Treatment of Chronic Nonunion of a Sternal Fracture With Bone Morphogenetic Protein

doi:10.1016/j.athoracsur.2007.11.006

The Annals of Thoracic Surgery

Volume 85, Issue 2, February 2008, Pages e12-e13

https://doi.org/10.1016/j.athoracsur.2007.11.006 Get rights and content

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.

Section snippets

Technique

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 × 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

Comment

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

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There are more references available in the full text version of this article.

Cited by (8)

Treatment of Chronic Nonunion of a Sternal Fracture With Teriparatide
2021, Annals of Thoracic Surgery
Citation Excerpt :
Successful attempts to use bone anabolic drugs for sternal nonunion have been published. Morgan7 reported a single case involving the local application of an absorbable collagen sponge with bone morphogenic protein-2 during surgery. In a more recent case report, Chintamaneni and associates8 reported a successful outcome of sternal fracture nonunion with teriparatide in a male patient with normal bone mass.
Role of Prx1-expressing skeletal cells and Prx1-expression in fracture repair
2020, Bone
Citation Excerpt :
There is compelling evidence that BMP2 has a critical role in fracture repair, including failed fracture repair in mice with BMP2-deficient osteochondroprogenitor cells [28–31]. Furthermore, BMP2 levels are reduced in fracture biopsies from patients with non-unions, and exogenous BMPs have some beneficial effects in treating non-unions [32–34]. We previously reported that in BMP2-haploinsufficient mice failure of proper fracture healing is associated with a disarranged increase of chemokine C-X-C motif-ligand-12 (CXCL12) expressed by pericytic cells [13].
The healing capacity of bones after fracture implies the existence of adult regenerative cells. However, information on identification and functional role of fracture-induced progenitors is still lacking. Paired-related homeobox 1 (Prx1) is expressed during skeletogenesis. We hypothesize that fracture recapitulates Prx1's expression, and Prx1 expressing cells are critical to induce repair. To address our hypothesis, we used a combination of in vivo and in vitro approaches, short and long-term cell tracking analyses of progenies and actively expressing cells, cell ablation studies, and rodent animal models for normal and defective fracture healing. We found that fracture elicits a periosteal and endosteal response of perivascular Prx1+ cells that participate in fracture healing and showed that Prx1-expressing cells have a functional role in the repair process. While Prx1-derived cells contribute to the callus, Prx1's expression decreases concurrently with differentiation into cartilaginous and bone cells, similarly to when Prx1+ cells are cultured in differentiating conditions. We determined that bone morphogenic protein 2 (BMP2), through C-X-C motif-ligand-12 (CXCL12) signaling, modulates the downregulation of Prx1. We demonstrated that fracture elicits an early increase in BMP2 expression, followed by a decrease in CXCL12 that in turn down-regulates Prx1, allowing cells to commit to osteochondrogenesis. In vivo and in vitro treatment with CXCR4 antagonist AMD3100 restored Prx1 expression by modulating the BMP2-CXCL12 axis. Our studies represent a shift in the current research that has primarily focused on the identification of markers for postnatal skeletal progenitors, and instead we characterized the function of a specific population (Prx1+ cells) and their expression marker (Prx1) as a crossroad in fracture repair. The identification of fracture-induced perivascular Prx1+ cells and regulation of Prx1's expression by BMP2 and in turn by CXCL12 in the orchestration of fracture repair, highlights a pathway in which to investigate defective mechanisms and therapeutic targets for fracture non-union.
Rugby player with an «elephant's foot» in the chest
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Treatment of posttraumatic sternal non-union with a locked sternum-osteosynthesis plate (TiFix)
2011, Injury
Citation Excerpt :
Plate osteosynthesis with two or more parallel plates has been reported4,8 with unsatisfactory results. Some authors suggested the use of bone morphogenetic protein12 or additional suture anchors.5 The case numbers of the above described methods vary between one to seven, reported restrictions and complications are sparse.
Only a minority of sternal fractures require osteosynthesis. Unstable non-union of the sternum is a very disabling condition which often requires treatment. The method most often used is tension-wiring. Due to loosening of the tensile strength or wire cut-out, this method often fails. We report the results of locked plate osteosynthesis of sternal non-union and displaced fractures.
Over a five-year period, 12 patients have been treated using this method in a multicentre trial. Mean age at trauma was 32.8 years, the implant used in all cases was an 8-hole titanium plate, the fixation of the screws is based on the principles of angular stable fixation.
In all cases the index procedure was possible, in all cases there was bony healing at follow-up examination.
Multidirectional locked plating offers a reliable method for the successful treatment of sternal non-union and displaced fractures.
Stabilisation of chronic flail chest: A novel approach of surgical fixation and osteogenesis
2009, Thorax
Surgical management of traumatic sternal body nonunions: Technical tricks and clinical experience
2023, Journal of Trauma and Acute Care Surgery

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How to do itTreatment of Chronic Nonunion of a Sternal Fracture With Bone Morphogenetic Protein

Section snippets

Technique

Comment

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

How to do it
Treatment of Chronic Nonunion of a Sternal Fracture With Bone Morphogenetic Protein