Table 2 Summary of literature review

Calori, 2013 [9]

Forearm:

19 radius

26 ulna

6 both

1 Monteggia

To assess efficacy of ‘monotherapy’ versus ‘polytherapy’ (diamond concept) in non-union

Retrospective cohort study:

Mono: n = 33, poly: n = 19

Non-union risk profiles:

NUSS score: mono: 36 ± 8.88, poly: 58.84 ± 9.44

Mx:

Both: debridement ± metalwork revision (stability)

Monotherapy Mx: ABG/MSC/BMP7/ABG or synthetic bone matrix

Polytherapy Mx: BMP7 + MSCs + ABG (53%) or synthetic bone matrix

Clinical:

3.65

Radiological:

6.18

Radiological union: mono: 63.6%, poly ‘diamond’: 89.5%

Time to union: Clinical union (months):*

mono: 5.29, poly ‘diamond’: 3.65

Radiological union (months):*

mono 8.43, poly ‘diamond’: 6.18

Miska, 2016 [12]

Humerus

To assess if individualising treatment for non-union based on diamond concept and risk score is effective

Retrospective cohort study: n = 50, Age 51.3 years (14–88)

Non-union risk profiles:

Mean Moghaddam scores: treated with BMP-7: 16.5, without BMP-7: 12.6, p = 0.83

Previous interventions: mean 1.5 (1–8)

Mx:

According to risk, individual aspects of diamond addressed:

Low–moderate risk: debridement and re-osteosynthesis only

Infected cases: two-stage Masquelet

If large defects > 2 cm or devitalised tissue:

Debridement ± BMP-7 ± RIA (MSCs, scaffold) from femur or iliac crest ABG ± re-osteosynthesis with stable plate (90%)

≥ 12

6

Radiological union: overall: 80.4%, those who received BMP-7: 6/8 (75%)

Patients successful in union much younger (46.6 ± 17.5 versus 62.4 ± 16.5 years), p = 0.031*

Risk scores: did not predict non-union

Only 6 patients managed with plate/cancellous bone/BMP-7. No MSCs used. No specific data given for these in terms of union rates compared with others

Giannoudis, 2015 [3]

Multiple site: femur (54.68%)

tibia (34.38%)

radius (3.13%)

clavicle (3.13%)

To assess efficacy of long bone non-union treated with the ‘diamond concept’

Prospective cohort study:

n = 64. Age 45 (17–83)

Non-union risk profiles:

All had at least 1 significant comorbidity, 65.63% suffered high-energy initial injury

17% initially open fractures.

≥ 1 previous interventions (1–5) in 43.75%

Mx:

Debridement + metalwork revision + Iliac crest BMAC (MSCs) + BMP-2 (5%) or BMP-7 (95%) + RIA contralateral femur for ABG (scaffold and osteogenic cells)

12 (12–32)

6 (3–12)

Radiological union: 63/64 (98%) by 12 months

Giannoudis, 2013 [4]

Femur: subtrochanteric

To assess clinical outcome of diamond concept in patients with IM nails in non-union surgery

Retrospective cohort study:

n = 14. Age 65 (33–92)

High-energy fracture in 4 patients

Mx: Debridement + blade plate or revision IM nail + RIA contralateral femur for ABG (scaffold and osteogenic cells) + BMP-7 + BMAC (MSCs) from iliac crest, watertight closure in layers

26 (16–48)

6.8 (5–12)

Using the ‘complete diamond’ for all patients: Radiological union: 13/14 (92%)

Goff, 2014 [8]

Proximal femur

(intertrochanteric)

To assess efficacy of diamond concept in challenging case of infected femoral non-union

Case report

n = 1, Age 31, male.

Hx and risk profile: 11 months following well-sited DHS for high-energy intertrochanteric fracture (RTA). Fit and healthy, non-smoker

Mx: Masquelet technique:

Stage 2 (at 2 months): Debridement, RIA contralateral femur for ABG (scaffold and osteogenic cells) + BMP-7 composite graft + removal of ex-fix and application of blade plate

6

Radiological union: 6 months

Clinical union: 6 months

Haubruck, 2018 [6]

Lower limb

69 femur

87 tibia

To assess which is superior in non-union surgery: BMP-2 or BMP-7

Retrospective case–control study: n = 156, Age 51 (18–64)

Mx:

One stage: limited + no infection

Two stage: (Masquelet technique): significant bone loss ± signs of infection

Both: debridement + metalwork revision + ABG (MSCs, scaffold) + BMP-2 or BMP-7

No concentrated BMA used

≥12

No data provided

Radiological union:* BMP-2: 42/46 (91%), BMP-7: 64/110 (58%)

Femur union: BMP-2: 11/14 (79%), BMP-7: 33/55 (60%)

Tibia union:* BMP-2: 31/32 (97%), BMP-7:24/55 (44%)

One stage: BMP-2: 7/8 (88%), BMP-7: 35/50 (70%)

Two stage:* BMP-2: 35/38 (92%), BMP-7: 29/60 (48%)

Ollivier, 2015 [13]

Tibia

To assess whether bone grafting essential as part of diamond concept for recalcitrant tibia non-union

Retrospective cohort study: n = 20, Age 46.8 (21–78)

Non-union risk profiles:

open fractures: 8, smokers: 5.

Mx:

Debridement + metalwork revision + implant composite graft (BMP and injectable rCPBS)

No MSCs/BMAC used

5 ± 2.3 (3–9)

Radiological union: 18/20 (90%): 12 had consolidated by 3 months, and 18 by 6 months

Micro: nil significant

Did not use all parts of diamond concept: no osteogenic MSC cells harvested or implanted

Moghaddam, 2015 [10]

Tibia

To assess outcomes of single-stage (G1) versus two-stage (Masquelet) repair (G2) methods in tibial non-union

Prospective cohort study: n: G1 = 52, G2 = 50. Age 47 ± 13.1 (15–76)

Previous interventions: G1: 3.2, G2: 6.7

Non-union risk profiles: open fractures: 44, fracture gap: 2.6 ± 3.4 cm

Moghaddam score:* G1: 13.8 ± 8.5, G2: 19.5 ± 9.5

NUSS score:* G1: 38.3 ± 11.7, G2: 48.2 ± 10.3

Mx:

G1: bone loss < 1 cm (mean 0.9 cm) + no infection

G2: bone loss > 1 cm (mean 4.0 cm) + signs of infection (Masquelet technique)

Both: debridement ± metalwork revision (97%), RIA (MSCs, scaffold) from femur (77%) or iliac crest ABG (23%) + BMP-7 + tricalcium phosphate

G1: 6.9 ± 3.1

G2:* 8.6 ± 2.9

Overall: 7.8 ± 3.1

Radiological union: G1: 84%, G2: 80%

Douras, 2018 [7]

Ankle: medial malleolus

To assess efficacy of diamond concept in medial malleolus non-union

Case report, n = 1 Age 20

Hx: 8 months following: Gustilo IIIb open bimalleolar fracture dislocation ORIF and free flap

Non-union mx:

Debridement + metalwork revision with cancellous screws and locking plate + BMAC (MSCs) and ABG (scaffold, MSCs) from iliac crest + BMP-2

6

Radiological union: by 6 months

Clinical union: by 3–6 months (fully WB)

Complications: none