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JINJ 7186 No. of Pages 3

Injury, Int. J. Care Injured xxx (2017) xxx–xxx

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Management of traumatic bone defects: Metaphyseal versus
diaphyseal defects
Taco J. Blokhuis
Department of Surgery, Maastricht University Medical Center +, Postbus 5800, 6202 AZ Maastricht, The Netherlands


Keywords: Although bone defects after trauma appear in different locations and forms, many clinicians have
Bone defect adopted a single strategy to deal with any defect. In this overview, a distinction is made between
Bone substitute metaphyseal, or cancellous defects, and diaphyseal, or cortical defects. The treatment goals and
Induced membrane technique
background of these two types of defects are discussed in order to describe the difference in strategy and
hence the difference in treatment method.
© 2017 Published by Elsevier Ltd.

Introduction of achieving these three goals depends on the patient and the
location and extent of the defect. An elderly patient with an
Bone defects appear in many shapes and sizes. However, tailor- extensive proximal tibia fracture differs, obviously, from a young
made approaches are seldom chosen. Many clinicians are familiar patient with a joint depression fracture of the calcaneus. Still,
with a strategy to deal with bone defects, but have adopted one healing of the defect should be achieved, in order to reach one or
strategy that fits all. Enormous developments have taken place more of the mentioned goals.
over the past decades in bone substitutes, but also in knowledge on The biological environment of metaphyseal defects is generally
bone biology. Therefore, the standpoint that a single technique or good. With the exception of specific sites such as the femoral head
material should be sufficient to cover all different bone defects, is [2], vascular supply to cancellous bone is generous, and bone
outdated. In this overview, a distinction between two types of bone turnover is higher than in cortical bone [3]. For these reasons it is
defects is made; metaphyseal and diaphyseal bone defects. These often assumed that a defect due to a fracture will heal by itself. A
two types of defects behave differently, as their biological and fracture hematoma should form and the cascade of bone healing
mechanical environment [1] is unequal. Moreover, the treatment would be initiated, resulting in filling of the defect. Unfortunately,
goals in these two types is not the same. Where mechanical increasing pre-clinical evidence shows that this is not the case
support for a joint surface and restoring bone stock are the main [4,5]; cancellous defects that are not filled with a bone substitute
goals in the metaphyseal defects, restoring cortical continuity is will only generate limited amounts of newly formed bone, leaving
the objective on diaphyseal defects. For these reasons, metaphyseal the majority of the defect open. In a recent clinical study using high
and diaphyseal bone defects require a differentiated approach. resolution CT imaging on wrist fractures [6] it was shown for the
first time in patients that healing of metaphyseal defects is not fast
Metaphyseal defects and straightforward. In wrist fractures with major cancellous bone
loss, those that required reduction upon initial treatment, imaging
Impression fractures around a joint are the usual cause for at 12 weeks still showed significant changes in bone density.
traumatic metaphyseal defects. Osteotomies, i.e. the high tibial Moreover, volumetric bone mineral density for the trabecular bone
osteotomy in degenerative gonarthrosis, is another common cause in all fractures decreased significantly to 2 years. Although the
for metaphyseal defects, but these are beyond the scope of this clinical outcome in these elderly patients is good, these data
overview. The treatment goals in these defects are 1) temporary support the idea that healing of a metaphyseal or cancellous defect
mechanical support of the affected articular surface, 2) healing or is a long and slow process, and that it could benefit from support.
filling of the defect itself, and 3) restoration of bone stock to Numerous studies have investigated the effect of bone
accommodate prosthesis placement in a later stage. The necessity substitutes in metaphyseal bone defects. Prospective studies have
shown beneficial effect of bone substitutes in specific indications,
specifically in tibia plateau fractures [7], calcaneus fractures [8,9]
E-mail address: (T.J. Blokhuis). and distal radius fractures [10]. Although the quality of the
0020-1383/© 2017 Published by Elsevier Ltd.

Please cite this article in press as: T.J. Blokhuis, Management of traumatic bone defects: Metaphyseal versus diaphyseal defects, Injury (2017),

Cochrane Database Syst with significant drawbacks. Josten C. The immense range of formed bone. a bone substitute material material. Clark AB. is of the prospective.13] and synthetic gradually disappear on the radiographs and be replaced by newly polymers to calcium phosphates [10. van der Meulen MC. However. which can be rather liquid after harvesting. scaffolds. randomized study. Nielsen DM. Injury 2008. choose RIA over iliac crest bone grafting. either using plates or intramedullary nails. Ideally.14(5):309– 17. Dynamic bone imaging with 99mTc-labeled diphosphonates and 18F-NaF: mechanisms and applications. Yu Y.1:37. However. From a biological Properties of calcium phosphate ceramics in relation to their in vivo behavior. have binding affected by the fracture. Pelletier MH. and provide the remodeling of the graft material.J. the RIA material can be trials [11]. Injury (2017). Walsh WR. The available materials an instrument in monitoring the healing process. which has been implemented widely over the last decade or so. Taking the less favorable biology of cortical versus cancellous bone from mechanically-loaded murine tibiae compared to metaphyseal bone into account. Moreover.2(395):3–32. Piert M. By doing so.31(5):1114–22. Shepherd KL. [9] Wee AT. Creating the correct these materials can be altered according to the (theoretical) needs amount of stability. J Nucl Med together: vascularity. Keszei AP. important arguments than graft volume or complication rate to [14] Blokhuis TJ. Release of angiogenic growth factors from cells therefore not without risk [22]. more encapsulated in alginate beads with bioactive glass. Leighton RK. the mechanical environment is a factor well- commercial products available illustrates that many properties of known to most orthopaedic trauma surgeons. Einhorn TA. below.25(8):483–7. 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