Can tibial nonunion be predicted at 3 months after intramedullary nailing?

Novel approaches to correlate computerized tomography imaging of bone fracture callus to callus structural mechanics

Estimating the mechanical properties of bone in vivo without destructive testing would be useful for research and clinical orthopedic applications. Micro-computerized tomography (μCT) imaging can provide quantitative, high-resolution 3D representations of bone morphology and is generally the basis from which bone mechanical properties are non-destructively estimated. The goal of this study was to develop metrics using qualitative and quantitative aspects of bone microarchitecture derived from μCT imaging to estimate the mechanical integrity of bone fracture calluses. Mechanical testing data (peak torque) and μCT image data from 12 rat femur fractures were collected at 4 weeks after fracture. MATLAB was used to analyze the callus μCT imaging data which were then correlated to the empirically determined peak torque of the callus. One metric correlated Z-rays, linear contiguities of voxels running parallel to the neutral axis of the femur and through the fracture callus, to peak torque. Other metrics were based on voxel linkage values (LVs), which is a novel measurement defined by the number of voxels surrounding a given voxel (ranging from 1 to 27) that are all above a specified threshold. Linkage values were utilized to segment the callus and compute healing scores (termed eRUST) based on the modified Radiographic Union Score for Tibial fractures (mRUST). Linkage values were also used to calculate linked bone areas (LBAs). All metrics positively correlated with peak torque, yielding correlations of determination (R2) of 0.863 for eRUST, 0.792 for Z-ray scoring, and 0.764 for a normalized Linked Bone Area metric. These novel metrics appear to be promising approaches for extrapolating fracture callus structural properties from bone microarchitecture using objective analytical methods and without resorting to computationally complex finite element analyses.

The Effect of Social Deprivation on Fracture-Healing and Patient-Reported Outcomes Following Intramedullary Nailing of Tibial Shaft Fractures

BACKGROUND

Social deprivation is a state marked by limited access to resources due to poverty, discrimination, or other marginalizing factors. We investigated the links between social deprivation and orthopaedic trauma, including patient-reported outcomes, radiographic healing, and complication rates following intramedullary nailing of tibial shaft fractures.

METHODS

We retrospectively reviewed 229 patients who underwent intramedullary nailing of tibial shaft fractures at our Level-I trauma center. The Area Deprivation Index (ADI), a validated proxy for social deprivation, was used to group patients into the most deprived tercile (MDT), the intermediate deprived tercile (IDT), and the least deprived tercile (LDT) for outcome comparison. The Patient-Reported Outcomes Measurement Information System (PROMIS) was used to measure the domains of Physical Function (PF), Pain Interference (PI), Anxiety, and Depression, and radiographic healing was assessed with the Radiographic Union Scale in Tibial fractures (RUST) system.

RESULTS

On univariate analyses, patients from the MDT reported worse PF, PI, Anxiety, and Depression scores than those from the LDT within the first year of postoperative follow-up. On multivariable regression analysis, PROMIS score outcomes were influenced by age, race, and smoking status, but not by social deprivation tercile. Furthermore, residing in the MDT was associated with a 31% increase in time to radiographic union compared with the LDT (β = 0.27; p = 0.01).

CONCLUSIONS

Following intramedullary nailing of tibial shaft fractures, social deprivation is associated with slower fracture-healing and potentially influences short-term PROMIS scores. These results warrant further investigation in additional patient populations with orthopaedic trauma and highlight the importance of developing interventions to reduce inequities faced by patients from low-resource settings.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

IC-Type Electric stimulation for delayed bone healing: monocentric evaluation over eight years of experience

