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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.

This systematic review and meta-analysis aimed to analyse negative effects of smoking in orthopaedic and trauma patients. A PubMed search was carried out for studies published until July 2020 regarding effects of smoking on fracture risk, nonunion, infection after orthopaedic surgery, and persisting nonunion after scaphoid nonunion surgery. Random effects models calculated for outcome parameters, and relative risks (RR) with 95% confidence intervals are provided. No adjustments for covariates were made. Heterogeneity was assessed with Higgins’ I2, publication bias with Harbord’s p (Hp), sensitivity analysis performed on funnel plots and quality of studies was analysed using the Newcastle-Ottawa Scale. Of 3362 retrieved entries, 69 were included in the final analysis. Unadjusted RR for smokers to develop vertebral (six studies, seven entries; RR: 1.61; p = 0.008; I2 = 89.4%), hip (11 studies, 15 entries; RR: 1.28; p = 0.007; I2 = 84.1%), and other fractures (eight studies, 10 entries; RR: 1.75; p = 0.019; I2 = 89.3%) was significantly higher. Postoperative infection risk was generally higher for smokers (21 studies; RR: 2.20; p < 0.001; I2 = 58.9%), and remained upon subgroup analysis for elective spinal (two studies; RR: 4.38; p < 0.001; I2 = 0.0%) and fracture surgery (19 studies; RR: 2.10; p < 0.001; I2 = 58.5%). Nonunion risk after orthopaedic (eight studies; RR: 2.15; p < 0.001; I2 = 35.9%) and fracture surgery (11 studies; RR: 1.85; p < 0.001; I2 = 39.9%) was significantly higher for smokers, as was persisting nonunion risk after surgery for scaphoid nonunion (five studies; RR: 3.52; p < 0.001; I2 = 0.0%). Sensitivity analysis for each model reduced heterogeneity whilst maintaining significance (all I2 < 20.0%). Smoking has a deleterious impact on fracture incidence, and (subsequent) development of nonunions and postoperative infections. Cite this article: EFORT Open Rev 2021;6:1006-1019. DOI: 10.1302/2058-5241.6.210058

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.

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.

Introduction Idiopathic Parkinson’s disease (PD) is a progressive neurologic disorder causing postural instability and unsteady gait. These patients are at increased risk for fractures and have inferior outcomes after treatment. Several studies have evaluated the incidence and outcome of PD patients after hip fractures. However, there are limited studies assessing the outcome of upper extremity fractures in these patients. In this study, we evaluated the outcome of PD patients that received surgical intervention for distal radial fractures (DRF). We hypothesize that these patients have an inferior outcome after surgery in comparison with non-PD patients. Methods Between May 2005 and May 2017, we retrospectively reviewed all of the patients with DRF and subsequently underwent open reduction and internal fixation (ORIF) at a level 1 trauma center. All of the surgeries were performed by fellowship-trained orthopedic surgeons. The inclusion criteria include patients with a definitive diagnosis of PD, non-pathological DRF, and a minimum follow-up of 1 year or up until the time of treatment failure was noted. Each PD patient was matched for age and gender to 3 non-PD patients. The primary objective was to determine the failure rate after surgical fixation for DRF. The secondary outcomes include time to treatment failure, reoperation rate, readmission rate, length of hospital stay, and postoperative complications. Results A total of 88 patients were included in this study (23 PD, 65 non-PD patients). All underwent ORIF and received standard postoperative follow-ups. The overall treatment failure rate in PD was 39.1% vs. 4.6% in the non-PD group (p < 0.05). The time to treatment failure were 9.11 ± 3.86 weeks and 14.67 ± 5.8 weeks for PD and non-PD, respectively (p < 0.05). PD patients had a significantly higher rate of failure when k-wires and ESF were used (p < 0.05%), while loss of reduction was the most common mode of failure in PD (44.4%). The length of hospital stay for PD was 5.3 ± 4.69 days compared with 3.78 ± 0.96 days for non-PD (p = 0.01). There were 3 PD patients readmitted within 30 days after surgery, and 1 patient had pneumonia after the surgery. Conclusion This study revealed that patients with PD have a high treatment failure rate despite surgical intervention for DRF. PD patients had a longer hospital stay and had a shorter time to treatment failure. In treating PD patients complicated with DRF, the surgeon must take into consideration the complex disease course of PD and the associated comorbidities such as osteoporosis, frail status, and frequent falls. Rehabilitation and disposition plans should be discussed in advance and longer hospital stays should be expected. Level of evidenceLevel IV, retrospective cohort study

