title: Management and outcome of diaphyseal aseptic non-unions of the lower limb: a systematic review.
abstract: OBJECTIVE
  To review current treatments utilising biological enhancement modalities and their efficacy for the management of lower limb long bone aseptic non-unions.
  
  
  METHODS
  A systematic review of English articles using PubMed Medline; Ovid Medline; Embase; and the Cochrane Library was performed, supplemented by a manual search of bibliographies.
  
  
  RESULTS
  Thirteen manuscripts met the inclusion criteria reporting on 428 patients. The overall healing had a pooled estimate of effect size at 94.3%. The calculated summarised estimate of effect size for deep infection rate (413 patients) was 2.3%. Three subgroups were then created on the basis of the exact type of graft used at the non-union site (ABG, BMP-7, BMP-7 + ABG). Comparison between the above subgroups revealed that ABG resulted in approximately 3-fold increase of the odds of healing compared with the use of BMP-7. Combined use of ABGs and BMP-7 improved the odds of healing by 3.5 times compared with BMP-7 alone. However, the previous median operations prior to the implantation of ABG or BMP-7 treatment was 1.09 versus 2.3 respectively (p = 0.02). Although the implantation of ABG was associated with a greater incidence of infection the documented differences did not reach significance.
  
  
  CONCLUSIONS
  Although ABG was found to have a higher success rate compared to BMP-7 (95% Vs 87%), patients treated with BMP-7 had a higher number of previous failed interventions, statistically significantly so (BMP-7 is used for the treatment of more recalcitrant non-unions). It is the surgeon's judgement that should determine the most suitable treatment modality, depending on the nature and characteristics (personality) of the non-union and the patient.
authors.affiliation: School of Medicine, University of Athens, Greece.
authors.forename: Spiros G
authors.initials: SG
authors.lastname: Pneumaticos
authors.affiliation: Leeds Teaching Hospitals, University of Leeds, United Kingdom.
authors.forename: Michalis
authors.initials: M
authors.lastname: Panteli
authors.affiliation: School of Medicine, University of Athens, Greece.
authors.forename: Georgios K
authors.initials: GK
authors.lastname: Triantafyllopoulos
authors.affiliation: "G. Hatzikostas" General Hospital, Ioannina, Greece.
authors.forename: Costas
authors.initials: C
authors.lastname: Papakostidis
authors.affiliation: Leeds Teaching Hospitals, University of Leeds, United Kingdom. Electronic address: pgiannoudi@aol.com.
authors.forename: Peter V
authors.initials: PV
authors.lastname: Giannoudis
mesh_terms: D018483:Diaphyses / Q000293:injuries; D019468:Disease Management; D017102:Fracture Healing; D005599:Fractures, Ununited / Q000601:surgery*; D006801:Humans; D035002:Lower Extremity / Q000293:injuries*; D019637:Orthopedic Procedures / Q000379:methods*; D016896:Treatment Outcome
keywords: Aseptic; Diaphysis; Femur; Long bones; Lower limb; Non-unions; Shaft; Tibia