Electrostimulation is suggested to positively influence bone healing for delayed unions of both fractures and osteotomies. This monocentric series aims to retrospectively assess the outcome of electrostimulation treatment for delayed union after traumatic fractures or knee osteotomy. Patients treated with electrostimulation for delayed union (no bony union on radiographic imaging at 90 days after osteotomy or fracture treatment) over an 8-year period were screened. The delay of treatment, success rate, revision rate and demographic data (age, sex, location of fracture, presence of osteosynthesis materials) were investigated. A questionnaire assessed objective (nicotine abuse, NRS pain assessment, activity levels) and subjective (comfort, usability, cost-effectiveness) aspects. Electrostimulation delivered radiographic healing in 75% of the fracture group and 66% of the osteotomy group. No statistical significant difference (N=136) in success rate was found for age, sex, presence of osteosynthesis material, delay or fracture location. Success rate did differ significantly with pain, activity level and smoking (p<0.05). Reflective questions to patients were answered mostly positively. The use of electrostimulation for the delayed union of fractures and knee osteotomies delivers high healing rates avoiding the burden of surgical reintervention. It is generally well received by the patient. No difference in success rate was found between sex, age or fracture location, nor did the delay of therapy onset or presence of osteosynthesis material seem to affect the success rate. Smoking had a negative influence on the efficacy of bone electrostimulation.

Predicting fracture healing with blood biomarkers: the potential to assess patient risk of fracture nonunion

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

Characteristics, Treatments, and Outcomes of Tibial Plateau Nonunions: A Systematic Review

BACKGROUND

Due to the rare incidence of tibial plateau nonunions, current studies are limited to small sample sizes and patient demographics. The aim of this systematic review is to quantify and report patient and fracture traits, possible risk factors, and treatment outcomes of tibial plateau nonunions.

METHODS

PubMed, Clinical Key, and MEDLINE were searched for articles published prior to August 2020 in accordance to the preferred reporting items for systematic reviews and meta-analyses (PRISMA). The authors used varying combinations of the following terms to identify relevant articles: "tibial," "plateau," "nonunion," "non-union." Studies were assessed for patient demographics, pre-revision nonunion characteristics, treatment, and post-revision outcomes.

RESULTS

Eight studies were included, yielding 31 tibial plateau nonunions (21 males, 10 females). The majority of nonunions were associated with high energy trauma (52.2%) and were Schatzker class VI (54.8%). Schatzker class I and II nonunions were not attributed to neglect, contradicting previous suggestions. Time to union was 4.0 months, the most common treatments being autologous bone grafting (76.7%) and revision plating (63.3%).

CONCLUSION

This study demonstrates the effectiveness of autologous bone grafts and revision plating for tibial plateau nonunions. Physicians may use these findings to guide decision making in the event of high energy plateau nonunions. Lastly, various limitations exist within the current literature, emphasizing the need for standardized reporting measures.

Comparison of Infrapatellar and Suprapatellar Approaches for Intramedullary Nail Fixation of Tibia Fractures

OBJECTIVE

To assess clinical, radiographic, and functional outcomes after intramedullary nail (IMN) fixation of tibia fractures with an infrapatellar approach compared to a suprapatellar approach.

DESIGN

Retrospective chart review.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Two hundred four patients with 208 tibia fractures treated with intramedullary nailing between 2008 and 2018.

METHODS

A retrospective chart review of tibia fractures was conducted. The clinical and functional outcomes of tibia fractures treated with IMN were compared between groups treated with an infrapatellar approach versus a suprapatellar approach. Multivariate models were created to control for confounding demographic, comorbidity, and injury-related confounders.

MAIN OUTCOME MEASUREMENTS

Outcome measures included nonunion, malunion, and infection. Subjective functional patient outcomes were assessed using pain interference and physical function Patient-Reported Outcome Measurements Systems scores.

RESULTS

There were 101 patients treated with infrapatellar nailing (49%) and 107 patients treated with suprapatellar nailing (51%). On multivariate analysis, suprapatellar nailing was independently associated with decreased risk of malunion (adjusted odds ratio, 0.165; 95% confidence interval, 0.054-0.501; P = 0.001) and decreased risk of postoperative knee pain (adjusted odds ratio, 0.272; 95% confidence interval, 0.083-0.891; P = 0.032). There was no difference in the rate of nonunion (P = 0.44), infection (P = 0.45), or Patient-Reported Outcome Measurements Systems pain interference or physical function scores.

