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Objectives To identify factors associated with the need for reoperations in patients treated surgically for fracture nonunion. Design Retrospective cohort study. Setting One urban Level 1 trauma center and an orthopaedic specialty hospital. Patients/participants This study included 365 patients who did not and 95 patients who did undergo a reoperation after nonunion repair. Intervention All patients who underwent fracture nonunion repair were identified. Baseline demographic, injury, and surgical information were collected. These factors were compared between patients who did and did not require an unplanned reoperation. Main outcome measurements An unplanned reoperation after index fracture nonunion surgery. Results When compared with patients who did not undergo a reoperation after their index fracture nonunion surgery, patients who underwent at least 1 reoperation had a greater proportion of those who sustained an open fracture, a high-energy injury, initial neurologic or vascular injuries, the need for a flap or soft tissue graft at initial treatment, and lower extremity injuries with univariate analysis. Unplanned reoperation was also associated with diagnosis of "infected" nonunion at initial nonunion surgery. Multivariate analysis confirmed initial nerve or vascular injuries and positive infection status were statistically significant predictors of a reoperation. Conclusions Initial injury characteristics such as nerve or vascular injury at initial injury and positive infection status at the index nonunion surgery were associated with the need for a secondary surgery after nonunion repair. Appropriate care of these patients should be aimed at adjusting expectations of unplanned reoperation in the future and potentially enhanced treatment strategies. Level of evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

AIM: Although nonunions are among the most common complications after long-bone fracture fixation, the definition of fracture nonunion remains controversial and varies widely. The aim of this study was to identify the definitions and diagnostic criteria used in the scientific literature to describe nonunions after long-bone fractures. METHODS: A comprehensive literature search was performed in PubMed, Cochrane Library, Web of Science, and Embase. Prospective clinical studies, in which adult long-bone fracture nonunions were investigated as main subject, were included in this analysis. Data on nonunion definitions described in each study were extracted and collected in a database. RESULTS: Although 148 studies met the inclusion criteria, only 50% (74/148) provided a definition for their main study subject. Nonunion was defined in these studies based on time-related criteria in 85% (63/74), on radiographic criteria in 62% (46/74), and on clinical criteria in 45% (33/74). A combination of clinical, radiographic and time-related criteria for definition was found in 38% (28/74). The time interval between fracture and the time point when authors defined an unhealed fracture as a nonunion showed considerable heterogeneity, ranging from three to twelve months. CONCLUSION: In the current orthopaedic literature, we found a lack of consensus with regard to the definition of long-bone nonunions. Without valid and reliable definition criteria for nonunion, standardization of diagnostic and treatment algorithms as well as the comparison of clinical studies remains problematic. The lack of a clear definition emphasizes the need for a consensus-based approach to the diagnosis of fracture nonunion centred on clinical, radiographical and time-related criteria. pmid: 34531088 ispartof: INJURY-INTERNATIONAL JOURNAL OF THE CARE OF THE INJURED vol:52 issue:11 pages:3200-3205 ispartof: location:Netherlands status: published

Introduction Fracture-related infection (FRI) is a severe post-traumatic complication which is occasionally accompanied by a deficient or even avital soft-tissue envelope. In these cases, a thoroughly planned orthoplastic approach is imperative as a vital and intact soft-tissue envelope is mandatory to achieve fracture union and infection eradication. The aim of this study was, to analyse if soft-tissue reconstruction (STR) without complications is associated with a better long-term outcome compared to FRI patients with STR complications. In particular, it was investigated if primary flap failure represented a risk factor for compromised fracture union and recurrence of infection. Patients and Methods Patients with a lower leg FRI requiring STR (local, pedicled and free flaps) who were treated from 2010-18 at the University Hospital Basel were included in this retrospective analysis. The main outcome measure was the success rate of STR, further outcome measures were fracture nonunion and recurrence of infection. Results Overall, 145 patients with lower leg FRI were identified, of whom 58 (40%) received STR (muscle flaps: n��=��38, fascio-cutaneous flaps: n=19; composite osteo-cutaneous flap: n��=��1). In total seven patients required secondary STR due to primary flap failure. All failures and flap-related complications occurred within the first three weeks after surgery. Secondary STR was successful in all cases. A high Charlson Comorbidity Index Score was a significant risk factor for flap failure (p��=��0.011). Out of the 43 patients who completed the 9-month follow-up, 11 patients presented with fracture nonunion and 12 patients with a recurrent infection. Polymicrobial infection was a significant risk factor for fracture nonunion (p��=��0.002). Primary flap failure was neither a risk factor for compromised fracture consolidation (p��=��0.590) nor for recurrence of infection (p��=��0.508). Conclusion: A considerable number of patients with lower-leg FRI required STR. This patient subgroup is complex and rich in complications and the long-term composite outcome demonstrated a high rate of compromised fracture consolidation and recurrent infections. It appears that secondary STR should be performed, as primary flap failure was neither a risk factor for compromised fracture consolidation nor for recurrence of infection. We propose to monitor these patients closely for three weeks after STR.

