fimudrf,unriu Original Article

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Medullary Bone Grafting by HA Bone Substitute in The Treatment of

Closed Femoral Shaft Fracture

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Chote pawasuttikul M.D.

Department of Orthopedics Surgery

Sawanpracharak Hospital

Nakhon Sawan

Sawanpracharak Medical journal

VoL S No. 3 September-December zo11ilfi a ofiufi s ffuuruu-#uatnru zmn

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UTIFI9IUO

Ad: n\ a FI n ul eJ afl o n nl: nr:rl a n rit u n:rn n tfi fl il'Lull,'l:.: n :tqr nlu nr :inr*rh n'qlqtru

n:rnnfruzT d'nrruuilBr(U

nciru.:rurinfln::uaailoflfindI:.,:lla1U1ad?:rrirhtfrind o-.:m{nrun:ar::d'q

prospective cohort studY

rid r s n :r Br n fr ut T r.t"n q r n a f6 ru n a :1 a : fi rfl T iu n

T :in ur"[ul:.,l v.t El'l U'] aqlclqq

ar::ri'r.l:rtrind rY..:uri 1 iln:lneJ 2553 6.r SO furrnru Zsildruru 31 nu

fir-hudtfi#unr:ifiqq-ur{lu Closed fracture shaft of femur mi.:il:vunnnrru

OTA classification tfiBr et 42 A3 81 82 utas CZ inr+rlBranr:rild'Br

ORIF with Broad DCP uarnrumat{Br6s.:n:tornrrfirtrifida.:'jr.r (cortical

od, ld,'

defects) erLtuntdu z n{u6a n{r.rfrtfiiunr:rJqnrilunrenn HA bone

Ioruif medullary gratt 'LuuiL?fun:eanvin t 2 Au unvnrielfrtritfiiun'r:

rla n rir a nryn n 1 9 nu :ru:l ru{a ru ayi'rltl fra U amr.: n ff fi n fr a ry n n1:;nul-qi--- '-'' cl ' $ .u {

unyfi nntelzunnt:fnr+rtfluural 6-1 z tdau irn:rrviflorynfrrudAA.u

Atv,il;'ddv[T{v\:TrUU't Ft1:O U Ar pir uqd u eiru tu tt.t tuuil1 a:6ru til:tttl 111 UU n fl 1*rUu

vr'rlrhat nri ru rlia dT,,: fir a nr:n n fl outn d ttnri unrtil5uu rfi uITYfl rL? a1q

n r:Ufiarufr pmoin:ran InunrmorAaufi fi:tpYunnrur"fiax"utrifiafl n'ir5aflav gs

1* 'n' o'''un;uu U"t6"tottndt'Odtt

ruanr:finur : {r_rruvy.:aarnrirufi#nururvTrlrJ"riumnriT .:fiu n{r.i4rtqnriran:v,n HA

r ad 6t e1 j q r:rfiaufin?Ja.lfl:rnfl

bone loruiE medullary graft "L{:ru;t'lnlLoau Lun

tz+.olto.g iu (fid'er 84-152 {u1 :rurtrarfiqnrru{rJrauader 8'2t1'9

,a * n 4udtri fi nr:r-t a n rir u n:r* n'lfi:rarur ar uad ulu nT :ufr a ru fi orta{fl :sn n

tgo.+t2O.Z {u (fid'fl nr-,un iu; :raruraT fiornrrufir"hauofia 9'011'g u6au

:s a, ur n r1, n.'' r rfr , u ff or riut a I n :, ot nlot ai 6 n r :in r*Ttl a a ti dtri fi n Tr ru

urn n rir.: riu (p:0. 362) tri l lun'p"rrr- nfi au'Lor 1'[u {r'lr avYl a a': n { r'r

?or:ai*avaqrl : {rJrun:yornfiutrri'nuruuilnr tfinr nt A2 A3 81 B2 uav C2 1t435fl141

fir ui6 oRr F with Broad Dcp fi n.r ara a'.:o'or 6m n:ror n udrfi u6r1il fi davirrjg,,

d.u.n:nilanrirAn:rnn HA bone Inaif medullary graft uflanryFlunlr

rfi a il fi or riur a l n :r or nlfiIn uhi lnr u fl '1 1 3 LLm l fl fr a ul or "1

Obiective

Setting

Design

Subiects

Method

Abstract

I To study result of closed femoral shaft fracture treatment by oRlF

withbroadDCPandmedullarybonegrafiingbyHAbonesubstitutes.

l Department of orthopaedics Surgery' Sawanpracharak hospital, Nakorn

Sawan

I A ProsPective cohort study'

: Thirty-one of closed femoral shaft fracture patients in sawanpracharak

hospital during January 1"t 201O-December 30th 2011'

r crosed femorar shaft fracture type A1, A2, A3, 81, 82 and c2 by Ao/

oTAclassificationWeretreatedbyoRlFwithbroadDCPandnocortical

defect after reduction and fixation. They were prospectively performed

byeithermedullarybonegraftingbyHAbonesubstitutes(n=12)orno

bonegrafting(n=19).Thecharacteristicdata,clinicaldata,treatment

dataandresultoftreatmentduringfollowupperiod6._12months

Wererecord,analyzeddatabydescriptivestatistic.Andcomparision

fr auluIn:rn:;gnlun ttinutl:nn:;qndut rfrnuuuf, n)flfi A ouIufr 3 n.u.-fi.n. 2554 lvledullarv Bone Grafting by

n r:ilqnri ran:;gnrfr auluIn:rn:;qn1un rtinurl:nn:;qndut tfrnttuutrncraflins bv H'A Bone Subslitute" in The Treatment

"of Closed femoral Shaft Fratture 129

Results

Conclusion

Key words

between group by Chi-square test for base line data and t-test for

means duration of bone healing.