CONCLUSIONS

Suprapatellar IMN fixation of tibial shaft fractures is independently associated with lower risk of malunion and postoperative knee pain compared to the infrapatellar approach. However, there are no functional differences between approaches.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Clinical Outcomes After Intramedullary Nailing of Intraarticular Distal Tibial Fractures: A Retrospective Review

The objective of this study was to evaluate the clinical and functional outcomes of intra-articular distal tibial fractures after intramedullary nail (IMN) and independent fixation compared with extra-articular fracture controls.

Methods

A retrospective chart review of distal tibial fractures treated with IMN was performed. Clinical outcomes were compared between fractures with and without intra-articular involvement. Outcomes included nonunion, malunion, ankle arthrosis, and infection. Patient-Reported Outcome Measurement System (PROMIS) scores were used to assess subjective outcomes.

Results

Of the 135 distal tibial fractures, 87 extra-articular and 48 intra-articular, no significant difference was observed in the rate of ankle arthrosis between intra-articular and extra-articular fractures (2% versus 0%; P = 0.35). Similarly, no difference was observed in the postoperative rates of infection (8% versus 3%; P = 0.25), the rate of nonunion (17% versus 10%; P = 0.29), or the rate of malunion (10% versus 21%; P = 0.17). No notable difference was observed in PROMIS scores between groups.

Conclusion

This study suggests that IMN is an acceptable method of fixation in select intra-articular distal tibial fractures. In the intra-articular group, low rates of ankle arthrosis were noted at intermediate follow-up, with no increase in nonunion, malunion, or infection compared with extra-articular fractures. Furthermore, PROMIS scores indicate similar functional outcomes in patients, regardless of intra-articular involvement.

Tibial Fracture Healing Score: A Novel Tool to Predict Tibial Nonunion

The aim of the study was to investigate the utility of a simple office-based tool in predicting the need for secondary intervention to obtain union in patients with tibial fractures. All patients 18 years and older with isolated tibial shaft fractures (OTA 41A, 42A-C, and 43A) treated with intramedullary nailing from 2013 to 2017 were screened. Eighty-seven patients met enrollment criteria. Surgeon assessment of the following 3 clinical parameters was performed at routine office visits and scored as follows: (1) pain (none/mild/decreased=1, no change/increased=0); (2) function (minimal limp/able to perform a single-leg stance=1, significant limp/unable to perform single-leg stance=0); and (3) examination (no/minimal pain with manipulation=1, pain with manipulation=0). Radiographic healing was assessed by the adjusted radiographic union scale in tibial fractures (aRUST). The tibial fracture healing score (TFHS) is the sum of 3 clinical scores (0 to 3) and aRUST score (1 to 3) at 3 months postoperatively. The overall nonunion rate was 11%. A RUST score of 5 or less and a sum of the 3 clinical scores of less than 2 at 3 months were found be predictive of nonunion. A TFHS of less than 3 at 3 months was more reliable in identifying patients requiring nonunion repair, especially for those with minimal radiographic healing (RUST score 6 or 7) at 3 months. The TFHS is a simple office-based clinical tool that may identify patients at high risk of nonunion (TFHS <3) following isolated tibial shaft fracture more effectively than clinical examination or radiographic assessment alone. [Orthopedics. 2020;43(4);e323-e328.].

Comparison of Clinical Outcomes After Intramedullary Fixation of Tibia Fractures Caused by Blunt Trauma and Civilian Gunshot Wounds: A Retrospective Review

OBJECTIVE

To assess the outcomes of patients who sustained blunt trauma tibia fractures compared with tibia fractures from civilian gunshot injuries when treated with intramedullary fixation.

DESIGN

Retrospective chart review.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

Two hundred and seven patients underwent intramedullary nailing for 211 tibia fractures.

METHODS

A retrospective review of tibia fracture(s) treated with intramedullary fixation with comparison of closed, open, and gunshot wound (GSW) fracture outcomes.