Fracture non-union is a significant orthopaedic problem affecting a substantial number of patients yearly. Treatment of nonunions is devastating to patients and costly to the healthcare system. Unfortunately, the diagnosis of non-union is typically made in a reactionary fashion by an orthopaedic surgeon based on clinical assessment and radiographic features several months into treatment. For this reason, investigators have been trying to develop prediction algorithms; however, these have relied on population-based approaches and lack the predictive capability necessary to make individual treatment decisions. There is also a growing body of literature focussed on identifying blood biomarkers that are associated with non-union. This review describes the research that has been done in this area. Further studies of patient-centered, precision medicine approaches will likely improve fracture non-union diagnostic/prognostic capabilities.

The purpose of this study was to evaluate the outcomes of fracture nonunion repair with autogenous iliac crest bone graft (ICBG) under regional anesthesia alone or in combination with other techniques compared to other anesthesia techniques. Overall, 137 patients were identified who underwent ICBG as part of a repair of a long bone fracture nonunion between January 1, 2013 and October 1, 2020. Surgical and anesthetic records were reviewed to classify patients by anesthesia type. General, spinal, and regional anesthetics were used as either the primary anesthetic or as a combination of regional nerve block with general or spinal anesthesia. Administration of regional anesthesia alone or in combination with general or spinal anesthesia (RA) and general or spinal anesthesia only (GS) groups differed in nonunion site distribution (p

OBJECTIVES To evaluate the outcomes of patients who underwent soft tissue flap coverage during treatment of a tibia fracture nonunion. DESIGN Retrospective analysis on prospectively collected data. SETTING Academic medical center. PATIENTS/PARTICIPANTS One hundred fifty-seven patients were treated for a fracture nonunion after a tibia fracture over a 15-year period. Sixty-six patients had sustained an open tibial fracture initially and 25 of these patients underwent soft tissue flaps for their open tibia fracture nonunion. INTERVENTION Manipulation of soft tissue flaps, either placement or elevation for graft placement in ununited previously open tibial fractures. MAIN OUTCOME MEASUREMENTS Bony healing, time to union, ultimate soft tissue status, postoperative complications, and functional outcome scores using the Short Musculoskeletal Functional Assessment (SMFA). This group was compared with a group of open tibial fracture nonunions that did not undergo soft tissue transfer. RESULTS Bony healing was achieved in 24 of 25 patients (96.0%) who received flaps at a mean time to union of 8.7 ± 3.3 months compared with 39 of 41 patients (95.1%) at a mean 7.5 ± 3.2 months (P > 0.05) in the noncoverage group. Healing rate and time to union did not differ between groups. At latest follow-up, the flap coverage group reported a mean SMFA index of 17.1 compared with an SMFA index of 27.7 for the noncoverage group (P = 0.037). CONCLUSIONS Utilization of soft tissue flaps in the setting of open tibia shaft nonunion repair surgery are associated with a high union rate (>90%). Coverage with or manipulation of soft tissue flaps did not result in improved bony healing rate or time to union compared with those who did not require flaps. However, soft tissue flap coverage was associated with higher functional scores at long-term follow-up. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The ability to study the bone microenvironment of failed fracture healing may lead to biomarkers for fracture nonunion. Herein the authors describe a technique for isolating individual cells suitable for single-cell RNA sequencing analyses from intramedullary canal tissue collected by reaming during surgery. The purpose was to detail challenges and solutions inherent to the collection and processing of intramedullary canal tissue samples. The authors then examined single-cell RNA sequencing data from fresh and reanimated samples to demonstrate the feasibility of this approach for prospective studies.

Biomedicines : open access journal 10(10), 2474 (2022). doi:10.3390/biomedicines10102474 special issue: "Special Issue "Molecular and Cellular Mechanisms of Bone and Cartilage Diseases" / Special Issue Editor: Dr. M. Alaa Terkawi, Guest Editor", Published by MDPI, Basel

Research objectivesdata analysis of the radiological methods different types of dysregenerations, based on the clinical cases.Material and methods. Literature review about radiation semiotics regeneration and dysregeneration phenomena, applicability of different types of radiological methods has been done. A review of 2 cases of delayed union and 5 cases of fracture nonunion is presented.Conclusion. Despite the improvement and technical simplicity of visualizing the phenomena of dysregeneration, it is difficult to differentiate delayed union from nonunion using only by radiological methods, respectively, a consensus of an orthopedic surgeon and a radiologist is required in each individual case. The clinician chooses the treatment tactics based on the complex data set, including radiological methods.

Clavicle fracture nonunion can lead to persistent pain and loss of shoulder function. Distal clavicle fractures have the greatest risk of nonunion and are often treated surgically. Bone grafting plays a vital role in the treatment of distal clavicle nonunion. Although multiple options for bone graft exist, the iliac crest has long been considered the gold standard for harvest. Despite its extensive use, multiple complications have been associated with iliac crest bone graft harvest. We advocate a surgical technique for arthroscopic bone graft harvest from the proximal humerus with open reduction and internal fixation of an ipsilateral distal clavicle nonunion.

