SLR - October 2019 - Joshua J. Wolfe

The ‘Diamond Concept’ for Long Bone Non-Union Management

Reference: Andrzejowski P, Giannoudis PV. The ‘Diamond Concept’ for Long Bone Non-Union Management. J Orthop Trauamatol. 2019; 20:21.

Scientific Literature Review

Reviewed By: Joshua J. Wolfe, DPM, MHA
Residency Program: SSM Health DePaul Hospital – St Louis, MO

Podiatric Relevance:
Management of non-unions is an integral part of the role of the podiatric surgeon. While the incidence of nonunion can vary, understanding the tenets of non-union management is imperative to effective management of these cases. The literature regarding the diamond concept for non-union management is lacking and identifying quality literature would contribute significantly to the understanding for non-union management.

Methods: This study utilized Ovid SP as well as Embase databases and Medline to identify articles addressing the diamond concept as well as long bone non-union management. Each article was assessed for level of evidence, study size, objectives, study type, patient characteristics, methods, non-union risk profile, assessment of union, length of follow up, time to union, and outcomes.

Results: Ten studies were identified that met inclusion criteria. Five were retrospective or case-control studies, three prospective cohort studies, and two case reports. A total of 548 patients were included in these studies. It was found that the success rate when treating non-unions, strictly according to the diamond concept, was 89 to 100 percent. When the diamond concept is not followed strictly the success ranged from 44 to 90 percent.

Conclusions: The management of non-unions is a difficult task, particularly in long bones. The authors demonstrated that the literature has exceptionally high results of union in patients where the diamond concept criteria are strictly adhered to. This article aids in improving the literature available to surgeons as they undertake this task. The diamond concept, addressing vascularity, host factors, osteoinduction, osteogenesis, osteoconduction and mechanical stability, provides a framework that surgeons can utilize to improve their outcomes. This study, while underpowered, does provide insight into an area where the literature is specifically lacking. It also provides a greater thought process regarding not only treating the factor, but also the host factors that have led to the non-union in the first place. This article was very beneficial as it provides instructive material with underlying evidence of its effectiveness. This is certainly something that can be applied to surgical management of non-unions in the podiatric surgeon’s practice.

Educational Opportunities