MAIN OUTCOME MEASUREMENTS

Outcomes included infection and nonunion.

RESULTS

The infection rate in closed and GSW tibia fractures was significantly lower compared with the infection rate of open fractures (1% vs. 9% vs. 20%; P = 0.00005). Significantly lower rates of nonunion in closed fractures compared with open fractures and GSW fractures were appreciated (8% vs. 20% vs. 30%; P = 0.003). There was no difference in infection or nonunion between GSW fractures with small wounds, no exposed bone, and minimal comminution and closed injuries (P = 0.24, P = 0.60). Conversely, there was a significantly higher nonunion rate in GSW fractures with large wounds, exposed tibia, and comminution compared with blunt injuries (P = 0.0014).

CONCLUSIONS

This study suggests that tibia fractures from civilian GSWs are heterogeneous injuries, and outcomes are dependent on the extent of soft-tissue injury, bone exposure, and bone loss. There are comparable infection rates in all fractures due to civilian GSWs and closed fractures, which are lower than high-grade open fractures. Tibia GSW fractures with exposed bone and comminution have higher complication rates and should be treated accordingly.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Association of Three-Month Radiographic Union Score for Tibia Fractures (RUST) with Nonunion in Tibial Shaft Fracture Patients

Objectives Nonunions of tibial shaft fractures have profound implications on patient quality of life and are associated with physical and mental suffering. Radiographic Union Score for Tibia Fractures (RUST) may serve as an important prognostic tool for identifying patients at a high risk of nonunion. Design We used data from the Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) and Fluid Lavage of Open Wounds (FLOW) trials to explore the association of three-month RUST scores with nonunion in patients with tibial shaft fractures treated with intramedullary nailing. We performed a retrospective cohort study nested within two multi-center, randomized controlled trials. Participants The patients included in the current study: (1) sustained a tibial shaft fracture and were enrolled in the SPRINT or FLOW randomized trials, (2) had initial operative management with intramedullary nailing, (3) showed radiographic evidence of an unhealed fracture at the three-month follow-up, and (4) their healing status (union or nonunion) was captured at 12-months postoperatively. Intervention Multivariable binary logistic regression was carried out to identify factors associated with nonunion, including open versus closed injury, fracture severity, fracture gap, and three-month RUST score. We determined the concordance statistic (c statistic) for our regression model both with and without the RUST score. Outcome Measurements and Results Of the 155 tibial fracture patients with complete data available for analysis, the overall rate of nonunion at 12 months was 30% (n=47). The mean three-month RUST score in patients with nonunion at 12 months was 4.8 (standard deviation (SD) 1.1) as compared to 6.3 (SD 1.7) for those healed at 12 months. In our multivariable regression analysis, open fractures conferred five-fold greater odds of nonunion at 12 months as compared to closed fractures (odds ratio (OR) 4.76, 95% confidence interval (CI):1.71-13.30). Further, three-month RUST scores of 4 and 5-6 were associated with a 47% (95% CI: 18%-73%) and 23% (4.5-51.5%) absolute risk increase of nonunion as compared to a score of ≥ 7, respectively. The addition of RUST scores to our adjusted regression model improved the c statistic from 0.70 (95%CI: 0.61-0.79) to 0.81 (95%CI: 0.74-0.88). Conclusion A third of patients with tibial shaft fractures who have failed to heal by three months will show nonunion at one year. Open fractures and lower three-month RUST scores are strongly associated with a higher risk of nonunion at one year. Further research is needed to establish whether prognosis in this high-risk group can be modified.

Scoring of radiographic cortical healing with the radiographic humerus union measurement predicts union in humeral shaft fractures

PURPOSE

The purpose of this study is to determine if the radiographic humerus union measurement (RHUM) is predictive of union in humeral shaft fractures treated nonoperatively.