The characteristics of the patients were similar in both groups. ln

medullary bone grafting by HA bone substitutes, mean union time was

124.0+16.3 days (range B4-152 days) and mean length of follow-up

was 8.2+1.9 months. ln no bone grafting group mean union time was

130.4+20.2 days (range 92-169 days) and mean length of follow-up

was 9.0+1.8 months. There was no significant difference in union time

(P=0.362) in both group. There were no any complication observed

in this study.

It appeared that ORIF with broad DCP and medullary bone grafting

by HA bone substitutes could be used for enhancement of bone healing

in closed femoral shaft fractures type 41 , A2, A3, 81 , 82 and C2

which no cortical defect after reduction and fixation.

HA bone graft substitutes, Closed femoral shaft fracture.

rrvi.,:Inmrrrnufl alin:Born (locked intramedullary

ad v lrhrrn:"ornfrutT v{nfirflu compression plate; ORIF with Broad DCP)?frfl1TTnt qt

atva avrTOruuruatJlFtrfi.tu 6a nt:g.iT norf nn5.:n:unn6?fl ttpiL:.lilEt'lu1n Lunl',lq.lm?nma1fl[tfinEi.:uutJ

fuq)^dairnBr 6raTE ORIF with Broad DCPvAvvia

autua.,leJ1a1 n u{m a n?1 N?\:aN?lO{ Ln:a'0il adj

LrnuffN.rlu frlnr:rirn'orifi ontr with BroadoVgi

DCP TrlLn{1fln?1

Aalsrnail fixation)('r fldl\u|rufi1fl1'lyuYlrflf,au

rio un'ir n1:il't ripruuuu rtloruuavfiprnr5t fir u

uaiuLausBtlSJn:vrlfl (open reduction and

internal fixation with broad dynamic.)) .i r 6l I Y,

fl 't'l3tLYl: fl daUnnuu o u Lu n1: Bl'l Fl Fl

ar::d'il:rtrindrrzar:

firuiE oRlF with Broad DcP na nr:{rU

rfi a nr:fi n n6lta.: uuriufamtnrru fl :vol fl (failed

plate fixation) riaufi n:sornovtfiaru6nri'u

{iu Magerl F. L[avnruv(2) :ru.rrul{'i'rwu1fi-vA

r-hrrurru:auas 5 n',:iauav 10 Riemer Llarnrur(')

:r utru'irlNuiasat 7 rirvriul:.rY! tl1u1a

ar::ri'il:rtrind or nfi o ru nta{ n rusfl 5:il nl:

il :cdrutr u nr:v[ru u1 q rufl 'l l l rTa u fl TTtJ

aailoilfi nd l luadhn.ri,a,"o plate fixation

tu fi r-Jr a n:rot n frurt ri'n rY.: uroifl 1 l . FI. 2549 6'1

fl lr.a. 2s51 Sasav 5.9, 10.1 LLav 19.1 mlaJ

6 u A a f q, t d. i t

ei-r n'u fitfr uurL{rudlnir nrrFlnulm tJluell

fl118 failed plate fixation tffnornmnls

d1rfi m niu orntmnfi nnT :airrYpr nmelal?fl an

ruai uln vr "fr

lfi orr el n:, 4 nkj rrfi ut n a nm il Iu LL:']

rarnr:vt n m nran#r-uduriu anm'ir': nr u

t a.r {rlr a I: nr-l :v'iT BYr uuat nr:rJ fr ffi m'rt a':

{rh et'Lu n r : r 6 u n.: rir vr rin n T udl.: tl n r rir l'1

vrd'tr.iT d'or uflufru(''')

rlo or.iulfr fi nr:6 pr fi uiE nr:rirt "1 ud turfi rJru mr ri.: n ri., ni, n'r : r.i r d'Br ttzu a 16 nlu {rJ r a

nrr4nri'n (MinimaltY lnvasive Plate6 "ufnmrottLl

Osteosynthesis: MIPO)(o) fl1:nnnl

n:rnnuuu'Luri locking plateo fi':firl:"fivrB

nrlldn'jr DCP plate id"Lfin'uaq|ufiru LLar

o vuvu a i J d--.- Xrira'flfiiunrrrufl urutvlLlttuffiau 1 uanalnu

u u d o e/ 4,---=-rufir{tfi n'r:illnr:n:rrtunr:tta}J rtn?o'l n:en n

aad6lanuarettfiill Lfr rriu nr:ilanri1fln:rnn

XAvtfi nufl oufi arJqnrir aolnrlu (autogenous bone

.3)graft) n1:ilQnri1fl flrYnnrflatfi arJqnrira

tanvi'ud (allogenic bone graft) nl:rJanrirs

n:rotntfiuru (bone graft substitutes) n1:ilnn

ri1 flt? n:vot nqr n rT'l {rJr a ua.: (autologous

bone marrow) nr:'LfiaT :titnl:to3ryGllnr

(growth facter) nr:'lfftv'lflr uin'nr:'[fin6u

dnmirqred' tflufru(u)

