Leeds-Genoa Non-Union Index: a clinical tool for asessing the need for early intervention after long bone fracture fixation

Dual-channel minimally invasive percutaneous cerclage for femoral shaft and metaphysis fractures during the internal fixation with intramedullary nails: case reports and technical description

When treating femoral fractures with closed reduction intramedullary nail fixation, excessive residual displacement of the fracture end can affect the fixation effect and prolong the healing time, which is difficult to manage intraoperatively. This article introduces a simple steel wire cerclage fixation technique, which is percutaneous and can control the incision within 1 cm without excessive reliance on specially designed surgical instruments. It is suitable for the reduction and fixation of oblique femoral metaphysis fractures and butterfly-shaped femoral shaft fracture blocks.

A Scoring System for Predicting Nonunion After Intramedullary Nailing of Femoral Shaft Fractures

INTRODUCTION

Femoral shaft nonunion negatively affects patient quality of life. Although multiple risk factors have been identified for femoral shaft nonunion after intramedullary nail (IMN) fixation, there is no quantitative model for predicting nonunion.

STUDY DESCRIPTION

The study is a retrospective cohort study of patients with femoral shaft fractures treated at two level one trauma centers who were followed to fracture union or nonunion. Patient, injury, and surgical characteristics were analyzed to create a quantitative model for nonunion risk after intramedullary nailing.

METHODS

Eight hundred one patients aged 18 years and older with femoral shaft fractures treated with reamed, locked IMNs were identified. Risk factors including demographics, comorbidities, surgical variables, and injury-related characteristics were evaluated. Multivariate analysis was conducted, and several variables were included in a scoring system to predict nonunion risk.

RESULTS

The overall nonunion rate was 7.62% (61/801). Multivariate analysis showed significant association among pulmonary injury (odds ratio [OR] = 2.19, P = 0.022), open fracture (OR=2.36, P = 0.02), current smoking (OR=3.05, P < 0.001), postoperative infection (OR=12.1, P = 0.007), AO/OTA fracture pattern type A or B (OR=0.43, P = 0.014), and percent cortical contact obtained intraoperatively ≥25% (OR=0.41, P = 0.021) and nonunion. The scoring system created to quantitatively stratify nonunion risk showed that a score of 3 or more yielded an OR of 6.38 for nonunion (c-statistic = 0.693, P < 0.0001).

CONCLUSIONS

Femoral shaft nonunion risk is quantifiable based on several independent injury, patient, and surgical factors. This scoring system is an additional tool for clinical decision making when caring for patients with femoral shaft fractures treated with IMNs.

Analysis of the influence of circumference and displacement of the third fracture fragment on the healing of femoral shaft fractures treated with intramedullary nailing

The effect of circumference and displacement of the third fracture fragment on fracture healing after intramedullary nailing of femoral shaft fractures with a third fracture fragment was investigated. A retrospective cohort study was conducted to analyze the data of 142 patients who suffered femoral shaft fractures with a third fracture fragment and were admitted to the First People's Hospital of Lianyungang from February 2016 to December 2021. According to the circumference of the third fracture fragments, these were divided into three types of type 1: 71 cases; type 2: 52 cases; and type 3: 19 cases. On the basis of the diaphyseal diameter, the degree of displacement of the third fracture fragment was classified into three degrees of degree I: 95 cases; degree II: 31 cases; and degree III: 16 cases. Postoperative follow-up was performed to compare the fracture healing rate, healing time, and the modified Radiographic Union Scale for Tibia (mRUST) at 9th month after surgery in each group. All 142 patients were followed up after operation, with an average of (14.7 ± 4.1) months, and the overall healing rate was 73.4%. When the third fracture fragments were displaced in degree II and III, the mRUST score at 9th month in the type 1 group was higher than that in the type 2 and 3 groups (P = 0.017). Logistic regression analysis showed that greater displacement of third fracture fragments and greater circumference were associated with lower fracture healing rates (P < 0.05). After intramedullary nailing of femoral fractures, the degree of third fragment displacement and circumference affect fracture healing, and the former has a greater impact. When the third fracture fragment is displaced to degree II or III and its circumference is type 2 or type 3, it significantly affects the fracture healing. Intraoperative intervention to reduce the distance of third displacement of the fragment is required to reduce the incidence of non-union.