METHODS

All patients with long bone fracture nonunion presenting to a single surgeon were enrolled in a prospective registry. This registry was queried to identify patients with humeral shaft fractures treated nonoperatively and developed nonunion. The nonunion cohort was matched to a three to one gender- and age-matched control group that were treated nonoperatively for a humeral shaft fracture and achieved union. Two fellowship-trained orthopedic traumatologists blinded to eventual union scored radiographs obtained 12 weeks after injury using the RHUM. A binomial logistic regression determined the effect of the RHUM on the likelihood of developing union.

RESULTS

Nine patients with humeral shaft fractures treated nonoperatively with radiographs 12 weeks after injury that developed nonunion were identified. These patients were matched to 27 controls. Logistic regression demonstrated the RHUM was a significant predictor of healing 12 weeks after humeral shaft fracture treated nonoperatively (p = 0.014, odds ratio 9.434, 95% CI for OR 1.586-56.098). All patients with RHUM below 7 went on to nonunion. All patients with RHUM above 8 healed. Three of seven patients (43%) with RHUM of 7 or 8 healed.

CONCLUSION

The RHUM demonstrated an increased likelihood of achieving union 12 weeks after injury. Orthopedic surgeons can counsel patients that fractures with RHUM scores of 6 or below are in danger of developing nonunion and can target interventions appropriately.

Trochanteric femoral nonunion in patients aged over 60 years treated with dynamic condylar screw

INTRODUCTION

Nonunions of trochanteric femoral fractures are uncommon due to a good blood supply of the cancellous bone of the trochanteric region. Nevertheless, if a nonunion occurs, complex revision procedures usually become necessary. The purpose of this study was to evaluate a series of aseptic trochanteric nonunions in patients aged 60 years or older, looking at outcomes regarding healing rate, implant-related complications and secondary surgeries.

MATERIAL AND METHODS

We conducted a retrospective chart review of patients with aseptic femoral trochanteric nonunions aged over 60 years. Nonunion treatment consisted of implant removal, debridement of the nonunion, and restoration of the neck shaft angle, followed by DCS plating. An additional 4.5-mm limited contact dynamic compression plate was placed in twelve patients anteriorly. The primary outcome measure was bony healing and time to healing in months. Secondary outcome measures included postoperative complications related to the index procedure, range of motion of the affected hip and postoperative mobility.

RESULTS

A total of 21 patients with a mean age of 69.1 years met the inclusion criteria. After a mean follow-up of 21.62 months, 17 of the 21 nonunions healed successfully. The mean healing time was 6.59 months. A total of six of the 21 patients needed secondary revision surgery. At the final follow-up, a full range of motion of the hip was seen in 17 of the 21 hips.

CONCLUSIONS

DCS treatment and preservation of the patient's femoral head can be successful for patients aged over 60 years with a well-preserved femoral head and acetabulum. However, preservation of the hip joint and revision plating might be associated with higher revision rates.

Radiographic union score for tibia fractures predicts success with operative treatment of tibial nonunion

BACKGROUND

The purpose of this study is to evaluate the ability of preoperative and postoperative radiographic union scores for tibia fractures (RUST) to predict treatment success of tibia fracture nonunion.

MATERIALS AND METHODS

Patients presenting for operative treatment of tibia fracture nonunion were enrolled in a prospective data registry. Enrolled patients were followed at regular intervals for 12 months. Preoperative and 12 week postoperative radiographs were reviewed and scored using the RUST criteria. Postoperative time to union was determined by clinical and radiographic measures. Multivariate regressions were conducted to predict time to union using preoperative and postoperative RUST while controlling for treatment method. Receiver operating characteristic (ROC) curve was conducted to determine the accuracy of preoperative RUST in predicting failure of treatment.

RESULTS

Sixty-eight patients with aseptic tibia fracture nonunion treated operatively were identified. Sixty-one patients achieved union. Mean preoperative RUST was 7.5 (SD 1.4). Mean postoperative RUST was 9.2 (SD 1.4). Multivariate linear regressions demonstrated that preoperative (p = 0.043) and postoperative (p = 0.007) RUST are significant predictors of time to union after tibia fracture nonunion surgery. ROC curve demonstrated preoperative RUST below 7 was a good predictor of developing persistent tibia fracture nonunion (AUC = 0.83, Sensitivity = 1.000, Specificity = 0.745).