Background A coronal fracture of the distal femoral condyle, known as a Hoffa fracture, seldom occurs and is easy to misdiagnose. Surgery treatment, including open anatomic reduction and internal fixation, is the primary method of treatment. However, cases involving nonunion are extremely rare. Case presentation We reported two cases in a 56-year-old female who visited our outpatient clinic with complaints of locking sensation, swelling, and pain, and a 64-year-old male patient who need additional care after having undergone surgery for a distal femur fracture. They presented with nonunion ofa Hoffa fracture (Letenneur type II), and these cases of nonunion were resolved surgically with debridement, two cannulated lag screws, a lateral extra-articular buttress plate, and the liberal use of autologous bone grafts. After surgery, the two patients were allowed to bear partial weight and perform exercises. They were allowed to walk with full weight-bearing after 3 months. No early complications, such as infection and loss of reduction, were noted after the revision surgery. At the one-year follow-up, both patients had excellent function and reported minimal pain, with a Lysholm score of 94. Conclusions Our case reports highlight the importance of the liberal use of autologous bone grafts, which allow stable reconstruction of the affected femoral condyle, thereby restoring joint congruence. A lateral extra-articular buttress plate in combination with two cannulated lag screws is recommended for nonunion in Hoffa fracture patients, and they need to be closely followed up to detect complications promptly, especially those related to nonunion.

Pseudoarthrosis is a complication that occurs in up to 12% of astragalus fractures. In this situation, 2main treatment options are considered: arthrodesis and secondary reconstruction. In this text we present the case of a patient who suffered this complication after not being diagnosed with the fracture he suffered and opted for secondary reconstruction with good results. Fracture nonunion affects up to 12% of patients suffering a talar fracture. Classically, most authors proceed to joint arthrodesis when facing such complication. A more recent approach consists on secondary reconstruction of the nonunion. In this paper we present the case of a reconstructed talar nonunion after an unnoticed talar body fracture with encouraging results.

OBJECTIVE The aim of this study was to compare the histological results of Accordion Maneuver (AM) with Compression Technique Alone (CA) in the treatment of atrophic fracture nonunion in a rabbit model. METHODS The study was performed on 91 male New Zealand rabbits aged six months, weighing 3.1 to 3.6 kg. The standardized models of atrophic nonunion with a 3-mm fracture were created in the tibias of rats. For the histomorphological study, 22 rabbits were randomly selected and sacrificed. The remaining 69 rabbits were divided into two groups based on the treatment technique: Group AM (n = 36) and Group CA (n = 33). The group AM was further randomly divided into four subgroups based on the amplitude and interval parameters: subgroup A1B1 (0 day, 4 mm; n = 9), subgroup A1B2 (0 day, 8 mm; n = 7), subgroup A2B1 (6 days, 4 mm; n = 10), and subgroup A2B2 (6 days, 8 mm; n = 10). A monolateral external fixator was employed in each group. Animals were sacrificed 6 weeks after the treatment, and bony healing was assessed both radiologically and histologically. The efficiency of bony healing was assessed using the bone content index, bone mineral density, and bone volume fraction indexes. RESULTS In X-ray and micro-computed tomography assessments, periosteal reaction was detected at the fracture site in all specimens. In group CA, sclerosis was observed at the ends of the fragments. Bony absorption, nonunion, and a little amount of island-like high density were also observed at the nonunion site. Among AM subgroups, sparse callus-like bone formation in A1B1 subgroup and a high density of callus connecting most parts of the gap and large amount of periosteal callus formation in A1B1 subgroup were observed. In A2B2 subgroup, the cortex was initially connected. No gap was observed, and the medullary cavity was recanalized. In histological analyses, the intermission of 0 day at rate of 8 mm was of the highest level of bony regeneration, and the intermission of 6 days at the rate of 4 mm was of the lowest level of bony regeneration (P < 0.05). CONCLUSION Based on the radiological and histological results obtained from the present study, AM seems to be more effective than CA in treating atrophic nonunion. AM can shorten the period of treatment. The interval of 0 day and an amplitude of 8 mm may be more proper for AM.

Bone marrow aspirate concentrate (BMAC) is an autologous cell composition that is obtained through a needle aspiration from the iliac crest. The purpose of this study was to evaluate the outcomes of patients treated with open reduction and internal fixation with BMAC supplementation for clavicle fracture nonunion. This was a retrospective case series of 21 consecutive patients with clavicle fracture nonunion that were treated with ORIF and BMAC supplementation between 2013 and 2020. Patients were evaluated for fracture union, time to union, complications related to surgical and donor site, and functional outcome using the Quick Disability of the Arm Shoulder and Hand (QDASH), subjective shoulder value (SSV), and pain. The mean age was 41.8 years. The mean follow-up was 36 months. Twenty (95.2%) patients demonstrated fracture union, with a mean time to union of 4.5 months. Good functional scores were achieved: SSV, 74.3, QDASH, 23.3, pain level, 3.1. There were no complications or pain related to the iliac crest donor site. Supplementary BMAC to ORIF in the treatment of clavicle fracture nonunion is a safe method, resulting in high rates of fracture union and good functional outcomes with minimal complications and pain.

The incidence of nonunion of fractures has been steadily rising owing to improved life expectancy following severe injuries along with rising cases of polytrauma. Once a nonunion is established, the chances of spontaneous healing are deemed to be quite low. Fracture nonunion continues to be a challenge in clinical practice with nonunions having a considerable impact on patient’s quality of life causing both functional and psychosocial disability. Low-Intensity Pulsed Ultrasound (LIPUS) therapy is being projected as a viable and non-interventional alternative to surgical management of nonunions and delayed unions. LIPUS therapy is being widely recommended as a standalone treatment option for the treatment of established nonunions and delayed unions as it is believed to promote healing in all phases of fracture healing viz., inflammatory, intramembranous ossification, chondrogenesis, endochondral ossification and remodelling. In the current scenario of varying results and unclear clinical role of LIPUS therapy, we present a prospective case series of fracture nonunions and delayed unions treated with LIPUS therapy at a large District General Hospital.