Ruedi and Luscher(n) Lturdtirlunr:

air riprn:sornfiuttinfi: uif; oRl F with Broad

DCP nr:finr:ilqnrirun:votn autologous

bone graft 1nnf.: George W Wood 11(to)

ruur:tjT rrr:fi nr:nral4nrirun:rnn autologous

bone graft "Lu n:dfi nr:rir rTrr n:sot n am (lon g

bone) fireliE ORIF with Broad DCP rufir

l ru fi ria.r'i1{? at fl :vq1 nfi un n rur n n'jT vrfi ':tu

ar ru t a.: t fr u r a u 2 { fl 'l u vr a'l q'rr ri a.: n :r q1 n tf, r fi

lunr.rr lfr ffi vlu'jr utt ln riry *r m'or fi nr:rtq n rit a

vn:vonm{fla{ruu 6a rJqnrilunssnnnnufo

fifinr:airfr'rr oRlF with Broad DcP LLau

r-1 q n riT u n:vor nil ru fi'l u LQvI1u:r ufi fi #nr*rutOO

nrrurirutuvilr nlNuu'lrl'l{fla{ George W

Wood ll

iEiifr s rud'r nlu rur nfi a orlu nr:rl a n rir El

'ltaddon:rnntian'jr16 onlay graft nouln:rafl

urtot"ogom bone graft ?1nuufirn:'olnuda. i v d d I I adA '

ttrju lcortex; fiumnmn u5aLtria.l?1t ?fiflda''l

dr-aol

rSsn'jr lnlay graft na Tlliaduu cortex

et o 'rlflt'Luia':rrfirrir autologous bone graft Lt

dt lfl ui6fifi a rurir ri'ulu nr: ufi a rufl aln a talnl-l'

v e ^ai?atil'l eomarrutisn'jr medullary gratt Inurir61 1

autologous bone graft ?l{nn LuLv.l:nn:rand, adzl(.,lYv v I

(medullary canal) rtluiEflL{inurn:r4nLru

rfiarufiernlu (nonunion; tuu3urru metaphysis

-trria qftri 3nn-En 2s54 Medurary,",.":ll,?,1i'1i'tqlT:*{ff;1ffi*?f.'T,Jli:ffiT':';lH'i:*:, shartFracture 13t

?la.r long bone rdu rirufruza.,lfl:vnnz1

(proximal tibia) uiadrurJalun:sFrfltLflu

(distal radius)( 1 r ) fra rfi ata.r nr:il4 n rit Et fl :vn n

Iotu autologous bone gratt 6afro.:r.iroinrrffrudoldaa

anmrttVtU.-l nOLTt?6UnTunnLt.,lfl?1il (lleac

crease bone graft) virbX{rJraurorrfiurfi r,r{ud a A qv I &

LdUtAAnN1n?U LtL?n1n1:9.t'tFlFrU'tUty{il?U

u1.::r u rfi nnr?vrLyr:fl fi auor n nr :rir d'olfi (")

o ai""[u n: rifi fr a.:rl n n cir u n:ror nil3ur ru

eJln 6'J orfl sutfinrr^n,"fi ou Hyorl*yupatite

{fin ceramic (HA bone) zuaruriu autogenousi oedo

bone graft ty,la L?lNa1u?un:vaneJ'lnY{a

Bucholz RW itarn[u-(13'14) finr*rn'r:r]nnrira

HA bone lorutrir.raruri'u autogenou.' oon"

graft vru'jrnr:'lfr HA bone ilanrilflnrvnn

firuifr onlay graft l3urflJ cortical defectsi,i,vTlul nn'l114u.ld?ud1:J?Ja{tdu:aL?{?a{fl TvFr fl

e't fl fl 1Tfi-fl tat lon g bone f ractu res'lfr zua rir tiq

lfr urihi6uvirri'unr:'1fi HA bone rlanrira

n:rnnlSulfU metaphyseal fractures

Paderni S uuavnrusltsr [fr stoichiometric

HA uas nonstoichiometric HA(16) ilanrirg

n:r4nfirai6 ontay graft 'Lu{1-lrnnrrr'nuru"-d

(ulnar) vinrravfizia.:'jr.: lru'jr HA boneU A Os 6t y y

Y]{ 2 "lUFt L?1,JA [Ufl1:nivmun15dT1.]n:vFtflYvd t u r 6t dLFrFtrmlnu d?u LunT6unl:!nnnlunlrnn HA

bone lrruid meoultary grai "Lu long bone

fracture r?trru diaphysis tritflufifierer fifra

ri'uflr*gru'jr HA bone arqqvlil:Lfl?u

nrvu'r u nr : tdo ru fi or ri'uz a{ fl TvFr nlpr atr-l

(endosteal circulation)(") 'Lufl 2oo7 Xu

Zhong-shi uarnruv('4 T1fl .r1unr:inr+T frrjrer

n:sn n fru?r vrh air m-n 6 or n6.r n:rn n fir u r*x"o

intramedullary nail fixation ttfi':n:vorntrilfrae,lAv.gadrv

FlnnU (nonunion) O?UXf,r'J'lFlnLAl intramed -v A a O rlY ad

ullary nail O8fl LtA?HnFl:.lnTvnn Lfi8.lFl?U?fr

nl: ORIF with Broad DCP m:i-lnnrirun:rnn{{v^d

autologous bone graft o?tllfi medullary graft6! ryr. ALu zu 1l? u 1 2 11u il a nl5Flfl 14-rv,,l11?',.l:uElvtl n',l{

ioAavdLAAfl LUnl:tuASJFlFtflUflA{n:vFtfl 7.5 tFtOU

fl 2008 Schwarlz Z LLavnruv('s) finurnr:

ilanrirfln:Enn HA bone LravflTvnntfrusJzfrFt!fa4lll,oXx

Fll{ 6l Lnaro medullary graft LLn2ultuoLUairYrrd9;6llnilnnnra Liln:rq 1,'l1t?1eJn1:dT1{n:uFtn Lfi N{{al n n1:il n nrir u n:vorn rfi fl eJil nzfi Fr

sgq

a1 nil rrf, u n'r:ninr:inur riilr u n:vn nqr q.l

Y v Y adrtuz'tltna?fl'lfi ORIF with Broad DCPv^u O f (, v (

?j at rJ?a fl Lu L:.:il EJrul a6{'l::nil:st1:fl 14q!