CONCLUSIONS

RUST preoperatively and postoperatively predicts outcome after nonunion surgery. RUST can be used as part of the complete clinical picture to shape patient expectations and guide treatment.

"Revision of subtrochanteric femoral nonunions after intramedullary nailing with dynamic condylar screw"

BACKGROUND

Nonunions of the subtrochanteric region of the femur after previous intramedullary nailing can be difficult to address. Implant failure and bone defects around the implant significantly complicate the therapy, and complex surgical procedures with implant removal, extensive debridement of the nonunion site, bone grafting and reosteosynthesis usually become necessary. The purpose of this study was to evaluate the records of a series of patients with subtrochanteric femoral nonunions who were treated with dynamic condylar screws (DCS) regarding their healing rate, subsequent revision surgeries and implant-related complications.

METHODS

We conducted a retrospective chart review of patients with aseptic femoral subtrochanteric nonunions after failed intramedullary nailing. Nonunion treatment consisted of nail removal, debridement of the nonunion, and restoration of the neck shaft angle (CCD), followed by DCS plating. Supplemental bone grafting was performed in all atrophic nonunions. All patients were followed for at least six months after DCS plating.

RESULTS

Between 2002 and 2017, we identified 40 patients with a mean age of 65.4 years (range 34-91 years) who met the inclusion criteria. At a mean follow-up period of 26.3 months (range 6-173), 37 of the 40 (92.5%) nonunions healed successfully (secondary procedures included). The mean healing time of the 37 patients was 11.63 months (± 12.4 months). A total of 13 of the 40 (32.5%) patients needed a secondary revision surgery; one patient had a persistent nonunion, nine patients had persistent nonunions leading to hardware failure, two patients had deep infections requiring revision surgery, and one patient had a peri-implant fracture due to low-energy trauma four days after the index surgery.

CONCLUSIONS

The results indicate that revision surgery of subtrochanteric femoral nonunions after intramedullary nailing with dynamic condylar screws is a reliable treatment option overall. However, secondary revision surgery may be indicated before final healing of the nonunion.

Value of a radiographic score for the assessment of healing of nailed femoral and tibial shaft fractures: A retrospective preliminary study

OBJECTIVES

To assess the value of a radiographic score for the detection of delayed union in nailed fractures.

METHODS

The modified radiographic union score (mRUS) values were determined by three separate radiologists on 259 radiographic sets of 58 nailed tibial or femoral fractures obtained at different timepoints after fracture (mean of 4.5 radiographic sets per fracture). A surgeon determined fracture outcome (normal or delayed union) at a mean of 192days after injury. Mean radiographic scores obtained at different timepoints after fracture were compared between fractures with normal or abnormal healing at follow-up.

RESULTS

The mean score values increased significantly over time for fractures with normal healing for all readers (p<0.001). The mean score values determined 11-14 weeks after injury were higher in fractures with normal healing than in fractures with delayed union at follow-up (p<0.05). Scoring of radiographs obtained at about 3 months after injury or later enabled detection of fractures with delayed union with a sensitivity of 0.63-0.77 and a specificity of 1.0 (area under curve: 0.77- 0.88).

CONCLUSIONS

The mRUS score can contribute to the detection of delayed union at a delay of about 3 months after injury in nailed shaft fractures.

Fracture healing: A review of clinical, imaging and laboratory diagnostic options

A fundamental issue in clinical orthopaedics is the determination of when a fracture is united. However, there are no established "gold standards," nor standardized methods for assessing union, which has resulted in significant disagreement among orthopaedic surgeons in both clinical practice and research. A great deal of investigative work has been directed to addressing this problem, with a number of exciting new techniques described. This review provides a brief summary of the burden of nonunion fractures and addresses some of the challenges related to the assessment of fracture healing. The tools currently available to determine union are discussed, including various imaging modalities, biomechanical testing methods, and laboratory and clinical assessments. The evaluation of fracture healing in the setting of both patient care and clinical research is integral to the orthopaedic practice. Weighted integration of several available metrics must be considered to create a composite outcome measure of patient prognosis.