Three predictive scores compared in a retrospective multicenter study of nonunion tibial shaft fracture

BACKGROUND

Delayed union, malunion, and nonunion are serious complications in the healing of fractures. Predicting the risk of nonunion before or after surgery is challenging.

AIM

To compare the most prevalent predictive scores of nonunion used in clinical practice to determine the most accurate score for predicting nonunion.

METHODS

We collected data from patients with tibial shaft fractures undergoing surgery from January 2016 to December 2020 in three different trauma hospitals. In this retrospective multicenter study, we considered only fractures treated with intramedullary nailing. We calculated the tibia FRACTure prediction healING days (FRACTING) score, Nonunion Risk Determination score, and Leeds-Genoa Nonunion Index (LEG-NUI) score at the time of definitive fixation.

RESULTS

Of the 130 patients enrolled, 89 (68.4%) healed within 9 months and were classified as union. The remaining patients (n = 41, 31.5%) healed after more than 9 months or underwent other surgical procedures and were classified as nonunion. After calculation of the three scores, LEG-NUI and FRACTING were the most accurate at predicting healing.

CONCLUSION

LEG-NUI and FRACTING showed the best performances by accurately predicting union and nonunion.

Effect of postoperative fracture gap on bone union: A retrospective cohort analysis of simple femoral shaft fractures

BACKGROUND

Intramedullary nailing (IMN) is considered the gold-standard treatment for femoral shaft fractures. The post operative fracture gap is commonly recognized as a risk factor for nonunion. However, no evaluation standard for measuring the fracture gap size has yet been established. In addition, the clinical implications of the fracture gap size have also not been determined so far. This study aims to clarify how we should evaluate fracture gaps when assessing simple femoral shaft fractures with radiographs and to determine the acceptable cut-off value of the fracture gap size in simple femoral shaft fractures.

METHOD

A retrospective observational study with a consecutive cohort was conducted at the trauma center of a university hospital. We investigated the fracture gap using postoperative radiography and the postoperative bone union of transverse and short oblique femoral shaft fractures fixed by IMN. The receiver operating characteristic curve analysis was conducted to obtain the fracture gap's mean, minimum, and maximum cut-off values. Fisher's exact test was used at the cut-off value of the most accurate parameter.

RESULTS

In the four nonunions among the 30 cases, the analysis using ROC curves revealed that the maximum value had the highest accuracy among the maximum, minimum, and mean values of fracture-gap size. The cut-off value was determined to be 4.14 mm with high accuracy. Fisher's exact test showed that the incidence of nonunion was higher in the group with a maximum fracture gap of 4.14 mm or greater (risk ratio = not applicable, risk difference = 0.57, P = 0.001).

CONCLUSION

In simple transverse and short oblique femoral shaft fractures fixed with IMN, the fracture gap on radiographs should be evaluated by the maximum gap in the AP and lateral views. The remaining maximum fracture gap of ≥4.14 mm would be a risk factor for nonunion.

[Artificial intelligence and novel approaches for treatment of non-union in bone : From established standard methods in medicine up to novel fields of research]

Methods of artificial intelligence (AI) have found applications in many fields of medicine within the last few years. Some disciplines already use these methods regularly within their clinical routine. However, the fields of application are wide and there are still many opportunities to apply these new AI concepts. This review article gives an insight into the history of AI and defines the special terms and fields, such as machine learning (ML), neural networks and deep learning. The classical steps in developing AI models are demonstrated here, as well as the iteration of data rectification and preparation, the training of a model and subsequent validation before transfer into a clinical setting are explained. Currently, musculoskeletal disciplines implement methods of ML and also neural networks, e.g. for identification of fractures or for classifications. Also, predictive models based on risk factor analysis for prevention of complications are being initiated. As non-union in bone is a rare but very complex disease with dramatic socioeconomic impact for the healthcare system, many open questions arise which could be better understood by using methods of AI in the future. New fields of research applying AI models range from predictive models and cost analysis to personalized treatment strategies.