Case Avascular necrosis (AVN) and nonunion are common complications encountered with scaphoid waist fractures. We present a case of a 23-year-old man presenting with a right scaphoid fracture nonunion associated with AVN of the proximal pole. He was treated with a 1,2 intercompartmental supraretinacular arterial bone graft (Zaidemberg technique) in combination with a dorsal plate yielding excellent functional and radiographic results. Conclusion Scaphoid waist fracture nonunion with AVN of the proximal pole is challenging to treat and combining the Zaidemberg technique along with dorsal plating allows for easy access and excellent healing.

We present the case of a 19-year-old man with an open fracture of the tibia and fibula secondary to an accident with an all-terrain vehicle. He underwent operative excisional irrigation, debridement, and fixation on the day of injury. His course was complicated by nonunion of the tibia fracture. Infection is a common factor in fracture nonunion, even in patients who receive appropriate surgical and antimicrobial management. Paenibacillus turicensis, an organism adapted to survive in the environment via spore formation, was responsible for nonunion in our patient. A brief discussion of this unusual organism, fracture nonunion, and the role of infection in etiology of nonunion follows.

Purpose: Fractures of the humerus account for 5%－8% of all fractures. Nonunion is found with an incidence of up to 15%, depending on the location of the fracture. In case of a manifest nonunion the surgeon faces a challenging problem and has to conceive a therapy based on the underlying pathology. The aim of this study was to describe our treatment concepts for this entity and present our results of the last five years. Methods: Twenty-six patients were treated for nonunion of the humerus between January 2013 and December 2017. Their charts were reviewed retrospectively and demographic data, pathology, surgical treatment and outcome were assessed. Results: The most frequent location for a nonunion was the humeral shaft, with the most common trauma mechanism being multiple falls. Most often atrophic nonunion (n = 14), followed by hypertrophic and infection-caused nonunion (each n = 4), were found. Our treatment concept could be applied in 19 patients, of which in 90% of those who were available for follow-up consolidation could be achieved. Conclusion: Humeral nonunion is a heterogeneous entity that has to be analyzed precisely and be treated correspondingly. We therefore present a treatment concept based on the underlying pathology. Key words: Humerus; Nonunion; Delayed union; Humeral fractures

Background The treatment of subtrochanteric fracture nonunion is challenging. Although revision with either an intramedullary or extramedullary device had been advocated with acceptable results, complications that require secondary procedures still arise. The use of an intramedullary device with augmentation plate fixation is a well-known approach for femoral or tibial diaphyseal nonunion. However, this approach has not previously been reported for subtrochanteric fracture nonunion. Materials and methods A series of 21 cases of subtrochanteric fracture nonunion treated with an intramedullary device in combination with augmentation side plating were collected and retrospectively reviewed after an average of 18 months of followup. Fourteen patients with a prior well-fixed intramedullary device were treated with side plating and bone grafting. Seven patients underwent revision nailing in addition to side plating and bone grafting. Results All fractures united well without major complication. The average time to union was 7.1 months. Conclusion The use of an intramedullary device with augmentation plate fixation is a reliable and decisive procedure for treating subtrochanteric fracture nonunion that produces satisfactory results with a low complication rate.

Purpose The purpose of this study was to determine the effect of regional anaesthesia as compared to general anaesthesia on clinical, functional, and radiographic outcomes following long bone fracture nonunion repair. Methods 262 patients who underwent operative repair of a long bone fracture nonunion and had at least 12 months of post-operative follow up were included in this study. Functional outcomes were assessed prospectively using the Short Musculoskeletal Function Assessment (SMFA) and Visual Analog Scale (VAS) pain scores prior to nonunion repair and at routine intervals post-operatively. Patients were divided into two matched groups based upon the type of anaesthetic method used in surgery. The regional anaesthesia cohort was composed of all patients who received regional anaesthesia (spinal anaesthesia or peripheral nerve block) alone or in addition to general anaesthesia, while patients who received general anaesthesia alone made up the general anaesthesia cohort. Univariate and multivariate analyses were performed to examine the effect of anaesthesia type on functional outcome scores, post-operative pain, bony healing, and complication rate. Results The regional anaesthesia and general anaesthesia cohorts each consisted of 131 patients. Multiple linear regression demonstrated there to be no significant association between anaesthetic method and total SMFA scores at all post-operative time points. Additionally, anaesthetic method was not associated with post-operative VAS pain scores, time to union, or the rate of post-operative complications. Conclusion In this cohort, the use of regional anaesthesia during operative repair of long bone fracture nonunion was associated with no significant difference in functional outcome scores or pain levels at all post-operative time points. Furthermore, the use of regional anaesthesia had no effect on the rate of post-operative complications. Either type of anaesthetic appears to be safe and effective in performing these surgeries.