Background: Nonunion is one of the medical conditions challenging the trauma specialists. Timely identification of people at high risk of nonunion is important to improve the prognosis of patients.Methods: We retrospectively analyzed the demographic and laboratory hematological characteristics of 338 patients with either clavicle or femoral fractures treated with ORIF in Shandong Provincial Hospital affiliated to Shandong University from January 2010 to May 2019. Descriptive statistics, univariate regression analysis, and multivariate regression analysis were conducted to confirm the independent factors associated with nonunion after ORIF.Results: The overall nonunion rate among the patients investigated in this study was ~6.8%, while the nonunion rates were 5.6% and 10.3% in clavicle and the femur fractures, respectively. Results of the univariate logistic regression analysis showed that the serum fibrinogen concentration (FIB), the hemoglobin count (HGB), the lymphocyte absolute value (LYMPH), the coefficient of variation of red blood cell distribution width (RDW-CV), the American Society of Anesthesiologists (ASA) classification, and the mechanism of injury were related to the occurrence of nonunion (p < 0.05). Results of the multivariate regression analysis showed that FIB (OR = 1.64, 95% CI of 1.14 to 2.36, p < 0.01), LYMPH (OR = 0.34, 95% CI of 0.15 to 0.77, p < 0.01), ASA classification (OR = 3.52, 95% CI of 1.20 to 10.31, p = 0.02), and injury mechanism (OR=3.13, 95% CI of 1.20 to 8.21, p = 0.02) were independently associated with the occurrence of nonunion.Conclusions: Our study has revealed that FIB, LYMPH, ASA classification, and injury mechanism are independently related to the occurrence of nonunion after ORIF, providing important guidance for clinicians to identify patients with high risk of nonunion in time, ultimately improving the prognosis and quality of life of patients.

Aside from the more common dorsal avulsion fractures, isolated triquetral body fractures are a rare injury and often missed. When they are identified, conservative treatment via immobilization is often the standard of care for initial treatment. Rarely, triquetral body fractures can develop into symptomatic nonunions, causing considerable pain and disability. Multiple classification schemes have been described to categorize triquetrum fractures; however, distal triquetrum fractures fit into none of the established models. There is scarce literature describing treatment of triquetral body fracture nonunions. The few reports that exist often use a variation of open reduction internal fixation with or without grafting as treatment. We present the case of an unusual triquetral body fracture nonunion that was successfully treated via surgical excision of the ununited distal fragment.

CASE A 71-year-old man with a proximal humerus fracture nonunion underwent surgery augmented by a fibular cortical strut allograft. On placing the allograft within the proximal humerus, fluoroscopic images showed 2 foreign bodies found to be broken drill bits located within the allograft. The drill bits were extracted, and the allograft was reprepared for use. CONCLUSION After 2 years of follow-up, no significant sequela related to the foreign bodies was noted. To the best of our knowledge, this case report represents the first-of-its-kind occurrence of broken drill bits found within bone allograft.

