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Preliminary Experience With Bone Morphogenetic Proteins in Scaphoid Nonunions, Kienböck’s Disease, and Chronic Nonunions of the Upper Extremity
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ABSTRACT
Following Urist’s original isolation of bone morphogenetic protein (BMP), several recombinant proteins of the BMP-osteogenic protein family have been produced, including rhBMP-2, rhBMP-4, and OP-1 (BMP-7) and shown experimentally to induce bone formation in rat, rabbit, sheep, and primate models. Partially purified human BMP (hBMP) has been used clinically in femoral and tibial nonunions and spinal fusions. This is the first study to describe the use of hBMP and rhBMP in hand surgery as an adjunct in the treatment of scaphoid nonunions, Kienböck’s disease, and forearm and hand nonunions.
Seven patients underwent implantation of 50-100 mg hBMP or rhBMP-7 for proximal pole scaphoid nonunions (n=2), Kienböck’s disease (n=3), and nonunions (n=2). One scaphoid nonunion underwent Kirschner wire fixation and hBMP implantation whereas the second underwent corticocancellous bone grafting and hBMP implantation. One patient with Kienböck’s disease underwent first dorsal metacarpal artery revascularization, cancellous bone grafting, and hBMP implantation; the remaining two patients underwent vascularized bone grafting and hBMP implantation. One patient with a chronic ulnar nonunion ulna underwent corticocancellous bone grafting, compression plate fixation, and 100-mg hBMP implantation. One patient with a nonunion of a previous bone graft of the thumb metacarpal and proximal phalanx underwent compression plating and OP-1 (rhBMP-7) implantation.
Follow-up ranged from 2-6 years. Both patients with scaphoid nonunions had complete pain relief and radiographic evidence of healing. Two patients with Kienböck’s disease had complete pain relief and the third patient had good pain relief. Serial radiographs revealed no further progression in lunate collapse. Magnetic resonance imaging in all three patients showed islands of increasing vascularity but not complete revascularization of the lunate. Follow-up radiographs of the two nonunions showed increasing consolidation of the bone grafted segment.
This is the first preliminary report on the use of partially purified hBMP and pure recombinant hBMP to augment the bony healing of scaphoid nonunions, Kienböck’s disease, and upper extremity nonunions. It is impossible to prove that BMP was responsible for the bony healing seen in these patients as other conventional techniques such as cancellous bone grafting, vascularized bone grafting, and compression plate fixation also were used. However, it is likely that BMP will have increasing clinical applications in future hand surgery.