#.: rn nvruil n1:il a fl ri1 u nrsn nla u autologousid,vAa

bone graft rfi arfllunr:n:v{un1:tfraeJAFtq

ava 3 e v'ua{fl:van LvttSrtu unvt-Ja.:nufl1?v failed{

tdY I u q, h tr dplate fixation LLnnna.lr'J1FlFlr.l1l?Elt7\ilan

A y ay I v j &mu{mlLL14U{ AA{ L?IL?A1zulAntv{N?U fl1:r{1u

i X a & t v ae)tvI tJ ? u tLn v LU L't,,t Ft :{ n'1 : il't Ft Fr Lfl t? n 1 u'l u

o6ryy j r udl vi u a c.t

r1 Lfi Fla{Laaurn:r.tlFrn Lur.rl-l?ElfliEInn Lnnilqrld t av t o d tr X

nlTd6U Ldfl n1 LflA1 fl LU nr:rm:A il rJ1 Fr Fr LTI N?U{uv^u a '

joiiozL6..:rirn1:ilan6i1ufl:vorfl HA bone fr.:{{q

d, u i vett u r

LilU?dFlyt?l',r1n.fl1u :1n1Liltrv!{ eJlrauflu

autotogous bone graft lautdonlfinl:rlnn

riretuuu medullary graft rrashirudrufiA

autogenous bone graft tv{aan:rEjtL?n'ln1:

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n ri EJulnff m"Lulur:.:n:va n

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zu'tFtnunefllTuilua 3o o- , c A 4

n1T Fl nulua{ 3J? m fl !:e6ht n t?\ a Fl fl 1*1g

,Ja?o.rfl'tsilanrirgn:sorfl HA bone lorui6{{medullary graft lu rirlr u n:vrt nfiut'tm-n

{g

ruL[ln (closed fracture) frinurlB,Et ORIF

with Broad DCP tLasn1flfid{{pr6fl.tn:tnnYu'dlAa

LtA?Lr.teJta{?'t\l (cortical defects)'il.,ltlilrr.utrj vr u :r em1 u n 1 : fi n u1lu a-n ururfi ru r ri a u

vi'ntfrrfirfi Grld 1 ?r-n) {rJaan:rornil-nu1.ledavvjYaAa

T1 U Ft O i Q Fr L: U.] fl :3 n n Lfi Lfl 1 yl tta ? El FI Fl :il fl ug

uriulausorl u n:vn nfir u 6il ufir6tprar El 6ilfi{Avr'f-ddYfl a n:va n nL LHu Lnfi raan rilu{Lnnuaa ufi alfr

q,

rfr nda.:'ir.rfl a.,r:a fl fihfl afi qv"Ld HA bone

a.:ld1u medullary canal q1ntiu6..1'[driarrfi or

uriulamsrYun:vnn (Arlid 2 n-.:) lun:dfida,Xr-

nBqniln1:unna0nLtlutud?u (bone fragment)q

rlanrirun:rafl HA bone Iprflrr{n.,ttuqg

Ardg/aomedullary canal U:t?rUd?UllttDlfl Ltn?A{U1

bone fragment tl'l?1dil:snl qild 3 n-{)

fi a-.: air n-n riri r a n n n utfr iu n1 Tyil n 1 un 1 ilqqo u v ^ \y y a, d

11 1U Ft fl 1514 Fl tFtU L8J t?11 nmil fl fl ',l:114 U U 0.1 0 tfl 1

uAvvav?1{iln:uFrnau?1fi n unvFlnnlilnT?aTnu1{

d,afdaLilUr?n'r 6-12 tFrou LauLtllllflnuLFltlAAAAAAAU

n'lT?uaa fl n:;fl n il n1Tlfl oeJ n n?uafl ua'l nfl T{$d e"r u

irheililfitaflfl rTU LeJv{uTafl nTvnnfi n uaer{

01n1:rSLrhprtru^auff uo.,:rirmu-nlnalru"lffteirfi T

(full weight bearing)yd

:?u:? il? a 3J na1 fl t?t5stll Elu LLav

d.vdoaiv!R',ry{rantr:u Lumn Luuuuuumnmd:1{?lu\e t9 Lu,u aa v aLnrrn zaarnfl? L1_l fl ailnil1.innufl ?atJanlT:ntl'l

{q{

:EEret?nT tun1Ttflaalfi pr?laitn:enn uaBg, A €9 9 AA

fi123tLm:n.ilau ? Ln:1v14?lo3Ja n? fl dU FI

Aod,ttYrAtT.tv\::tuu1 ultfluoL1lun1T0flnr nltQnEl

,irdde,unvrirurfl u.,r LUulJl Frrolu rrliuu tfi fl u?aNn4luolv t y v d

n'l Lil:vm?1{ n n eJ n? u n1Tila doL Lnd ttn']?q

(Chi-square Test) uasLilEflutfi uu:vtlsttatjrd

nl:tta lJ FlFr?la{ nrea fl [n fl n1Til n dauYl

A<?fift1tflRu'l

drLilu prospective cohort study

nriruriradr.: 6a ridrun:rnnfrutrtinornq{g

.b As, - v o f-ou Ft tfi na:1a: n t?'tTil n1::nu1 Lu [:.flt1 fl 1uraqq

d , u dZ, r ad?::nilTvtlTnua{uFr 1 eJn:1n}J 2553 6l.l

I

3'l #umnru 2ss4 aT upiturri 20-G0 fl lilfisr,df5AzI[:ntu't?1']1u Lil3Jn1:Llntqu?a{:3uuou ?l:fld - id t y vlyu aa viln:enntrnnfi nfl auT'lrJFr?u Ln:un1:?uQflflg

