The devastating effects of humeral nonunion on health-related quality of life

Intraoperative frozen section analysis for detection of fracture-related infection in nonunion of the upper limb. Diagnostic accuracy study

INTRODUCTION

During revision surgery for the management of patients presenting with long-bone upper extremity nonunion, it is crucial to rule out fracture-related infection (FRI). This is especially true if there are clinical signs suggestive of FRI, or if there is a history of prior FRI, open wound fracture, or surgery. This study aimed to determine the efficacy of frozen section analysis (FSA) in providing real-time diagnosis of FRI in patients with upper-limb long-bone nonunion undergoing revision surgery.

PATIENTS AND METHODS

We included previously surgically treated patients who underwent revision surgery for chronic/late-onset nonunion of the long bones of the upper limbs over a 9-year period. We retrospectively applied the FRI criteria to identify eligible patients and recorded their clinical features and demographic characteristics. In all included patients, samples for microbiological analysis and FSA were collected simultaneously during revision surgery. Patients were categorized according to intraoperative culture results as having aseptic or infected nonunion. The sensitivity, specificity, positive and negative predictive values, and accuracy of FSA test were calculated and compared using microbiological analysis as the reference standard test. The concordance rate between FSA and definitive histopathology was also determined.

RESULTS

Sixty-two patients who were surgically treated for nonunion of the arm or forearm were included in this study. Septic nonunion was diagnosed intraoperatively in 9 patients based on FSA findings, while microbiological analysis confirmed septic nonunion in 8 patients. The sensitivity and specificity of FSA were 88 % (95 % confidence interval [CI] [47, 100]) and 96 % (95 % CI [87, 100]), respectively. Positive and negative predictive values were 78 % (95 % CI [47, 93]) and 98 % (95 % CI [89, 100]), respectively, with an overall test accuracy of 95 % (95 % CI [87, 99]). Cohen's Kappa coefficient between FSA and definitive histopathology was 0.74 (95 % CI [0.5, 1]).

CONCLUSIONS

FSA showed high sensitivity and specificity for the detection of active infection during revision surgery for nonunion of the upper limb. Owing to its high negative predictive value, it can reliably rule out active infections during revision surgery. Since the results are obtained immediately during revision surgery, this approach offers the significant advantage of enabling real-time decision-making.

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.

Predictive Model Development to Identify Failed Healing in Patients after Non-Union Fracture Surgery

Bone non-union is among the most severe complications associated with trauma surgery, occurring in 10-30 % of cases after long bone fractures. Treating non-unions requires a high level of surgical expertise and often involves multiple revision surgeries, sometimes even leading to amputation. Thus, more accurate prognosis is crucial for patient well-being.Recent advances in machine learning (ML) hold promise for developing models to predict non-union healing, even when working with smaller datasets, a commonly encountered challenge in clinical domains. To demonstrate the effectiveness of ML in identifying candidates at risk of failed non-union healing, we applied three ML models-logistic regression, support vector machine, and XGBoost-to the clinical dataset TRUFFLE, which includes 797 patients with long bone non-union.The models provided prediction results with 70% sensitivity, and the specificities of 66 % (XGBoost), 49 % (support vector machine), and 43 % (logistic regression). These findings offer valuable clinical insights because they enable early identification of patients at risk of failed non-union healing after the initial surgical revision treatment protocol.

Factors Associated With Episode of Care Adverse Events After Humerus Nonunion Repair

BACKGROUND

Humeral nonunions have devastating negative effects on patients' upper extremity function and health-related quality of life. The objective of this study was to identify factors independently associated with 30-day complication, hospital readmission, and reoperation after surgical treatment of humeral nonunions.

MATERIALS AND METHODS

A retrospective case-control study was performed using the American College of Surgeons National Surgical Quality Improvement Program database by querying the Current Procedural Terminology codes for patients who underwent humeral nonunion repair from 2011 to 2020. The study outcomes were 30-day complication, hospital readmission, and reoperation.