Risk factors for nonunion following surgically managed, traumatic, diaphyseal fractures: a systematic review and meta-analysis

Background

Methods

Results

Conclusion

Treatment of Distal Metaphyseal Tibial Fractures with Anterolateral Plates or with Anterolateral-Medial Plates: A Retrospective Series

Distal metaphyseal tibial fractures (3-5 cm from the joint with zones of comminution or <3 cm from the joint) are challenging to fix and are associated with many complications. The study objective was to evaluate the functional outcomes and complications after treating distal metaphyseal tibial fractures using anatomical anterolateral tibia locking plates or anterolateral-medial plates. This retrospective study included 57 patients with distal metaphyseal tibial fractures. Thirty patients were treated by open reduction internal fixation with anterolateral plates; 27 patients were treated with anterolateral-medial plates. Patients were followed at regular intervals. The time to fracture union and complications were recorded. We evaluated the stage of fracture healing using the Radiographic Union Score for Tibial fractures. The patients treated with anterolateral plates had significantly higher rates of loss of reduction and malunion than those treated with anterolateral-medial plates (p = .02 and p = .002, respectively). There were no significant differences in the radiographic union scores (p = .22), non-union (p = .17), incision necrosis (p = .91), or infection (p = .94) between the 2 groups. The functional outcomes were assessed using the American Orthopedic Foot and Ankle Society hindfoot-ankle score at the 12-month follow-up. The mean hindfoot-ankle scores were 90.9 ± 5.0 (range 79 to 100, median 90) and 92.3 ± 5.1 (range 82 to 100, median 92) for the anterolateral plates and anterolateral-medial plates, respectively (p = .29). For distal metaphyseal tibial fractures, anterolateral-medial plates may be worthwhile for reducing loss of reduction and malunion.

Scoring systems for early prediction of tibial fracture non-union: an update

Purpose

To evaluate the available tibial fracture non-union prediction scores and to analyse their strengths, weaknesses, and limitations.

Methods

The first part consisted of a systematic method of locating the currently available clinico-radiological non-union prediction scores. The second part of the investigation consisted of comparing the validity of the non-union prediction scores in 15 patients with tibial shaft fractures randomly selected from a Level I trauma centre prospectively collected database who were treated with intramedullary nailing.

Results

Four scoring systems identified: The Leeds-Genoa Non-Union Index (LEG-NUI), the Non-Union Determination Score (NURD), the FRACTING score, and the Tibial Fracture Healing Score (TFHS). Patients demographics: Non-union group: five male patients, mean age 36.4 years (18–50); Union group: ten patients (8 males) with mean age 39.8 years (20–66). The following score thresholds were used to calculate positive and negative predictive values for non-union: FRACTING score ≥ 7 at the immediate post-operative period, LEG-NUI score ≥ 5 within 12 weeks, NURD score ≥ 9 at the immediate post-operative period, and TFHS < 3 at 12 weeks. For the FRACTING, LEG-NUI and NURD scores, the positive predictive values for the development of non-union were 80, 100, 40% respectively, whereas the negative predictive values were 60, 90 and 90%. The TFHS could not be retrospectively calculated for robust accuracy.

Conclusion

The LEG-NUI had the best combination of positive and negative predictive values for early identification of non-union. Based on this study, all currently available scores have inherent strengths and limitations. Several recommendations to improve future score designs are outlined herein to better tackle this devastating, and yet, unsolved problem.

Development of the Italian fractures registry (RIFra): A call for action to improve quality and safety

In recent years, there has been an increasing interest in the development of arthroplasty registries, therefore, in our country, the Italian Arthroplasty Registry (RIAP), was issued by the National Law No. 221/2012. In the last decade, however, some European countries -namely Sweden, Denmark, Norway, and Germany (in development)- have introduced another nationwide orthopaedic registry than arthroplasty registers: the fracture registry. The development of this new tool aims to improve quality and safety in fracture management, thus trying to provide a better postoperative quality of life in trauma patients. Based on these findings, the AO-Trauma Italy Council encouraged the development of a national fracture registry in Italy. The present study aims to (1) provide an overview of the fracture registries in Europe and (2) to develop, for the first time, a pilot Italian Fracture Registry (RIFra). Thirteen AO-Trauma Italy members, chairmen of Level-I orthopaedic and trauma centres, diffused throughout Italy, were involved in the RIFra project. The RIFra form, developed between November 2019 and March 2020, consists of 5 main sections, namely: epidemiologic data, previous surgical procedure (if any), patient and fracture features, surgical procedure, surgical implant details. This study constitutes the first step to start, in future years, the bureaucratic procedure leading to the final establishment of a RIAP-like fracture registry in Italy.