The technique of circular external fixation has been widely applied to treat an array of orthopaedic pathologies, including acute fractures and fracture nonunions. The evolution of this technology has led to many exciting new applications and designs: the hexapod—a highly sophisticated frame with six adjustable struts attached to rings that relies on the principle of projective geometry. The hexapods are currently used in acute fracture management and several indications for the use in complex clinical scenarios (open fractures, bone deficiencies, difficult fracture reductions and soft-tissue deficits) do exist. Furthermore, a key role for hexapods is in fracture nonunion management: hypertrophic, atrophic and infected nonunions all have very diverse aetiologies but all may be effectively managed with the hexapod frame. We present a number of complex cases that were treated surgically by the Limb Lengthening and Complex Reconstruction Service in our institution. The wide variation of challenging scenarios that may be treated effectively with the hexapod frame demonstrates the versatility and efficacy of this technology in current orthopaedic practice.

Case Although congenital nonunion of the clavicle is a well-known pathology in children, posttraumatic nonunion is a rare entity. Nonunion after open reduction and internal fixation of a clavicle fracture is exceptional in the pediatric population. We report on a patient presenting posttraumatic pseudarthrosis of the clavicle after surgical treatment. Pseudarthrosis was resected, and the defect was bridged with an iliac crest autograft, supplemented with bone morphogenetic protein, and fixed with an elastic stable intramedullary nail. Conclusion This procedure offered enough stability for achieving fracture consolidation and is a safe alternative to plating in clavicle nonunion.

Objective To report the results of patients with short oblique diaphyseal tibia fractures treated with minimally invasive plate osteosynthesis (MIPO). The secondary aim was to understand the effect of fracture location (midshaft or distal 1/3) on outcomes. Methods Twenty-eight patients with short oblique (>30°) tibial shaft fractures (AO/OTA 42A2) treated with plate and MIPO technique between 2015 and 2019 were retrospectively assessed. Age, gender, follow-up time, fracture type (open or closed), operation time, postoperative infection rate, union time, ankle joint range of motion, and complications were analyzed. Patients’ radiographs at a minimum 1-year follow-up were evaluated for malunion, nonunion, and implant-related complications. Results Mean age and follow-up time were 47.0 ± 15.7 years and 18.3 ± 12.1 months, respectively. Mean bone union time was 3.66 ± 1.04 months in middle 1/3 diaphysis and 4.23 ± 1.48 months in distal 1/3 tibia fractures. Seven (25%) patients developed superficial infections. Mean union time, malunion rate, coronal and sagittal angulation, operation length, and infection rate were similar between the groups. Conclusion MIPO is an effective method for treatment of short oblique diaphyseal tibia fractures, and results in few complications. Both distal and midshaft fractures have similar union and malunion rates.

BACKGROUND: Cyclooxygenase-2 (COX-2) has been found to be important for fracture-healing in animal models, raising concerns about use of nonsteroidal anti-inflammatory drugs (NSAIDs) and selective COX-2 inhibitors after fractures. We evaluated associations of NSAIDs, COX-2 inhibitors, and opioids with nonunion after long-bone fracture. METHODS: Using private health insurance claims data from Optum’s de-identified Clinformatics Data Mart database from January 1, 2000, to September 30, 2015, we identified adults with a single long-bone fracture or commonly paired long-bone fractures who had 1 year of available follow-up data. Using multivariable logistic regression models, we examined associations between NSAID, COX-2-inhibitor, or opioid prescription fills after the fracture and the risk of nonunion within 1 year, defined as a nonunion diagnosis with a procedure to treat the nonunion. RESULTS: A nonunion diagnosis with a procedure to treat the nonunion was identified after 2,996 (0.9%) of the 339,864 fracture episodes, with rates varying by fracture site. The risk of that outcome was greater in patients who had filled COX-2-inhibitor prescriptions (adjusted odds ratio = 1.84 [95% confidence interval = 1.38 to 2.46]) or opioid prescriptions (1.69 [1.53 to 1.86]), but not in patients who had filled nonselective-NSAID prescriptions (1.07 [0.93 to 1.23]) after the fracture. Results were similar when the outcome definition was changed to just a nonunion diagnosis. CONCLUSIONS: COX-2 inhibitors, but not nonselective NSAIDs, were associated with a greater risk of nonunion after fracture. Opioids were also associated with nonunion risk, although patients filling prescriptions for opioids may have had more severe fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

CASE A 54-year-old man presented with a comminuted left midclavicle fracture that progressed to a symptomatic nonunion after nonsurgical management. Nonunion open reduction and internal fixation (ORIF) was performed, but a left brachial plexopathy developed 48 hours postoperatively. Imaging failed to demonstrate an emergent cause. The patient was monitored and completely recovered, with occasional neuralgia and mildly limited forward elevation of the shoulder. CONCLUSION Development of a brachial plexopathy 48 hours after routine clavicle nonunion ORIF using plate fixation is an unusual complication. Future studies are needed to determine if this "wait-and-see" approach can be generalized to similar cases.

The failure of bony union following a fracture, termed a fracture nonunion, has severe patient morbidity and economic consequences. This review describes current consensuses and future directions of investigation for determining why, detecting when, and effective treatment if this complication occurs. Current nonunion investigation is emphasizing an expanded understanding of the biology of healing. This has led to assessments of the immune environment, multiple cytokines and morphogenetic factors, and the role of skeletogenic stem cells in the development of nonunion. Detecting biological markers and other objective diagnostic criteria is also a current objective of nonunion research. Treatment approaches in the near future will likely be dominated by the development of specific adjunct therapies to the nonunion surgical management, which will be informed by an expanded mechanistic understanding of nonunion biology. Current consensus among orthopedists is that improved diagnosis and treatment of nonunion hinges first on discoveries at the bench side with later translation to the clinic.