'irtflu closed fracture shaft of femur tfrnr

41 42 A3 81 82 ttNY C2 N13J AO/OTA

cl assif i cation lfiil nr :in r*r frr ui 6 r.i r d'n uu u

ORIF with Broad DCP lLnvnlumn{{et6a.,:

nru4 n rfi?tri fi rio.:'ir.,: (cortical defects) {rJr a.u

&o,6,,4.yi.,:fi il Brqiru?u 3 1 nu urri.,: rflu n ri rufi fi n1ril n nqru

ciran:rq1n HA bone lorui6 medullary graftqI

, -il ,a12 AU tLAvfl Ailfl LrJ]Jn1:lanfl1ufl:vnn 1 I FtU

qqlql

v t, \ Yv I v d d

ru11? EJm n nu LnTU n1Tzu',t Fl nq1 n ttl\mfl nu tFl u?{qu f V^u

NULFIUgJ?AE]U

nr:ilancirfln:san HA bone lprai6(u$

medullary graft 'Luu3t?runiuqnidrin "lfi nnq,

A;Abone tuamt'Janaln Bovine cancellous bone

ldnthflu medullary canal ri auo-n 6ai n:vnr fl

j A & r,r ,- t e(t-test) 11Ft?1sJL{OIJU[ilUaflfl?ITAEIAg 95

,*)flfr a quufl 3 n.u.-fi.n. 25s4

n tr il onritttt'r':von,fiulfluI xttrn:vqrnluo r:You rI:nn:rqnciua rfint'utilo .

Nredullary Bone Grafting t,t il'^'ffi; ;;tt,,iil.t'ilil;;;;;

ruanltflRUr

frr-lrantt 2 nriil fi #nr*rutfidrfuj irm n

u \v r a A-

rir.:n'u 'Loruri tflFI 41fl flun?a{fl:snflmufl

Ft'ru AO/OTA classification zrfirtfivt-n LLa'

I: n rl:s'ir ri'r ( nl1 r1.tfi 1 I {r-h a n { u fi inr*r frr a

i6 ontr with Broad DCP umsilandlfln:unnt ad Ov

HA bone Lotarfi medullary graft LflTrUut?a'l

tunr:tfiarufiozatn:vptfl 84-152 {u :"t1"ioj

L? n1 toa a"Lu nlr tf,'a N n n?1 a{ n:va fl

e4.0_16.3 {u Inrsfi :turt?a16nnlru frrhua -d- a

iurtlnrisJ6-12 IFIAU tAaU 8.2+1.9 LnaU L s

fltfiiunr:inrnfrruiE ontr with Broad DcP

ruritri fi nr:il an rir a n:vn n'lfi:tfl ,urnr'Lu;av

nr:tfrarufr afladflTsFl fr 92-169'lu :eugL?a'l

rafifllunr:rfrolfi Brta{fl:srlfl 1 30-4t20 -z iu

Irrufi:"svL't41fi ornrru{r-hu 6-12 rdau

rqdu 9.ot1.a u6au LLasQlflfllrYlndauil'l{

afi fi l ru'ir:sei vLt a1'Lu nr: tfi a ru fi nt o.: n:cn n+ u V aEfll td I v

1or fl n1:5nu1Yl',1 da'ir o Lru ru n?1 eJ ttn n m1{ f,lu

t d v o v i -. 'l ,

a d'r.r fi u u 6it m rg (nl:'l',:m 2) Lt lltunttstt?l:fl-Ao-ur{aufirirnrualnnl::nu1 t{u f,l1lrnrsolfl

irir{iaru6Brn'u (nonunion) uur.rafiorrda ra4a

d a A ' L-n1:dil tfr tl nr:E ol n5.:? a{ LLr'Ju Lafi Yal il fl :rE fl

qru q

(failed plate fixation)

al?o1:€rtA. t Ytt {'

a1nilnfl1:Hnulnur1ilillUYld 2 fl aeJ

r 6 td, v i q vd u a

r{ru"Lunit{lurigrfl o'1fl Laau Lnntnu{nuna-----d o q

il:vrurru 30 fl un"finr:nrua1fl?antrfiFlA-

?lo.ln:vaflfrunnrru AO/OTA classification{o , v A - l e t.Fr-.-.-"Lunnnriu

fl1a1ivtfl ndlu Lfl rut1lu1l-l?l?1 LLayqq

u,. i v ,at I o asTr-h ulfr unSttriil [:nil:ea1 Btl rrafl1:rfl t+1t,

rhhsnrirufi fi nr:rlonriran:v4n HA bone

I-*; ;:orur" g,.rft ,fi ,,,liu#tru ri'r firJr u

n 6i sJffl il fi nr:ila n rir n n:sq n l'lu'jr:;a Jrr n'r' '-.i--' '--- ql ql

i o A a -q-.Y-t^^..YrqfiEilun.r:rfi au horta.:n:rq nlu{th s rft z n{ru

vrtvTd--4-.Q.4lrirrmnpir.:nu Lotutt:rust?a'ltflau Lun15trlu

Y -u, I u d j

a.:dr uu n'lil ttn n rir.: nu LLavil :vusL'l a-l taa EJ

6) a vtt & I I"Lunr:6nmrilridreffl.l 2 nnlJil:eu1ru 8-g Lnau

n'.rrlJqnri.unrrinI^u autologousa r a' aaicr i --'Y^ i '

bone graft fi a'jrrfluTEfr tilunaailTutJlnmdrl

Lv\:1en:uotfl autologous bone fiqruarur-ifiY . a .v & -- \t'

nruyT{ 3 il:snm 6a nr:a5l{Lilan:snnLato{A o6t9^ Y

(osteogenesis) n15L14uEl?u1 L?1tnnn15d:1d

n:uan (osteoinductive) uac n1:#flrjr'lfrufi4

n1:6;ldtdrn-"rn (osteoconductive)(1e)

ru ri"[u r]o q r.iul fi fi n r r ru A nr d1 rfi riT a'r rlfi run u

autologous bone graft Halatfin uriu

Demineralized bone matrix, Purified human,

BMP, CaPOo, CaSOo, Hydroxyapatite utnr

Bone marrow aspirate tflufiu('o)

riruiu n:r4ntfi uru Hydro4yapatite("' ")

urr5uruldo1 nnlTd{ tn:tvYtdt:tneJ fi :atrt:uN

qr n{a n o::ruzr 6 uriu rlvnri.:rta n:'qr n #n{

4nrn1{tnfr 6a Ca,o(POo)u(OH), 6io,oio'ilu

3 nriru ifiuuri cement ceramic uLar composite

grafi'n)'Lun{ru ceramic (HA bone) finruaadfi

uriu'Lufiru osteoconductive d'orirvrfirfi rflus,ivalnr:.,:iT .: ufr a auu auufl1:{ afl ? a{ Ldu ta a a

capillaries LLas perivascular tissue rhtU{i a' - -nisotfl lorsYi'rlil'Lun1:ilQrlnlTtfla8JFln?la{ e .,

