Download - Neiman 2
-
7/30/2019 Neiman 2
1/2
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:[email protected]
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
mailto:[email protected]:[email protected] -
7/30/2019 Neiman 2
2/2
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
020207
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Hernigou+P%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Mathieu+G%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Poignard+A%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Manicom+O%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Beaujean+F%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Rouard+H%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Rouard+H%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Beaujean+F%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Manicom+O%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Poignard+A%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Mathieu+G%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Hernigou+P%22%5BAuthor%5D