Fracture healing is a complex biological and biomechanical process that depends upon a sequence of factors to take place in an often-forgotten about biomechanical environment. Generally, fracture healing proceeds in one of two ways. When fracture fragments are brought directly into contact with each other and stabilized in a manner that limits motion, healing generally takes place by primary/direct bone healing. Primary bone healing includes both contact and gap healing, and in these scenarios fracture healing generally does not include callus formation. Secondary/indirect fracture healing generally occurs when the biomechanical environment during healing allows some motion at the fracture site. Secondary bone healing, unlike primary bone healing, includes the development of a soft callus comprised mostly of cartilage, followed by ossification of this soft callus, and eventually complete fracture healing and remodeling. When fractures fail to heal in the expected time frame, they are considered to be a nonunion. The multiple clinical examples in this chapter highlight the relationship between the biomechanical environment provided by external and internal means of fracture stabilization and the type of fracture healing to be expected. This chapter also includes a description of these types of fracture healing as well as a couple of examples of the approach and treatment of fracture nonunion.

The objective of this study was to review the efficacy of a treatment approach for patients with positive intraoperative cultures during fracture nonunion surgery. The authors performed a retrospective case series at a level I trauma center. In this series, 60 patients without preoperative concern for infection were surgically treated for fracture nonunion. The treatment course of patients after fracture nonunion surgery, including culture results, antibiotic administration, and the presence of clinical infection and radiographic union, was studied. Sixty patients underwent fracture nonunion surgery. Twenty-four patients had a positive intraoperative culture. Fourteen patients had only a positive broth culture, 6 had only a positive routine culture, and 4 had positive mixed (routine and broth) cultures. The most common bacteria was coagulase-negative staphylococci, isolated in 19 of 24 patients, and the only isolated organism in 13 of 24 patients. Patients with a positive broth culture were not treated with antibiotics. Four of 10 patients with either a positive routine or mixed culture grown within 3 days of surgery were treated with antibiotics. All patients achieved clinical healing without signs of infection, and all but 2 patients achieved radiographic union at a mean follow-up of approximately 5 years. In the setting of fracture nonunion surgery, patients with only a positive broth culture and those with only a positive routine or mixed cultures that grew in a delayed fashion (>3 days postoperatively) did not require antibiotic treatment to achieve healing. [ Orthopedics . 2019; 42(6):e532–e538.]

Background Leg pain in athletes is a common condition and is often related to tibial stress fracture. When non-operative treatment fails, the optimal surgical treatment is controversial. The aim of this study was to report a case of tension band plating of an anterior tibial stress fracture nonunion, treated previously with intramedullary nailing. To the best of our knowledge, this is the first reported case in which tension band plating was placed without removing the preexisting intramedullary nail. Case presentation The tibial shaft is a common location of stress fracture in athletes. Anterior tibial stress fractures are difficult to manage. When conservative treatment fails, intramedullary nailing is the mainstay of treatment. However, nonunion is a serious complication. In our case, a non-united anterior tibial stress fracture, treated with intramedullary nailing, was addressed with the application of a compression prebended plate over the nail in a 23-year-old French man of African origin who is an elite football player. At 3-months postoperatively he was pain free and started light exercises. At 6-months postoperatively, complete radiologic union of the fracture was evident. He was symptom free; he resumed at that time a full training program and he returned to play football at preinjury high competition level. Conclusions Compression plating is a valuable method of treating non-united anterior tibial stress fractures. We believe that anterior tension band plating is superior to intramedullary nailing in managing anterior tibial stress fractures, not only after failure of intramedullary nailing, but also as a first-line surgical treatment. This technique offers advantages, such as no violation of the extensor mechanism and risk of anterior knee pain, and directly addresses the underlying problem of distraction forces acting on the anterior tibial cortex and compromising fracture healing. Especially in high-level athletes, who cannot tolerate prolonged inactivity, early surgical intervention of anterior tibial stress fractures with tension band plating is a reliable option that can accelerate recovery.

Introduction: Isolated distal ulnar fracture is an uncommon injury. Only a few case series that look into the management of ulnar fracture nonunion have been reported in the literature. Case presentation: A middle-aged manual worker presented to us for isolated fracture of his left distal ulna. He received open reduction and fixation of the distal ulnar fracture using distal ulna locking plate. It was complicated with nonunion and he complained of persistent wrist pain. This distal ulnar fracture nonunion was finally treated by Sauve-Kapandji procedure with good functional outcome. Discussion: Displaced distal ulnar fracture should be reduced anatomically with rigid fixation to prevent disruption of the distal radioulnar joint. Fracture nonunion was traditionally managed with revision osteosynthesis and bone grafting. It is, however, technically difficult at the distal ulnar region because of the poor bone stock and lack of soft tissue coverage. Conclusion: We have demonstrated that the Sauvé-Kapandji procedure is a good treatment alternative for distal ulnar fracture nonunion.

