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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.

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: Supracondylar humerus fractures are the most common form of elbow fracture in children and adolescents. At present, treatment planning is based on the Gartland classification. Reduction and percutaneous pinning are done for Gartland type III fractures. In cases where closed reduction is unsuccessful, the procedure is converted to open reduction. However, there is no consensus on which patients are more likely to require conversion to open reduction. The aim of this study was to investigate the effect of fracture location on the rate of conversion to open reduction and clinical outcomes. METHODS: A total of 112 patients who underwent early surgery for Gartland type III supracondylar humerus fracture between August 2011 and August 2017 were evaluated. The patients’ age, sex, facture location, post-operative loss of reduction, and complications were noted. The fractures were classified according to fracture level relative to isthmus (high level) or at/below the isthmus (low level). Closed reduction was initially preferred. Open reduction with percutaneous pinning was performed, when necessary. Flynn’s criteria were used to evaluate elbow motion after treatment. RESULTS: Mean follow-up time was 39 months (16–62 months). The mean age of the patients was 6.4±2 years (1.4–12 years). Thirty-nine of the patients were female, 73 were male; 32 fractures were in the dominant arm, 80 were in the non-dominant arm. Ninety of the fractures were classified as high level (proximal) and 22 as low level (distal). Patients with low-level fractures were significantly younger (p0.05). CONCLUSION: The Gartland classification provides important guidance for the treatment of supracondylar humerus fractures, but may have limitations. Our results suggest that revising the classification by incorporating fracture location may be more beneficial for pre-operative planning. © 2022, Turkish Association of Trauma and Emergency Surgery. All rights reserved.

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.

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.

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.

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 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

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 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.

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.

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 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.