Background: Extracorporeal shockwave is recommended as the first choice for the treatment of fracture nonunion, However, some patients with fracture nonunion have poor response to extracorporeal shockwave therapy. The present study aimed to investigate related factors which may affect the clinical efficacy of extracorporeal shockwave on fracture nonunion. Methods: Ultrasound examination was applied to observe nonunion gap, local blood supply, hardness of callus and hematoma formation before and after extracorporeal shockwave therapy. The patient's condition was followed up for 12 months after extracorporeal shockwave therapy. Four correlations and regression analysis methods were applied to analyze the factors which were correlated the clinical efficacy of extracorporeal shockwave. Receiver-operating characteristic analysis revealed that the cut-off of the fracture nonunion gap was 4.200 mm and the cut-off of the hardness of callus/impulse energy was 2.555. Single factor linear correlation analysis, multi-factor linear regression analysis, single-factor logistic regression analysis were applied. Results: The four ultrasound signs were significantly correlated with extracorporeal shockwave therapy: nonunion gap (r = -0.723; OR = 3.074), local blood supply (r = 0.611; OR = 0.191), hardness of callus/impulse energy (r = -0.510; OR = 19.942), and hematoma formation (r = 0.722; OR = 0.015). Conclusions: Nonunion gap larger than 4.200 mm and hardness of callus/impulse energy larger than 2.555 are risk factors of extracorporeal shockwave therapy outcome, and good local blood supply and effective hematoma formation induced by extracorporeal shockwave therapy are protective factors. By analyzing the related factors of extracorporeal shockwave therapy on fracture nonunion, clinicians may screen out the patients with fracture nonunion who are not suitable for extracorporeal shockwave therapy, and reduce the risk of fracture nonunion.

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: Undisplaced subtle ligamentous Lisfranc injuries are easy to miss or underestimate, and many cases are treated without surgical fixation. It has not yet widely known whether conservative treatment for undisplaced subtle ligamentous Lisfranc injuries may lead to a poor outcome. The purpose of this study is to compare the outcomes of conservative versus surgical management (percutaneous position screw) of undisplaced subtle ligamentous Lisfranc injury. Methods: We analysed 61 cases in this retrospective study, including 38 males and 23 females. Forty-one patients were managed conservatively, while 20 patients received surgical treatment involving minimal invasive percutaneous position screw. American orthopaedic foot &ankle society (AOFAS), foot function index (FFI, including FFI disability, FFI pain score and activity limitation scale) scores, Maryland foot score and short form-36 (SF-36) were recorded and compared after a follow-up of 10- 16 months (average 12.3). Results: Patients in the surgical management group had higher scores in all evaluation methods (p < 0.05). The complications in the conservative management group had higher incidence, mainly including secondary diastasis (34.1% vs. 5.0%), joint stiffness after 3 months (82.9% vs. 0%), and secondary arthrodesis (12.2% vs. 0%). The highest rate of complication in surgical management group was temporary forefoot pain (55.0%). Conclusion: The results of this study suggest that the outcomes of the surgical management with percutaneous position screw fixation are better than the conservative management to treat undisplaced subtle ligamentous Lisfranc injuries. This study can serve as a resource for orthopaedic surgeons in recognizing and managing such injuries. Key words: Undisplaced subtle ligamentous Lisfranc injuries; Conservative management; Surgical management; Percutaneous position screw; Complications

Calcaneovalgus foot deformities are present in up to 35% of patients with lumbar spina bifida. Resultant heel weight bearing causes complications include those associated with pressure ulcers. Early surgical reconstruction is advocated to prevent deformity progression and rigidity. Several surgical techniques in paediatric populations have been described, but there remains a paucity of literature regarding reconstruction of chronic calcaneovalgus feet in adults. This case report describes our experience using the Ilizarov technique in the reconstruction of an adult presenting with chronic calcaneovalgus feet. This is a 34-year-old lady with myelomeningocoele spina bifida of lumbar level 5 who presented with a history of multiple admissions for cellulitis and infections of bilateral heel pressure sores. Rigid calcaneovalgus deformities of both feet (45° on the right, 40° on the left) were noted on clinical examination and radiological investigations. Reconstruction with an Ilizarov frame allowed for gradual correction of both soft tissue and bone, correcting heel weight bearing ambulation, with the aim of preventing further complications from infected heel ulcers. While the correction of bony deformities is crucial, management of chronically contracted soft tissue must not be overlooked. An Ilizarov frame requires both an experienced surgeon and a motivated patient, but it allows for accurate reconstruction of bony deformities, while allowing management of surrounding chronic soft tissue contractures with good functional outcome. Keywords: Ilizarov technique, Calcaneus, Foot deformities, Contracture, Meningomyelocele

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.