Treatment of aseptic non-union after intramedullary nailing without removal of the nail

Failure of bone healing after intramedullary nailing of a diaphyseal long bone fracture is a severe complication that requires an effective management to ensure the best chances for successful bone-union and termination of a long period of incapacity and morbidity for the sufferers. Traditional procedures require removal of the existing nail and re-fixation with wider nail, plate or external fixation constructs. The concept that bone union can be obtained with the existing nail in situ is gaining popularity as its removal adds trauma and potential complications and prolongs the operating time. This article reviews all techniques that have been proposed for the management of aseptic diaphyseal long bone non-unions that stimulate bone healing without removing the existing nail.

Does weight-bearing assignment after intramedullary nail placement alter healing of tibial shaft fractures?

INTRODUCTION

There is no consensus regarding postoperative weight-bearing (WB) assignment after treatment of tibial shaft fractures with an intramedullary nail. This study aims to determine if the postoperative WB assignment after tibia intramedullary nail placement alters healing.

METHODS

Closed AO type 42A fractures treated with a reamed statically-locked intramedullary nail over a 10-year period were retrospectively reviewed from injury at 2, 3, 6, 9 and 12 month intervals until union or revision. Patients were categorized according to postoperative weight-bearing assignment: weight-bearing-as-tolerated (WBAT) or non-weight-bearing (NWB). Patients with additional diagnoses that confound routine fracture healing were excluded. Postoperative radiographic union scores for tibial fractures (RUST), coronal/sagittal angulations, and length were compared between different weight-bearing groups. Union was defined as a RUST≥10 at a painless fracture site.

RESULTS

A total of 83 patients achieved union (32 WBAT, 51 NWB). Both WB groups had similar preoperative demographics. Average age was 37±13 years and follow-up averaged 1.3±0.2 years. There were no significant differences in average time to radiographic union between NWB versus WBAT groups (5.5 vs. 6.1 months, respectively; P=0.208) nor radiographic healing at 2, 3, and 6-month intervals (P=0.631). There were two nonunions and one fracture shortened in the NWB group. There were no reoperations for symptomatic or broken hardware in either cohort.

CONCLUSION

Immediate WBAT after statically-locked intramedullary nail placement in simple tibial shaft fractures does not alter the time until or course of radiographic union.

LEVEL OF EVIDENCE

IV.

Early prediction of tibial and femoral fracture healing: Are we reliable?

INTRODUCTION

To evaluate the ability of orthopaedic trauma subspecialists to predict early bony union in femoral and tibia shaft fractures.

MATERIALS AND METHODS

Eight orthopaedic trauma subspecialists prospectively predicted the probability of bony union at 6 and 12 weeks post-operatively for an aggregate of 48 femoral and tibial shaft fractures treated at a Level 1 trauma centre. An additional orthopaedic trauma subspecialist was blinded to treating surgeon and adjudicated healing at 18 weeks. The Squared-Error Skill Score (SESS) determined the likelihood of accurate forecasting for bony union.

RESULTS

Nine patients were lost follow-up, resulting in 39 fractures (81.25% retention) including 20 femoral and 19 tibial fractures. Fourteen fractures were open, 15 were not-yet united at final follow-up. SESS values were 0.25-0.77. The ability to predict union (sensitivity) was 1.000. The ability to predict nonunions (specificity) was 0.330-0.500. The probability of a correct predicted union was 0.727 and correct predicted nonunion at final follow-up was 1.000. AO/OTA type A fractures pattern predictions were highly accurate. As body mass index increased, predictions trended toward decreased accuracy (p=0.06). Tobacco use, age, gender, associated injuries, open fractures, and surgeons' years in clinical practice were not associated with accuracy of predictions.

