title: Radiological assessment of the PRF/BMSC efficacy in the treatment of aseptic nonunions: A retrospective study on 90 subjects.
abstract: BACKGROUND
  Nonunion is a major orthopaedic concern because of treatment difficulty, high costs and devastating effects on the patients' life quality. Therefore, there is interest in the use of bone substitutes and cell-based strategies to augment fracture repair. We aimed to verify if Platelet Rich Fibrin (PRF) added with bone marrow stromal cells (BMSC) was able to improve the reparative process in the aseptic nonunion, and to establish whether it was worthwhile with atrophic nonunion. The primary outcome was radiological union. As secondary endpoint, the healing time was assessed, and the radiological consolidation grade at each follow-up.
  
  
  METHODS
  We identified 113 subjects with tibia or femur nonunion and retrospectively created two groups. Group A was constituted by 56 subjects who underwent the standard procedure, i.e. Judet decortication with/out internal fixation devices, and opposite cortical homoplastic stick. In 57 patients, the standard procedure was modified by adding PRF and BMSC carried by homologous lyophilised bone chips (group B). The same surgeon performed all the operations. To our knowledge, no data are reported in the literature about such application. Since a "gold standard" for healing quantification does not exist, a new scoring radiological system was applied, at 1.5, 3, 6, 12 and 24 months after treatment.
  
  
  RESULTS
  At the final 24-month follow-up, the radiological union percentage was 94,12 in group B and 95,12% in group A. A decreased healing time was demonstrated in the presence of PRF/BMSC in comparison with the standard procedure. When we compared the radiological scores at each follow-up, we found that the PRF/BMSC combination significantly improved the consolidation grade at 1.5-, 3- and 6-month follow-up in femurs and at 1.5-month follow-up in tibiae. Furthermore, an improved consolidation grade was demonstrated in the atrophic subjects treated with adjuvants compared to atrophic patients treated with the standard procedure at 1.5-month follow-up.
  
  
  CONCLUSIONS
  This study supports the concept that the use of PRF/BMSC, during the standard procedure, is effective in shortening nonunion healing time. It could allow an early mobilization of patients, minimizing suffering, and could be an effective tool to reduce the health-care costs resulting from this issue.
  
  
  METHODS
  Therapeutic level III.
authors.affiliation: Conservative Surgery Orthopaedic and Innovative Techniques Unit, Department of Complex Orthopaedic-Trauma Pathology, Rizzoli Orthopaedic Institute, Bologna, Italy.
authors.forename: D
authors.initials: D
authors.lastname: Dallari
authors.affiliation: Conservative Surgery Orthopaedic and Innovative Techniques Unit, Department of Complex Orthopaedic-Trauma Pathology, Rizzoli Orthopaedic Institute, Bologna, Italy.
authors.forename: N
authors.initials: N
authors.lastname: Rani
authors.affiliation: Conservative Surgery Orthopaedic and Innovative Techniques Unit, Department of Complex Orthopaedic-Trauma Pathology, Rizzoli Orthopaedic Institute, Bologna, Italy. Electronic address: giacomo.sabbioni@gmail.com.
authors.forename: G
authors.initials: G
authors.lastname: Sabbioni
authors.affiliation: Conservative Surgery Orthopaedic and Innovative Techniques Unit, Department of Complex Orthopaedic-Trauma Pathology, Rizzoli Orthopaedic Institute, Bologna, Italy.
authors.forename: A
authors.initials: A
authors.lastname: Mazzotta
authors.affiliation: Service of Immunohematology and Transfusional medicine, Rizzoli Orthopaedic Institute, Bologna, Italy.
authors.forename: A
authors.initials: A
authors.lastname: Cenacchi
authors.affiliation: Orthopaedic Pathophysiology and Regenerative Medicine Unit, Department of Complex Orthopaedic-Trauma Pathology Rizzoli Orthopaedic Institute, Bologna, Italy.
authors.forename: L
authors.initials: L
authors.lastname: Savarino
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001860:Bone Plates; D001861:Bone Regeneration; D005260:Female; D005264:Femoral Fractures / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D005337:Fibrin / Q000627:therapeutic use*; D005593:Fracture Fixation, Internal / Q000379:methods*; D017102:Fracture Healing / Q000502:physiology; D005599:Fractures, Ununited / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D006801:Humans; D008297:Male; D045164:Mesenchymal Stem Cell Transplantation; D059630:Mesenchymal Stem Cells; D008875:Middle Aged; D011859:Radiography; D012189:Retrospective Studies; D013978:Tibial Fractures / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D005337:Fibrin
keywords: BMSC; Nonunion; PRF; Radiological grade