Aims Clavicle fracture nonunions are extremely rare in children. The aim of this systematic review was to assess what factors may predispose children to form clavicle fracture nonunions and evaluate the treatment methods and outcomes. Methods We performed a systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, aiming to find papers reporting clavicle fracture nonunion in children under the age of 18 years. Data was collected on patient demographics, fracture type, mechanism of injury (MOI), surgical intervention and reported outcome. Two independent reviewers evaluated all the data. Results A total of 13 articles reporting 21 cases of clavicle fracture nonunion were identified. The mean age at time of injury was 11.4 years (4 to 17). Falls were the most common MOI. The majority of nonunions occurred after displaced fractures on the right side. Six were refractures. Mean time of presentation following injury was 13.5 months (4 to 60). In all, 16 were treated surgically. Radiographic union was eventually achieved in 12 cases, with functional outcome satisfactory in all cases. Conclusion Clavicle nonunion is an extremely rare but possible complication in children. The majority occur after displaced right-sided fractures or refractures and present around one year after injury. Surgical fixation provides good radiographic healing and functional outcomes. Level of evidence IV

Aim. To carry out literature analysis devoted to pathological mechanisms of delayed union and nonunion of limb fractures and the influence of various osteosynthesis strategies on bone healing in polytrauma. The risk of bone fractures nonunion in polytrauma increases with high-energy complex comminuted and open fractures with severe injuries of soft tissues and bones, bruised lung, shock and severe massive blood loss. The development of a systemic inflammatory response affects local immune responses in the fracture zone to the early inflammatory phase of bone healing and disrupts subsequent osteogenesis and angiogenesis processes. Early stable-functional osteosynthesis using minimally invasive techniques creates optimal conditions for bone healing. When following the tactics of the stepwise treatment of Damage Control Orthopedics, the risk of infectious complications and fracture nonunion increases with the duration of treatment in the apparatus of external fixation. Conclusion. In polytrauma a violation of consolidation of bone fractures of the extremities occurs more often than in isolated trauma. Risk factors of fracture nonunion in polytrauma are the severity of bone and soft tissue damage, shock, acute blood loss and systemic inflammatory response, as well as unjustified delay in the final stable fixation of long bones fragments or using traumatic methods of their early osteosynthesis without taking into account the severity of the condition of the injured.

Scaphoid fractures are the most common fractures of the carpal bones, corresponding to 60%. Of these, 10% progress to nonunion; moreover, 3% can present necrosis of the proximal pole. There are various methods of treatment using vascularized and non-vascularized bone grafts. To evaluate and compare the rate of scaphoid consolidation with necrosis of the proximal pole using different surgical techniques. The authors conducted a review of the literature using the following databases: PubMed and BIREME/LILACS, where 13 case series were selected (ten with use of vascularized bone grafts and three of non-vascularized bone grafts), according to inclusion and exclusion criteria. In most cases VBGs were used, especially those based on the 1,2 intercompartmental supraretinacular artery, due to greater reproducibility in performing the surgical technique.As fraturas do escafoide são as mais comuns dos ossos do carpo, correspondem a 60%. Dessas, 10% evoluem para não consolidação; além disso, 3% podem apresentar necrose do polo proximal. Existem vários métodos de tratamento com enxertos ósseos, vascularizados e não vascularizados.Avaliar e comparar as taxas de consolidação do escafoide com necrose do polo proximal com diferentes técnicas cirúrgicas.Fez-se uma revisão na literatura nas bases de dados PubMed e Bireme/Lilacs, das quais foram selecionadas 13 séries de casos (dez com uso de enxertos ósseos vascularizadose três enxertos ósseos não vascularizados), de acordo com os critérios de inclusão e exclusão.Enxertos ósseos vascularizados foram usados na maioria dos casos, principalmente naqueles baseados na artéria intercompartimental suprarretinacular 1 e 2, devido à maior reprodutibilidade na técnica cirúrgica.

CASE We describe 2 patients with nonunion of the clavicle and dynamic compression of the subclavian artery. In both patients, no structural abnormality of the subclavian vessels was evident at rest; however, with the arm in hyperabduction, arterial occlusion occurred because of the mobility of the fracture and a prominent callus. CONCLUSION This small case series demonstrates an important and, to our knowledge, unreported clinical complication of clavicle fracture nonunion. We believe that this complication is worth considering as a rare but important cause of pain in patients with delayed union or nonunion of the clavicle.

The use of stem cells in orthopedics has gained recognition and popularity for a variety of clinical problems. The important source of stem cells for clinical use is from the bone marrow and the adipose tissue. The main indication for stem cells in orthopedics includes nonunion of the fractures, avascular necrosis (AVN), cartilage damage, and tendinopathies.

