Highlights
- •This study demonstrate that the rate of unsuspected infection is high after tibial open fracture.
- •The high risk of late infection after grafting a nonunion with a standard graft is confirmed by this study.
- •An important finding of this study is the reduced rate of late infection in patients treated with early implantation of bone marrow concentrate graft.
Abstract
Introduction
Open fractures are at risk of nonunion; surgeons are reluctant to propose early standard
bone grafting after open fractures, preferring to wait in order to adequately assess
the facture status of infection. Bone marrow contains mesenchymal stem cells (MSCs)
and granulocyte and macrophage precursors identified in vitro as colony forming units-granulocyte
macrophage (CFU-GM), both of which have a prophylactic action against infection. We
therefore tested the hypothesis that early injection of bone marrow concentrate would
be useful in these fractures.
Methods
We evaluated a series of 231 patients who had received early percutaneous implantation
of bone marrow concentrate (BMC) to treat open fractures (with gap less than 10 mm)
that were Gustilo-Anderson Type II or III. The results were compared with those of
67 control (no early graft) patients and with those of 76 patients treated with an
early, standard of care, iliac bone graft. All patients were treated with external
fixation and were considered to have an aseptic fracture at the time of early grafting,
but the actual status of infection was re-assessed at the time of grafting by histology
and/or analysis of the aspirate. The bone marrow graft contained after concentration
49,758 ± 21,642 CFU-GM-derived colonies/cc and 9400 ± 1435 MSCs/cc which represents
an important increase compared to the level of CFU-GM cells and MSCs present in a
standard auto-graft. Healing was evaluated at 9 months.
Results
The rate of unsuspected infections was higher than 15% in the 3 groups. Bone union
and removal of external fixation was achieved at 9 months by 50.7% of patients in
the Control Group, by 86.8% of patients in the group with a standard bone graft, and
by 87.4% of patients in the bone marrow group. A 90% risk reduction (p = 0.005) in the need for an invasive standard bone graft to treat a nonunion and
in the risk of infection was observed when bone marrow was proposed as early injection
to the treatment of type II or type-III tibial fractures.
Conclusion
Bone marrow concentrate for early grafting in open fractures with limited gap was
efficient for healing while decreasing infection.
Keywords
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Article info
Publication history
Published online: December 31, 2020
Accepted:
December 14,
2020
Footnotes
This paper is part of a Supplement supported by the European Society of Tissue Regeneration in Orthopaedics and Traumatology (ESTROT).
Identification
Copyright
© 2020 Elsevier Ltd. All rights reserved.
