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TREATMENT OF TIBIAL NONUNION AND DELAYED UNION BY PERCUTANEOUS INJECTION

OF CONCENTRATED AUTOLOGOUS STEM CELLS:AN ALTERNATIVE TO OPEN SURGICAL REPAIR A CASE REPORT

RafaelNeiman,MDOrthopedicTraumaSurgeonsofNorthernCalifornia

151NorthSunriseAve.,1005Roseville,CA95661

(916)782-1217E-Mail:neiman3@yahoo.com

CASE HISTORY:A49YOnon-smokingfemalewithceliacdiseasesustainedbilateralspiralobliquetibiafractureswhileskiing.Initialtreatmentinvolvedintramedullaryfixation.

Fig.1

Sevenmonthspost-injury,patientstillreportsbilateralleg

pain(R>L).X-raysshoweddelayedunioninthelefttibiawithminimalcallusformation(Radiograph:Figure1)whiletherighttibiashowednoevidenceofcallusformationandalargeanteriorfracturegap.Opensurgicalrepairwithexchangenailingwasofferedbutthepatientpreferredlessinvasiveoptions.Patienthasusedanexternalbonegrowthstimulatorforthreemonthswithnosignificantchange.

Fig.1REATMENT OPTIONS:1. Reamedexchangenailing.2. Openreductionandinternalfixation(ORIF)aftertake-downofnonunionandiliaccrestorother

autologousbonegraft.3. Percutaneousinjectionofconcentratedautologousstemcellsfrombonemarrowaspirateconcentrate.

TREATMENT PLAN:Atsixmonthspost-injurythepatienthasadelayedunionofthelefttibiaandanonunionoftherighttibia,withpersistentpainandareluctancetoopensurgicalrepair.Sincethepatientwasanon-smoker,satisfactorynutritionalstatus,andhadreasonableexpectations,withskinandlocaltissuesingoodconditionandadequatelimbalignment,thedecisionwasmadetopursuetheleastinvasiveintervention.Bonemarrowtakenfromtheiliaccrestwasconcentratedtoproduceahighdoseofautologousstemcells(bonemarrowaspirateconcentrate-BMAC)andwaspercutaneouslyinjectedintothetibialfracturenonunionsites.Thistreatmentmodalityhasbeenshowntohealtibialnonunions 1.Efficacyappearstoberelatedtothetotalnumberofprogenitorcellsdeliveredtothenonunionsite.Inhealingimpairedpatients,bonemarrowaspiratealoneorwithinadequateconcentration 1,2,3,4,isnotastherapeuticallyeffectiveasBMACduetolower

numbersofprogenitorcellsdeliveredtothefracturesite.MATERIALS AND METHODS:AfterpreppingthebonemarrowaspirationkitcomponentsandfollowingGeneralAnesthesia,asingleincisionwasmade2cmposteriortotheanteriorsuperioriliacspineoneachiliaccrest.An11gmultiportbonemarrowaspirationneedlewithstyletinplacewasintroducedatthesuperioraspectoftheiliaccrest.Theneedlewasadvanced4to6cmintothebonecavity.Thestyletwasremovedandanaspirationsyringewasattachedtothehuboftheneedle.Marrowwasaspiratedbyshortquickpullsonthesyringewhichallowed4to5mLmarrowtobeaspiratedforeachpullonthesyringe.Theneedlewaswithdrawnapproximately2cmandrotated90degreesandtheprevioussteprepeated.Whenthesyringe

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containedapproximately15mLofmarrow,thesyringewasremovedfromtheneedleandthemarrowwasinjectedintoasterilebloodbagcontainingananticoagulant.Thesestepswererepeated(twoiliaccrestneedlepunctures)until120mLofbonemarrowwasharvested.Thetotalbonemarrowaspirationtimewasapproximately15minutes.ThebonemarrowwasthenplacedintotheSmartPRePBMAC(HarvestTechnologiesCorp.Plymouth,MA)disposablecontainersforprocessing.Approximately15minuteslater,20mLofbonemarrowaspirateconcentratewasavailableforinjection.

An18gneedlewasusedtopercutaneouslyinjectBMACintoandsurroundingthefracturenonunionsites,usingfluoroscopytoverifyneedleplacement.ThepatienttoleratedboththebonemarrowaspirationandtheBMACinjectionswell.Followingsurgery,thepatientwasinstructedtoremainnon-weightbearingfor4weeksandremainedimmobilizedinremovableshortlegboots.RESULTS:Duringfollow-upvisits,patientreportedlesspain.Palpationoftheanteriorrighttibiaproducedsometenderness.Goodrangeof

motionwaspresentinthekneeandankle.X-raysobtainedfourweekslatershowconsolidationofthelefttibiaandsignificantnewcallusformationoftherighttibia.Uponfurtherfollow-up4weekslater(eightweekspostBMACtreatment),patientreportsminimalpain.X-raysshowrighttibiahashealed,althougha

spikeofbonehasinterposedfibroustissuethatcontinuestohealbutwithnoclinicalsymptoms(Radiograph:Figure2).Thepatienthasnowreturnedtounlimitedactivity.

Fig.2

CONCLUSION:IthasbeenwidelyreportedbyConnolly,Gangji 5,Hernigouandothersthatpercutaneousdeliveryofahighconcentrationofadultstemcellscanenhancetherateandamountofboneformation.Inmyexperience,theHarvestBMACsystem(bonemarrowaspirateconcentrate),hasallowedmetoquicklyandeffectivelyproduceatherapeuticdoseofadultstemcellsatthepatientbedsidethatresultedinimprovedhealing.Percutaneousinjectionofhighdosestemcellsmayofferthesurgeonandpatientanewtherapeuticoption

whentreatingtroublesomenonunionsordelayedhealingfractures.1HernigouP,MathieuG,PoignardA,ManicomO,BeaujeanF,RouardH.;Percutaneousautologousbone-marrowgraftingfornonunions.SurgicalTechnique.JBoneJointSurgAm.2006Sep;88Suppl1Pt2:322-7

2Hernigou,P,etal,PercutaneousAutologousBone-MarrowGraftingforNonunions:InfluenceoftheNumberandConcentrationofProgenitorCells, JournalofBoneandJointSurgery,2005;87-A;1430-1437

Fig.2

3 LiebermanJR,Commentary& Perspective onPercutaneousAutologousBoneMarrowGraftingfor Nonunions byHernigouP et al,Journalof Boneand JoinSurgery,2005;87-A;1430-1437;eJBJS,July20054Connolly,JF,etal,DevelopmentofanOsteogenicBone-MarrowPreparation,JournalofBoneandJointSurgery,June1989;684-691

5GangjietalTreatmentofOsteonecrosisoftheFemoralHeadwithImplantationofAutologousBone-MarrowCells. JournalofBoneandJointSurgery,2004JuneN686-A;1153-1160

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