ObjectivesA successful outcome following treatment of nonunion requires the correct identification of all of the underlying cause(s) and addressing them appropriately. The aim of this study was to assess the distribution and frequency of causative factors in a consecutive cohort of nonunion patients in order to optimise the management strategy for individual patients presenting with nonunion.MethodsCauses of the nonunion were divided into four categories: mechanical; infection; dead bone with a gap; and host. Prospective and retrospective data of 100 consecutive patients who had undergone surgery for long bone fracture nonunion were analysed.ResultsA total of 31% of patients had a single attributable cause, 55% had two causes, 14% had three causes and 1% had all four. Of those (31%) with only a single attributable cause, half were due to a mechanical factor and a quarter had dead bone with a gap. Mechanical causation was found in 59% of all patients, dead bone and a gap was present in 47%, host factors in 43% and infection was a causative factor in 38% of patients. In all, three of 58 patients (5%) thought to be aseptic and two of nine (22%) suspected of possible infection were found to be infected. A total of 100% of previously treated patients no longer considered to have ongoing infection, had multiple positive microbiology results.ConclusionTwo thirds of patients had multiple contributing factors for their nonunion and 5% had entirely unexpected infection. This study highlights the importance of identifying all of the aetiological factors and routinely testing tissue for infection in treating nonunion. It raises key points regarding the inadequacy of a purely radiographic nonunion classification system and the variety of different definitions for atrophic nonunion in the current mainstream classifications used for nonunion. Cite this article: L. Mills, J. Tsang, G. Hopper, G. Keenan, A. H. R. W. Simpson. The multifactorial aetiology of fracture nonunion and the importance of searching for latent infection. Bone Joint Res 2016;5:512–519. DOI: 10.1302/2046-3758.510.BJR-2016-0138.

Ankle fracture nonunion is a rare occurrence following closed or operative intervention. When it does occur, patients can experience debilitating symptoms that limit daily function. Malleolar nonunion can be caused by patient factors, such as smoking, malnutrition, or vascular insufficiency. Surgeon factors, such as insufficient or inappropriate operative fixation, also play a role. Several adjuncts, such as bone grafting, bone morphogenic protein, and bone stimulation, are useful in treating nonunions. Through a multimodal approach, malleolar nonunions are reliably treated with operative fixation leading to good patient outcomes with minimal complications.

Background Scaphoid fractures in the pediatric population are rare. The majority of nondisplaced fractures tend to unite; however, there is an increased risk of nonunion in proximal pole fractures. Limited evidence exists in their outcomes, owing to the scarcity of the fracture pattern. Case Description A 13-year-old boy who presented late after developing a traumatic proximal pole scaphoid fracture developed nonunion. He was treated conservatively owing to it being asymptomatic and developed union at 18 months. Literature Review No previous case of proximal pole pediatric scaphoid fractures with established nonunion that has developed union with conservative management has been described. Clinical Relevance The authors highlight a unique case of an established proximal pole scaphoid nonunion in a child progressing to union with nonoperative intervention. Owing to its rarity and difficulty in obtaining research, we recommend consideration of nonoperative management of asymptomatic nondisplaced proximal pole fractures in children.

Hydatid disease is an infrequent parasitic infestation caused by cestode, most commonly, Echinococcus granulosus. Bone involvement is distinctly uncommon. We would like to share our experience of a rare case of hydatid disease of femur in a 24-year-old male who presented with nonunion of subtrochanteric fracture. Histopathology showed typical lamellated wall and dagger-shaped hooklets. In view of its rarity, hydatid disease often remains an unsuspected infection of the bone.

Background Isolated capitate nonunion is rare. No consensus on the appropriate treatment for this condition exists. Case Description We reported two cases of capitate fracture nonunion presenting several months after untreated high-impact wrist trauma. Treatment was delayed as both patients' nonunions were missed on conventional radiographs. Both were ultimately diagnosed with advanced imaging and successfully treated with internal fixation and autogenous bone grafting. The relevant literature pertaining to capitate nonunion was reviewed. Literature Review Immobilization and internal fixation with bone grafting for capitate nonunion have been described in the literature. Loss of vascular supply and progression to avascular necrosis is a concern after capitate nonunion. Clinical Relevance We present two cases and review the literature on the diagnosis and treatment of this rare injury to guide management. Internal fixation with autogenous bone grafting could play a role in management for this rare condition.

Case: Two cases of symptomatic distal phalangeal fracture nonunion that were treated with a course of digital splinting and daily external low-intensity pulsed ultrasound (LIPUS) treatment are presented. Osseous union, symptom resolution, and full range of motion were successfully achieved in both cases without surgery. Conclusion: Digital splinting and daily LIPUS should be considered as a treatment option for symptomatic nonunion of the distal phalanx in cases that do not require correction of bone deformity.

Navicular fracture is still challenging disorder to treat because there is a risk of nonunion, avascular necrosis and symptomatic osteoarthritis.A 40-year-old woman with an ununited fracture of the tarsal navicular bone was treated with localized naviculocuneiform arthrodesis (arthrodesis of the navicular, the middle cuneiform, and the lateral cuneiform). Fusion with the navicular, the middle cuneiform, and the lateral cuneiform as well as union of fracture of the navicular was confirmed on the radiographs.Localized naviculocuneiform arthrodesis using a locked plating system is one of the options to treat nonunion of the navicular bone.

The estimated rate of fracture nonunion is between 5% and 10%, adding significant cost to the health care system. The cause of fracture nonunion is multifactorial, including the severity of the injury, patient factors resulting in aberrancies in the biology of fracture, and the side effects of pain control modalities. Minimizing surgeon-controlled factors causing nonunion is important to reduce the cost of health care and improve patient outcomes. Opioids, alcohol, and nonsteroidal anti-inflammatory drugs have been implicated as risk factors for fracture nonunion. Current literature was reviewed to examine the effects of opioids, alcohol, and nonsteroidal anti-inflammatory drugs on fracture union.