The Non-Union Scoring System (NUSS) aims to classify non-unions according to their severity and relate them to four treatment categories. The main purpose of this study was to evaluate the reliability of the NUSS. In addition we assessed its clinical validity. Forty-four Patients with a tibia non-union between 2005 and 2015 were included in this study. Data from all included patients were scored independently by three observers according to the NUSS criteria. The interobserver agreement was evaluated using the intraclass correlation coefficient (ICC). The interobserver agreement of the Weber–Cech system was assessed using Fleiss’ kappa. Finally, the clinical validity of the NUSS was analysed by comparing outcomes of the actual treatment groups to the proposed treatment groups following from the NUSS scores. Forty-four patients were included. The comparison of NUSS scores between observers showed substantial agreement [ICC; 0.78 (0.67–0.86)]. The comparison of the Weber–Cech classification between observers showed only fair agreement [Fleiss κ; 0.30 (0.17–0.42)]. The χ2 test for the treatment groups according to the NUSS and the treatments at index procedure showed an independent relation (χ2 = 5.794, 6 degrees of freedom, p: 0.447). In contrast, the proposed treatment strategy corresponds well to the definitive treatment (χ2 = 29.963, 9 degrees of freedom, p

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 provide a comprehensive survey of the literature related to the current efficacy of biomarkers for predicting fracture healing. Methods: EMBASE and PubMed, were searched using the following terms: fractures, biomarkers, ununited, and nonunion with the assistance of a medical librarian. The initial search yielded 199 records. Additional search of Google Scholar and review of the references yielded zero additional records. The 165 unique records were screened, of which 105 were excluded due to experimental treatments, non-fracture related bone healing, animal studies, and study group design failure to compare union versus nonunion fracture outcomes. This left 21 articles for full review. Results: 19 serum biomarkers were reviewed for nonunion predicative capability. From this cohort 9 biomarkers had promising results including; bone formation markers OC and PINP, bone resorption markers TRAP and OPN, growth factors VEGF and PGF-1, TEMRA and TReg cells, and miR-193a-3p. 15 SNPs on 11 genes were examined. The polymorphisms with the greatest potential for increased risk of nonunion based on odds ratio include; SMAD6 rs2053423 T/T genotype OR = 10.27. IL-1b rs2853550 T allele OR = 5.9. NOG rs1372857 G/G genotype OR = 4.56. NOS rs2297514 OR = 3.98. and PDGF CCG haplotype OR = 3.57 Conclusion: There remains an unmet clinical need to develop predictive parameter(s) for bone healing that are objective, reproducible, preferably continuous, unique to the individual, and optimally based on a readily accessible biologic measurement. Ultimately yielding a biomarker predictive of future nonunion that is additive, or superior, to that of known clinical risk factors for nonunion. Clinical Implications: Accurate biomarkers could identify patients at early times post-injury who may benefit from intervention to promote healing, thus circumventing unnecessary delays in nonunion intervention. Additionally, biomarkers could eliminate preemptive surgery in patients with early slow progression who are otherwise on a healing trajectory.

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.