, v q9/ d' | |

rirsn:sotnilnLt HA bone Liluf,?ur'ldtJ:1tl

(,v-€

dr::riil:rtlinutx{d1:

tiu autologous bone graft 'Lun:rfififiatlfi

autologous bone graft il3ru1cutJ1fl "1 Iorufi

f, ari.rlfi lfi uuri "1fi uil u ar : r n fi aufi a atfr l n ufi a ru

ufi 41fr n:rn n fidr u{ a n rfir rfi auf, a arln nriru

fi utrlfi 6du nr:il a nrir a n:'qnlunr: ri'r pTBr

ufl au n:rotn#uun't nr:inr*tfl adaflfl ann:rafl

Iorunr:rir r-rrr.rdr{afl afl n urav'Lri HA bone

EtdlJ autologous bone graft rflrhJuunu drmiu

n:r4nv{nn:tfl tong bone nr:'[fi HA bone

u{luianrlanrirfluitrru metaphysis [Lae

fi.ruuucdr1fr'tfiirruri'u autologous bone graft

6.:qstfiila6(")

nr:finurtoi Hannouche D LLnvnrur(t)

Itu'j r n ru a e*l ri6 osteoco n d uctive pr": n ril rt a't

HA bone tei umrur"aru'tu nr:lfirJq n rir a n:en n

firuifi onlay graft fifidal'ir':niT d !rl:.lvfl1:

uo3 qt a.: idrud, n "

q nlvmi o r ufl rtrtl fi fi :" or'u

fi rta.: #u MT rfu n'r: 6 n*t ufodn:'rirlu n ri a'r

uvd

fi n:r4n umnv{n uua'nr uud'tq'n tTa': n:rnn urt

iiuufir1ilfitia.:'irl uuf,tlnnrirufl:rnn HA bone

frrai'o medullary gratt fitnlot'jrnr:n:"fiu

n1inafl?!o.:n:rnnlmriarqosu'larn:au fi r filu

"[uta'ln:v4nul^l:rraqi"lu medullary canalu ad'6an:rnn

f,a6to',:nr:rlqnriT unl&n nn'l u1fiu

fi r.l q n riT a a qlufiii Aal n'r:hi n:se1 u n'r tn fr au

i6 onruv graft Yi'flfiufi Brnr:n:'fiunT :uflarufi Br

ta.,:n:rn nlfiadrlfr rl:rfiilEnrt{ q1nnlr

6 pr ntru tlafl 1{fi1n uE nqu:dvlu'j'r fi nr:i8 n

rfl ou riutalnrYSnfi unrnvTnnn:T u q1nf,asad

d'ufir*grufi 'lr nr:il an rir u n:vnnLn uto

medullary graft alqer?Tn?r1{ endosteal

ci rc u I ati o n ( 1 1 ) d.: r{l u{ a a'u fi r*g'r ulu n : dlfi

autologous bone graft fiils'ifrnr:udarudn1u

au?1lJFl (resorbtion; uun'[un:rflnr:rlanriT a

n:rnnfiru HA bone fi'':fi:raYru'jr Sauns

95 tal HA bone finr:ufiaalanrfllu 26-28

d'rl orrd' nr sm #l nr:il a n rir u ('a 6':hiririiqdtil

rTrrtrll endosteal circulation rirmiun:vuru

nr: ufi o u 6 or fiu a dr t d eJ UT rrit at nru Fl fl

(remodeling phase) fial'Lfiurart{lufl''u'

6.r fi at fi nr:fi or nrtl {rJr a'Lu nI: 6 nr*rdri o d n

A:Etluylu{

In errthtrl n:rn n fiutrr{n uunrfnur

Iora locked intramedullary nail fixation qJlfi

trat'[unlrr^t, ru 6 or'ttol fl TBFI fl d:rrut ru

g-o ufiau(26) n1:Aflu'lta': Reimer LLflrnfllr(3)

'Lun{rufiinurfira oRlF with Broad DCP

uuarilanrilufl:rolfl autologous bone graft

ir ru fir s'[fi urnr'[unr:tfi aru fi q16'1 1:rfl fl_ vN

tq6n t z d'r-tBrrd' ernn'r:fi nr*r nftfi {rltun{ru

iiinu'rfiraid ontr with Broad DcP LLaY

s^d

rJqnriran:rnn HA bone leruiE medullary

grat "[fiurarlunl:ufi arufi Brtra':fl:unn uq6fl

124.8iu vr6arhrlJlru 17'B #iln1v{ funrnrn{'r

lfi'jT n'r:ilnnrirsn:votn HA bone loruifi

medullary graft dllJ'r:avirlfi uacfiuu'ilflil

'[unr:n:rfiu nT : rfi o ufi ntar n:tqnlfi drvriu

{iiu'iloludauuurdrta'1 Ruedi and Luscher(e)

fi 'ir nr:fi nr:il a n rir s nrrn n4n n{':lu nr: riT

n:vnnfrutti'nfirui"o oRlF with Broad DcP

un"fr at nl:4nfl1:3'11u41 fl fl 1:r'ir n'or gir urmri't

fi aa.rufi aunriue'nlanciru autogenous bone

flfi a qrufi 3 n u -n n 25s4 Medurary ,,".T1,?il'11",81T:*'g};1ffi11"?f.'?"Jln:;u;"U:f i:l::, shart Fracture 1 35

ad

graft d1ru't:fl LAOn2fi fl1:UAnfl 1fl n:vnn LLilU

medullary gratt lora"Lfr Hn bone tfiddjiE{a6 n n:rlvr fl .:fr nr:fr nr:fi nr+ri{a ri alr-l

