title: Outcomes and complication rates of different bone grafting modalities in long bone fracture nonunions: a retrospective cohort study in 182 patients.
abstract: BACKGROUND
  Novel bone substitutes have challenged the notion of autologous bone grafting as the 'gold standard' for the surgical treatment of fracture nonunions. The present study was designed to test the hypothesis that autologous bone grafting is equivalent to other bone grafting modalities in the management of fracture nonunions of the long bones.
  
  
  METHODS
  A retrospective review of patients with fracture nonunions included in two prospective databases was performed at two US level 1 trauma centers from January 1, 1998 (center 1) or January 1, 2004 (center 2), respectively, until December 31, 2010 (n = 574). Of these, 182 patients required adjunctive bone grafting and were stratified into the following cohorts: autograft (n = 105), allograft (n = 38), allograft and autograft combined (n = 16), and recombinant human bone morphogenetic protein-2 (rhBMP-2) with or without adjunctive bone grafting (n = 23). The primary outcome parameter was time to union. Secondary outcome parameters consisted of complication rates and the rate of revision procedures and revision bone grafting.
  
  
  RESULTS
  The autograft cohort had a statistically significant shorter time to union (198 ± 172-225 days) compared to allograft (416 ± 290-543 days) and exhibited a trend towards earlier union when compared to allograft/autograft combined (389 ± 159-619 days) or rhBMP-2 (217 ± 158-277 days). Furthermore, the autograft cohort had the lowest rate of surgical revisions (17%) and revision bone grafting (9%), compared to allograft (47% and 32%), allograft/autograft combined (25% and 31%), or rhBMP-2 (27% and 17%). The overall new-onset postoperative infection rate was significantly lower in the autograft group (12.4%), compared to the allograft cohort (26.3%) (P < 0.05).
  
  
  CONCLUSIONS
  Autologous bone grafting appears to represent the bone grafting modality of choice with regard to safety and efficiency in the surgical management of long bone fracture nonunions.
authors.affiliation: Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado Denver, School of Medicine, 777 Bannock Street, Denver, CO 80204, USA. philip.stahel@dhha.org.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Flierl
authors.forename: Wade R
authors.initials: WR
authors.lastname: Smith
authors.forename: Cyril
authors.initials: C
authors.lastname: Mauffrey
authors.forename: Kaan
authors.initials: K
authors.lastname: Irgit
authors.forename: Allison E
authors.initials: AE
authors.lastname: Williams
authors.forename: Erin
authors.initials: E
authors.lastname: Ross
authors.forename: Gabrielle
authors.initials: G
authors.lastname: Peacher
authors.forename: David J
authors.initials: DJ
authors.lastname: Hak
authors.forename: Philip F
authors.initials: PF
authors.lastname: Stahel
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D055396:Bone Morphogenetic Protein 2 / Q000627:therapeutic use; D016025:Bone Transplantation / Q000009:adverse effects / Q000379:methods*; D005260:Female; D005264:Femoral Fractures / Q000601:surgery; D017102:Fracture Healing; D005599:Fractures, Ununited / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000601:surgery*; D006801:Humans; D006810:Humeral Fractures / Q000601:surgery; D008297:Male; D008875:Middle Aged; D011184:Postoperative Period; D011859:Radiography; D011994:Recombinant Proteins / Q000627:therapeutic use; D012086:Reoperation / Q000379:methods; D012189:Retrospective Studies; D013978:Tibial Fractures / Q000000981:diagnostic imaging / Q000601:surgery; D014182:Transplantation, Autologous / Q000009:adverse effects / Q000379:methods; D014184:Transplantation, Homologous / Q000009:adverse effects / Q000379:methods; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: C525718:BMP2 protein, human; D055396:Bone Morphogenetic Protein 2; D011994:Recombinant Proteins
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