Introduction: Treatment of infected non-unions of the tibia is a challenging problem. The cornerstones of optimal infected non-union treatment consist of extensive debridement, fracture fixation, antimicro-bial therapy and creation of an optimal local biological bone healing environment. The combination of S53P4 bioactive glass (BAG), as osteostimulative antibacterial bone graft substitute, and bone marrow as-pirate concentrate (BMAC) for the implantation of mesenchymal stem cells and growth factors might be a promising combination. In this paper, preliminary results of a new treatment algorithm for infected non-unions of the tibia is presented.Methods: In this retrospective case series patients with infected non-unions of the tibia are treated ac-cording to a new treatment algorithm. Patients are treated with extensive debridement surgery, replace-ment of the osteosynthesis and implantation of S53P4 BAG and BMAC in a one-stage or two-stage proce-dure based on non-union severity. Subsequently patients are treated with culture based antibiotic therapy and followed until union and infection eradication.Results: Five patients with an infected non-union were treated, mean age was 55, average NUSS-score was 44 and the average segmental bone defect was 4.6cm. One patient was treated in a one-stage pro-cedure and four patients in a two-stage induced membrane-, or "Masquelet"-procedure. On average, 23 ml S53P4 BAG and 6.2 ml BMAC was implanted. The mean follow-up period was 13.6 months and at the end of follow-up all patients had clinical consolidation with an average RUST-score of 7.8 and complete eradication of infection. Discussion: These early data on the combined implantation of S53P4 BAG and BMAC in treatment of infected non-unions shows promising results. These fracture healing results and eradication rates resulted in promising functional recovery of the patients. To substantiate these results, larger and higher quality studies should be performed.(c) 2021 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/ )

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.

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.

The aim of the present study was to investigate the incidence of scaphoid fracture surgery by obtaining data from the national discharge register in Finland, a country of 5 million inhabitants, for the period from 1997 to 2014. A total of 1380 patients with scaphoid fracture were treated surgically. Half of the patients were aged under 28 years and 84% were men. The surgical treatment of scaphoid fractures was classified into two groups. There were 640 (46%) primary fracture fixations and 740 (54%) treatments of fracture nonunion. The overall incidence of all scaphoid fixations increased twofold (from 14.8 to 30.1 per 1,000,000 person-years) and threefold in the primary fixation group (from 5.5 to 17.8 per 1,000,000 person-years) during the study period. Level of evidence: III

Novel and combined tissue transfers from the lower extremity provide new tools to combat soft tissue defects of the hand, foot, and ankle, or fracture nonunion. Flaps can be designed for special purposes, such as providing a gliding bed for a grafted or repaired tendon or for thumb or finger reconstruction. Propeller flaps can cover soft tissue defects of the leg and foot. In repairing severe bone and soft tissue defects of the lower extremity, combined approaches, including external fixators, one-stage vascularized bone grafting, and skin or muscle flap coverage of the traumatized leg and foot, have become popular.

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.

Distal Symes amputation is commonly performed on the hallux and central toes but this procedure is not generally associated with the 5th toe. We present a case series of four patients who underwent distal Symes amputation to successfully treat tip of 5th toe pathologies including diabetic neuropathic ulceration with chronic osteomyelitis, painful 5th hammertoe associated with fracture non-union through the distal interphalangeal joint synostosis, tip of toe gangrene, adducto varus hammertoe associated with Lister's corn. A pictorial demonstration of surgical technique is provided to assist surgeons with patient selection and surgical planning. Distal Symes amputation of the 5th toe is a versatile procedure that can be performed to successfully to manage tip of 5th toe pathologies without the need to perform partial 5th ray amputation. This procedure is highly conducive to being performed in a clinic-based procedure room under local anesthesia and we have seen high patient acceptance due to quick recovery, pain relief, and improved cosmetic appearance when compared to complete digital or partial ray amputation.

Stress modulation is the concept of manipulating bridge plate variables to provide a flexible fixation construct that allows callus formation through uneventful secondary bone healing. Obtaining absolute stability through the anatomic reduction of all fracture fragments comes at the expense of fracture biology, whereas intramedullary nailing, which is more advantageous for diaphyseal fractures of the lower extremity, is technically demanding and often may not be possible when stabilizing many metaphyseal fractures. Overly stiff plating constructs are associated with asymmetric callus formation, early implant failure, and fracture nonunion. Numerous surgeon-controlled variables can be manipulated to increase flexibility without sacrificing strength, including using longer plates with well-spaced screws, choosing titanium or stainless steel implants, and using locking or nonlocking screws. Axially dynamic emerging concepts, such as far cortical locking and near cortical overdrilling, provide further treatment options when bridge plating techniques are used.

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.