6anr:r.lqnriT Unrrnn HA bone IBreri6

medullary graft d'lilr:nn:rflunr:rdarufi Br

6lr-"vyad?o.0n:rnn tunl:il''ln:ranau?1mnn?u'1f,'

oRtF with Broad DCP 1fr6n'j{rjfinr:r.lAn.drtr

riran:vnnfi:oLel

auJI"Lu rirj r cr n:sn n frumfin uarin ur fir s.u ql

Adivvdlfi ORIF with Broad DCP 11tl'lflfiA.lQFlt;U.ly A eu rd'

'n:rn n r{1fr udrtri fr da.o'ir.: d'r ru.r:fl il a n rir a{{f aal A

n:u8n HA bone Lafl?fr medutlary graft tylo.u

y A a rea- I r

n:vnunlTrro eJ n q?a.0 n:En nlfiIn ulilr{unrrrqq!

yAuil:n{au t6r 1

2.

3.

9'A

1. Wiss DA. What's new in orthopaedics trauma. J Bone and Joint Surg 2002; 84-A(11);

2111- 9.

Magerl F, Wyss A, Brunner C. Plate osteosynthesis of femoral shaft fractures in adults:

a follow-up study. Clin Orthop 1979; 138: 62-73.

Riemer BL, Butterfield SL, Burke CJ 3'd, et al. lmmediate plate fixation of highly

comminuted femoral diaphyseal fractures in blunt polytrauma patients. Orthopedics

1992; 15(8):907-16.

4. Thompson F, O'Beirne J, Gallagher J, Sheehan J, Quinlan W. Fractures of the

femoral shaft treated by plating. J lnjury 1985; 16(8): 535-8.

5. Gardner MJ, Evans JM, Dunbar RP. Failure of fracture plate fixation. J Am Acad

Orthop Surg 2009; 17(1O): 647-57.

6. Apivatthakakul T, Lauhapoonrungsee A, Chiewcharntanakit S. Monimally invasive

plate osteosystesis (MIPO) of proximal and distal femoral fracture: a result ol 20

cases. J Thai Orthop 2000; 25: 36-8.

7. Smith WFl, Zira BH, Anglen JO, Stahel FP. Locking plates: tips and tricks. J Bone

Joint Surg 2007; B9-A (10): 2298-307.

136 Irfi nraqrniqa dr::6il:s{lindtr{drT

B. Hannouche D, Petite H, Sede L. Current trends in enhancement of fracture healing-

J Bone Joint Surg. 2001; B3-B (2): 157-64.

g. Ruedi TP, Luscher JN. Results after internal fixation of comminuted fractures of

the femoral shaft with DC plates. Clin Orthop '1979; 138: 74-6.

10.George W WOOD ll. General principle of fracture treatment. In: Canale ST, editor-

Campbell' s operative orthopaedics. 1 1'h ed. St Louis Missouri: Mosby elsevier;

2008. P. 3017-84.

ll.Crenshaw AH Jr. Surgital techniques and approaches. ln: Canale ST, editor-

Campbell' s operative orthopaedics. 11'h ed. St Louis Missouri: Mosby elsevier;

2008. P.4-22.

l2.Ahlmann E, Patzakis M, Roidis N, Shepherd L, Holtom P. Comparison of anterior

and posterior iliac crest bone grafts in terms of harvest-site morbidity and functional

outcomes. The Journal of Bone and Joint Surgery 2002; 84:716-20.

13. Bucholz RW, Carlton A, Holmes RE. Hydro4yapatite and tricalcium phosphate bone

graft substitutes. orthop clin North Am 1987: 18: 323-34.

14. Bucholz RW, Carlton A, Holmes RE. lnterporous hydroxyapatite as a bone graft

substitutes in tibial plateau fracture. Clin Orthop Relat Res 1989; 240: 53-62-

15. paderni S, Terzi S, Amendola L. Major bone defect treatment with osteoconduction

bone substitute. Musculoskeleton surgery 2009; 93(2): 89-96.

l6.GuzmdnVdzquezC, Pifi'a Barba C, Mungur'a N. Stoichiometric hydroxya patite

obtained by precipitation and sol gel processes. Revista Mexicana de fi5ica 2005;

51(3): 284-93.

17. Xu Z,Lin Bo-wen, Wang J, Li R. lnternal fixation with lengthened plates and medullary

bone grafting to treat nonunion following breakage of femoral intramedullary nails.

Hainan Medical Journal. 2008; 08(2): 10-8.

1g. SchwarlzZ, Doukarsky-Marx T, Nasatzky E, et al. Differential effects of bone graft

substitutes on regeneration of bone marrow. Clin Oral lmplants Res. 2008; 19(12):

1233-45.

lg.Greenwald AS, Boden SD, Goldberg MV, Khan Y, Laurencin CT, Rosier RN.

Bone-graft subsitutees: facts, fictions & application. Cur J Bone Joint Surg 2001:

83-A (SuPPl. 2): 9B-103.

ilfl8 auiufi s n.s.-'.n.2s54 Medurary ,",."l11,?,11'11,'tulHll"l:ff1fi3*+[']',.lffilTT;]H'fi]Hr shart Fracrure 1gT

20. De Long WG Jr, Einhorn TA, Kovalj K. Current concepts review bone grafts and

bone grafts subsitutes in orthopaedic trauma surgery. J Bone Joint Surg 2007;

B9-A (3): 649-58.

