Ann Thorac Surg 2008;85:e12-e13. doi:10.1016/j.athoracsur.2007.11.006
© 2008 The Society of Thoracic Surgeons
How To Do It
Treatment of Chronic Nonunion of a Sternal Fracture With Bone Morphogenetic Protein
Anthony Morgan, MA, FRCS*
Department of Thoracic Surgery, Bristol Royal Infirmary, Bristol, United Kingdom
Accepted for publication November 5, 2007.
* Address correspondence to Dr Morgan, Department of Thoracic Surgery, Bristol Royal Infirmary, Marlborough St, Bristol, BS2 8HW, United Kingdom (Email: anthony.morgan{at}ubht.nhs.uk).
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Abstract
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Chronic nonunion of sternal fractures, up until now, has been treated by osteosynthetic plating with or without autologous bone grafting. A new technique is described involving the use of bone morphogenic protein to stimulate bone growth at the fracture site, thereby eliminating the need for bone grafting.
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Introduction
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Nonunion of sternal fractures is the most common after median sternotomy [1]. However, in a small number of cases it follows traumatic injury, and in someone whose living depends on supreme physical fitness, it is of huge financial importance.
A 26-year-old professional Rugby football player suffered a transverse fracture of the sternum in March 2005 by falling chest down on the knee of an opponent. He complained of considerable pain after the incident, and a chest roentgenogram showed a transverse fracture of the sternum. He was treated conservatively since he was such a fit sportsman, as it was expected that he would heal quickly. After 3 months, serial roentgenograms had shown no sign of union or callus formation. Internal fixation offered the chance of rapid fixation and fracture healing.
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Technique
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At operation, the sternal fracture was exposed and the bone ends freshened with a rotary drill. After accurate repositioning of the two sternal edges with fixating clamps, a Sternaloc (Lorenz Surgical Inc, Jacksonville, FL) titanium eight-hole plate was positioned across the fracture secured by 2.7 x 12 mm screws. The postoperative recovery was unremarkable. Sternal roentgenograms taken 10 weeks later showed good apposition of the sternal ends, but no sign of callus or union. As his career depended on physical fitness and healing of the sternum, it was decided to try to stimulate bone growth and healing by using bone morphogenetic protein.
At the second operation, the Sternaloc plate was found to be in an optimal position and not in any way loose. Using a high-speed precision rotary drill, the bone ends of the sternum were freshened to provide room for the collagen sponge, which had been soaked with 12 mg of Dibotermin alpha. (InductOs [Wyeth Pharmaceuticals, Taplow Berks, UK]).The postoperative phase was unremarkable and nonsteroidal anti-inflammatory medication was avoided.
A computed tomographic scan performed 4 months later showed complete healing of the fracture with extensive new bone formation, and shortly afterwards the patient resumed his career as a professional Rugby football player.
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Comment
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Most sternal nonunion is a result of cardiac surgery and involves a median sternotomy [1]. Transverse sternal fractures are much less common, and plating has been proposed as the optimal method [2, 3] with or without autologous bone grafting [4]. This is associated with a separate incision and possible complications at the donor site, which in a young athlete would be undesirable. Bone morphogenic protein is a genetically engineered recombinant version of a naturally occurring protein that enhances bone healing. It is supplied as a freeze dried powder that is reconstituted and applied to an absorbable collagen sponge that is wedged between the two faces of the fracture. The use of bone morphogenic protein was first reported in clinical fracture fixation in a man in 1988 [5]. Since then it has been used in a number of areas [6, 7]. Orthopedic surgeons are the main users for acute tibial shaft fractures, and in the United Kingdom it is used by spinal surgeons to promote bone healing after spinal fusion.
No report of its use in nonunion of sternal fractures has been found by the author. Although it is expensive, the return of a young professional sportsman to his full earning potential more than justifies the cost. Whether this would be justified in the case of an elderly osteoporotic fracture is a question for each individual healthcare system to decide.
Faced with nonunion of a transverse sternal fracture that has been osteosynthetically treated, the addition of bone morphogenic protein would seem to be effective by eliminating the need for autologous bone grafting.
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References
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- Loop FD, Lytle BW, Cosgrove DM, et al. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity and cost of care Ann Thorac Surg 1990;49:179-187.[Abstract]
- Hendrickson SC, Kroger KE, Morea CJ, et al. Sternal plating for the treatment of sternal non-union Ann Thorac Surg 1996;62:512-518.[Abstract/Free Full Text]
- Wu LC, Renucci J, Song DH. Rigid-plate fixation for the treatment of sternal non-union J Thorac Cardiovasc Surg 2004;128:623-624.[Free Full Text]
- Bertin KC, Rice RS, Doty DB, Jones KW. Repair of transverse sternal nonunions using metal plates and autogenous bone graft Ann Thorac Surg 2002;373:1661-1662.
- Johnson EE, Urist MR, Finerman GA. Bone morphogenetic protein augmentation grafting of resistant femoral nonunions: a preliminary report Clin Orthop Relat Res 1988;230:257-265.[Medline]
- Westerhuis RJ, van Bezooijen RL, Kloen P. Use of bone morphogenetic proteins in traumatology Injury 2005;36:1405-1412.[Medline]
- McKee MD. Recombinant human bone morphogenetic protein-7: applications for clinical trauma J Orthop Trauma 2005;19(Suppl 10):S26-S28.[Medline]
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Abstract
Introduction
