion in cancer patients. Clin Orthop Relat Res 1990:280-5. 9. Hoe-Hansen CE, Norlin R. Intramedullary cancellous screw fixation for nonunion of midshaft clavicular fractures. Acta Orthop Scand 2003;74:361-4. 10. Laursen MB, Dossing KV. Clavicular nonunions treated with compression plate fixation and cancellous bone grafting: the functional outcome. J Shoulder Elbow Surg 1999;8:410-3. 11. Li Y, Shi S, Liu Z, Li Z, Wang R, Guo Y, et al. Treatment of humeral shaft nonunion with interlocking nail and percutaneous injection of bone marrow [in Chinese]. Zhonghua Wai Ke Za Zhi 2000; 38:732-5, 42. 12. Ma HL, Chen TH, Hung SC. Development of a new method in promoting fracture healing: multiple cryopreserved bone marrow injections using a rabbit model. Arch Orthop Trauma Surg 2004; 124:448-54. 13. Marti RK, Nolte PA, Kerkhoffs GM, Besselaar PP, Schaap GR. Operative treatment of mid-shaft clavicular non-union. Int Orthop 2003;27:131-5. 14. Matsuda Y, Sakayama K, Okumura H, Kawatani Y, Mashima N, Shibata T. Percutaneous autologous bone marrow transplantation for nonunion of the femur. Nippon Geka Hokan 1998;67:10-7. 15. Neviaser RJ, Neviaser JS, Neviaser TJ, Neviaser JS. A simple technique for internal fixation of the clavicle. A long term evaluation. Clin Orthop Relat Res 1975:103-7. 16. Olsen BS, Vaesel MT, Sojbjerg JO. Treatment of midshaft clavicular nonunion with plate fixation and autologous bone grafting. J Shoulder Elbow Surg 1995;4:337-44. 17. Sim R, Liang TS, Tay BK. Autologous marrow injection in the treatment of delayed and non-union in long bones. Singapore Med J 1993;34:412-7.