Purpose of the study: Nonunion, which is a biological failure, requires revision, usually an aggressive operation. Haematopoietic bone marrow contains colony forming unit fibroblasts (CFU-F) which could favour bone healing. The purpose of this work was to determine whether a minimally invasive procedure, injection of CFU-F into the nonunion space, could favour bone healing without further procedure.

Material and methods: Our series included 43 patients: 36 male and 7 female, mean age 39.9 years. Forty-seven atrophic and aseptic nonunions of long bones were treated with percutaneous injection of concentrated autologous bone marrow: 27 tibias, 17 femurs, 3 humeri. Bone marrow was harvested from the posterior iliac crests (346 ml) then centrifuged to keep the leuko-platelet fraction (78 ml). This concentrate was injection into the nonunion space under radioscopic guidance. Efficacy was assessed on the basis of clinical criteria (complete pain-free weight-bearing, absence of contention, absence of mobility) and on radiographic criteria (healing of 3/4 corticals).

Results: Thirty nonunions healed: 19 tibias (70%, 11 femurs (65%) and 0 humerus. Mean time to healing was 5.9 months (2.4–15.6). Factors of poor prognosis were: smoking, alcohol, diabetes, corticosteroids, radiotherapy, history of sepsis (p=0.01). Early grafting increased the chances of success (p=0.04). Age, initial skin opening, type of fixation did not have a significant impact on healing. The number of CFU-F had an effect on the rate of healing.

Discussion: This technique is effective for the treatment of nonunion of the lower limb, allowing bone healing in two thirds of the cases with a minimally aggressive procedure. The method is easy to perform but requires a rigorous technique for the different phases of puncture, concentration and reinjection. Nonunions unresponsive to conventional methods, and thus corresponding to multifactorial problems, probably constitute the limitation of this method. Cell expansion or differentiation techniques could be helpful in improving the success rate but at the present time the osteogenic potential of these cells remains to be elucidated as a function of their stage of maturation.

Conclusion: Percutaneous grafts of concentrated autologous bone marrow can be a useful contribution to the therapeutic armamentarium for nonunion. Morbidity is low and the method does not compromise future options. It can be proposed as a first-intention solution for the treatment of long bone nonunion.

Purpose of the study: Basimetatarsal osteotomy to correct hallux valgus deformity by subtraction of a lateral wedge does not take into account the distal angle of the first metatarsal (DMMA). The purpose of this study was to demonstrate that the preoperative DMMA has an effect on the correction of the metatarsophalangeal angle and the duration of the result.

Material and methods: This retrospective study included 76 patients, mean age 58 years (84 feet). The M1P1 angle of the first ray was 34 on average, the DMMA 10 (two-thirds of the patients had a DMAA > 10. The same operator used the same technique for all procedures: lateral wedge osteotomy of the base of the first metatarsal with metatarsophalangeal release. Basal osteotomy of the first phalanx was performed for severe deformity. Radiographic measures were made on the dorsoplantar anteroposterior images in the weight-bearing condition preoperatively, at four weeks and at last follow-up. All images were read by an independent observer. Mean follow-up was 11 months. The DMMA measurement was the angle between the distal joint surface of the first metatarsal and the alignment of its diaphysis.

Results: Mean postoperative correction of the hallux valgus was 25 with a mean M1P1 of 9. This result remained stable without loss of correction at last follow-up. The mean postoperative DMAA was 10 and remained unchanged.

Discussion: Determination of the DMAA can be difficult because of preoperative pronation of the forefoot, compromising the reliability of the measurement. The literature also reports intraobserver and interobserver variability of this angle. Mean follow-up was not greater than one year, but the loss of correction generally occurred during the first six postoperative months. The operative technique enabled sufficient and stable correction over time. A pathological value for DMAA, even if large and uncorrected, does not prevent a good correction of the M1P1 angle and to maintain that correction. The clinical result is also the same irrespective of the preoperative DMMA.

Conclusion: Wedge osteotomy of the base of the first metatarsal is a reliable procedure for the treatment of hallux valgus. The value of the DMAA has no effect, in our experience, on the quality of the correction, or on the duration of the result.