21. Damien CJ, Parsons JR. Bone graft and bone graft substitutes: a review of current

technology and applications. J Appl Biomater 1991; 2(3): 187-208-

22. Finkemeier CG. Current concepts review bone-grafting and bone-graft substitutes.

J Bone Joint Surg 2002; 84-A (3): 454-64.

23. Bae H, Field JS. Bone grafting/bone graft subsitutes. ln: Lieberman RJ, editor.

AAOS complehensive orthopaedic review. Philadelphia: American Academy of

Orthopaedic Surgeons; 2009. p. 111-5.

Z4.Knaack D, Goad ME, Aiolova M, Rey C, Tofighi A, Chakravarthy P, ed al. Resorbable

calcium phosphate bone substitute. J Biomed Mater Res 1998; 43: 399-409.

25. Buckwalter JA, Einhorn TA, March J. Bone and joint healing. ln: Bucholz RW,

Heckman JD, Coutr-Brown C,editors. Rockwood and green's fracture in adult. 6th

ed. Philadelphia: Lippincott William&wilkins; 2006. p. 297-312-

26. Nork SE. Fracture of the shaft of the femur. ln: Bucholz RW, Heckman JD, Coutr-Brown

. C, editors. Rockwood and green's fracture in adult. 6'h ed. Philadelphia: Lippincott

William&wilkins; 2006. p. 1845-914.

I

138 IIe nmqil;qo d?:T6.il?g{1;ndt?{d1T

n1:1{d 1 a-nururrirhJzaln{run"radr.l

uanufus

HA Bone (n:12) No HA bone (n=19)

o"rueultauavl drurulSauar;P value

BI

I?TFI

t'lu

n€',:

alEl

15-2e fl

30-3e tl

4o-4e fll

50-5e fl

uodu (SD) (tl)v

tfl nra,lnrrmnnliJ Ao/orA

classification

A1

A2

A3

B1

B2

C2.r/ Av

fl'l?11',]flfin

fl?1

ilt'a

I:nrl:r'ird"lrl tdLNTI

I:nn:runlBo'1fi17

I:nnlrrupr-ulafrna.:fy

L:nnruurry

e(75.0)

3(25.0)

4(33.3)

4(33.3)

2(16.7)

2(16.7)

36.5(12.8)

1(8.3)

2(16.7)

2(16.7)

1(8.3)

4(33.3)

2(16.7)

e(75.0)

3(25.0)

B(66.7)

2(16.7)

1(8.3)

1(8.3)

0

13(68.4)

6(31.6)

8(42.1)

6(31.6)

1(5.3)

4(21.0)

36.2(12.3)

8(42.1\

3(15.8)

2(10.5)

1(5.3)

4(21.o)

1(5.3)

15(78.e)

4(21.1)

13(68.4)

2(10.5)

3(15.8)

0

1(5.3)

0.694

0.950

0.399

0.798

0.489

fipra:r

nnilgntiuorcqnrfisrluln:m:lEnlun r:inu tl:an:ugndurtftuyuf,o. -., _Bone Grafting by HA Bone SubstitutJin The Trealment'of Closed Femoral Shafr fract"re 139ild e qfud a n.a.-o.n. zss4

A@Fl1T1.lYl 2 ,{AnlTTnU'l

o,JAn.l::nu1

HA Bone (n=12) No HA bohe (n=19)

uoda (so) uada (so)P value

oaYu,v-13El3L',la.I[unr:thun{u']?1un (?u)

Toe Touch Weight Bearing

Partial Weight Bearingaia

:vEl3t?a'l Lunl:tnail nnfl adn:38 n

({'u)

ierjsL?a1flr:annrru{rhu (ufi au)

42.0(5.6)

82.8(15.2)

124.0(16.3)

8.2(1-e)

4.2(7.0',)

86.2(17.0)

13O.4(20.2)

e.0(1.8)

0.366

0.579

0.362

0.268

t,it

E

!lI

i

.,oo Ira o.,.orBnu dartd[r-lt-",IainritTdda,

Slid r rlrod'xfirha :rufi t n:,otnfiu"uln"n tfinr ng

n

:rlii r fl. Lrdn.rn.r:rmiurudufruirrrun:rfln grlri r n. rda'0nr:rl6nrira HA bone{ ,

loortoucv - ci" q {

m'nrfiarlanriru HA bone{

.al

:ily) 1 .1.{d 561 v --!.^- a. fl'ty\tdn'ru:u-Lufl'l:unnt:lantxn''lrl1{ 6l

^.) u ) nr:il0nrilunrrqn,fiulflulnrrn:rgn'lunr:Ynurl:nn:;qnriurr#nrrruflo-Ufl 8 aUUYt 3 n.u.-D.n. 2554 Medullary Bone Grafling by H"A Bone Substitute" in The Treatment "of closed Femoral Shaft Fracture 141

:ilfi z n. - ?. nlvlr6ntr:ridaur.ireier

:rlfi z n.U

:ilfi z q.g

- .1. nlTilanrirs HA bone

aod6ovj

- {. fi1?\ ta n{15 El [u n''l :u Fl Fl5'] a?1 L'l a1 n'1.1 6l

ar::nil:rzrindr:znr:

.{T'tult 3s FiraEj'I.,:{rJra

VUAn:rannu?lftln aua c2{

--r-i ^ d € t t uTUn 3 n. - fl. R1y{ran{r:EjriouillFlFl

,.J d 6rt v j?1.1?1 3 A. - *. rlnran.ilr:u-Lunr:una:?afir?n]Fi.t.l.l