RESULTS

Of the 1306 patients in our cohort, 135 patients (10%) developed a complication, 66 patients (5%) were readmitted to the hospital, and 44 patients (3%) underwent reoperation during the 30-day postoperative period. Multivariable logistic regression analysis showed that older age, longer operative time, partially dependent functional status, congestive heart failure, bleeding disorder, and contaminated wound classification were associated with 30-day complication after humeral nonunion repair. Older age and disseminated cancer were associated with 30-day reoperation after humeral nonunion repair. Disseminated cancer was associated with 30-day readmission after humeral nonunion repair.

CONCLUSION

Using a large database over a recent 10-year period, we identified demographic and comorbid factors independently associated with episode of care adverse events after humeral nonunion repair. Patients 50 years or older had approximately three times the incidence of complications, readmissions, and reoperations in the first month after humeral nonunion repair compared with patients younger than 50 years. Our findings are relevant for preoperative risk stratification and counseling. [Orthopedics. 2024;47(4):e181-e187.].

Clinical, Radiologic, and Functional Outcomes following Bone Grafting for Metacarpal Non-Unions: A Systematic Review

Objectives: Metacarpal non-unions are complex hand defects that can lead to severe hand impairment. Treatment may require the use of artificial or autologous bone grafts. This systematic review aims to describe the outcomes of bone grafting following metacarpal non-union in an attempt to establish an optimal therapeutic protocol for this complication. Methods: A systematic review was conducted in adherence with PRISMA guidelines. Data collection and analysis were performed in duplicate and confirmed by a third investigator. Our primary outcomes focused on radiological time to bone fusion and rates of non-union. Additionally, functional outcomes and complications were analyzed as means of central tendency. Results: Eighteen studies were included in the systematic review, accounting for a total of 47 patients. The average follow-up time was 12.4 months. Fourteen studies analyzed radiological outcomes, with atrophic non-union representing the most common type. The time to bone fusion, assessed radiologically, following bone graft was an average of 6.9 months (n = 14), with a 100% rate of union in 42 patients. Regarding patient-reported pain improvement, 76% of patients experienced pain relief. Moreover, all patients reported a complete subjective return to baseline hand function. Adverse events, limited to hematoma and seroma, were seen in three patients, representing a complication rate of 11.8% in the examined population. Conclusions: Metacarpal non-union can be treated successfully via vascularized and non-vascularized bone grafting. Based on the available evidence, bone grafts demonstrate favorable union rates, post-operative pain reduction, hand function recovery, earlier bone fusion times, and minimal complications in the context of metacarpal non-union management.

Consistent Protocol-Based Management of Humerus Shaft Nonunion: An Analysis of 100 Cases

Introduction

Humerus shaft nonunions are very disabling and challenging to treat. The current study aims to analyse the rate of union and the incidence of complications following a consistent protocol in treating humerus shaft nonunion.

Methodology

We did a retrospective analysis of 100 patients with humerus shaft nonunion treated over an eight-year period from 2014 to 2021. The mean age was 42 years (range 18-75 years). There were 53 male and 47 female patients. The average time interval from injury to nonunion surgery was 23 months (range 3 months to 23 years). The series included 12 recalcitrant nonunions and 12 patients with septic nonunion. All patients underwent freshening of fracture edges to increase the contact surface area, stable fixation with a locking plate and intramedullary iliac crest bone grafting. Infective nonunions were treated in a staged manner, following a similar treatment protocol after the elimination of infection in the first stage.

Results

Complete union was achieved in 97% of the patients with a single procedure. One patient achieved union after an additional procedure, while two patients were lost to further follow-up. The mean time to union was 5.7 months (range 3-10 months). Three patients (3%) had postoperative radial nerve palsy, which recovered completely within 6 months. Three patients (3%) had a superficial surgical site infection, while one patient (1%) developed a deep infection.

Conclusion

Intramedullary cancellous autologous grafts combined with stable fixation by compression plating achieve a high union rate with minimal complications.

Level of Evidence

III.

Level of Clinical Care

Level I Tertiary trauma centre.