CONCLUSIONS

At 12-weeks post-operatively orthopaedic trauma subspecialists can confidently predict the union state in this patient population. This data is most useful in the nonunion patient, directing early intervention, thereby decreasing patient disability and discomfort.

Anterior augmentation plating of aseptic humeral shaft nonunions after intramedullary nailing

INTRODUCTION

Humeral shaft nonunion after intramedullary nailing is a rare but serious complication. Treatment options include implant removal, open plating, exchange nailing and external fixation. The objective of this retrospective study was to determine whether augmentation plating without nail removal is feasible for treating a humeral shaft nonunion.

MATERIALS AND METHODS

Between 2002 and 2014, 37 patients (mean age 51, range 20-84 years) with aseptic humeral shaft nonunions prior to intramedullary nailing were treated with augmentation plating. The initial fractures had been fixed with retrograde nails (10 cases) or anterograde nails (27 cases). There were 34 atrophic nonunions and 3 hypertrophic nonunions. Nonunion treatment of all patients consisted of local debridement through an anterior approach to the humerus and anterior placement of the augmentation plates. Supplemental bone grafting was performed in all atrophic nonunion cases. All patients were followed until union was radiologically confirmed.

RESULTS

Union was achieved in 36 patients (97 %) after a mean of 6 months (range 3-24 months). There was one case of iatrogenic median nerve palsy that showed complete spontaneous recovery 6 weeks postoperatively. One patient sustained a peri-implant stress fracture that was treated successfully by exchanging the augmentation plate to bridge the nonunion and the fracture. No infections or wound healing complications developed. At a mean follow-up of 14 months, all patients showed free shoulder and elbow motion and no restrictions in daily or working life.

CONCLUSIONS

The results indicate that augmentation plating using an anterior approach is a safe and reliable option for humeral shaft nonunions after failed nailing, and the treatment has no substantial complications. Because the healing rates are similar to the standard technique of nail removal and fixation by compression or locking plates, we consider this technique to be an alternative choice for treatment.

Nonunion of the Femur and Tibia: An Update

Delayed union and nonunion of tibial and femoral shaft fractures are common orthopedic problems. Numerous publications address lower extremity long bone nonunions. This review presents current trends and recent literature on the evaluation and treatment of nonunions of the tibia and femur. New studies focused on tibial nonunion and femoral nonunion are reviewed. A section summarizing recent treatment of atypical femoral fractures associated with bisphosphonate therapy is also included.

Predictors of Patient Reported Pain After Lower Extremity Nonunion Surgery: The Nicotine Effect

BACKGROUND

Nonunion of long bone fractures is a serious complication for many patients leading to considerable morbidity. The purpose of this study is to elucidate factors affecting continued pain following long bone nonunion surgery and offer better pain control advice to patients.

METHODS

Patients presenting to our institutions for operative treatment of long bone fracture nonunion were enrolled in a prospective data registry. Enrolled patients were followed at regular intervals for 12 months using the Short Musculoskeletal Function Assessment (SMFA), visual analog scale (VAS), physical examination, and radiographic examination. The registry was reviewed to identify patients with a tibial or femoral nonunion that went on to union with complete follow up. Univariate analyses were conducted to identify patient characteristics associated with postoperative pain. Identified patient factors with univariate p-values <0.1 were included in multivariate linear regression models in order to identify risk factors for pain 3 months, 6 months, and 12 months after nonunion surgery.

RESULTS

Ninety-one patients with tibial or femoral nonunion who went on to union and had complete follow-up were identified. A Friedman test revealed mean pain score decreased significantly by 3 months postoperatively (p<0.0005). Univariate analyses demonstrated age (p=0.016), days from injury to nonunion surgery at our institution (p=0.067), smoking status (p<0.0005), wound status at time of injury (p=0.085), anesthesia (p=0.045), and nonunion location in the bone (p=0.047) were associated with postoperative pain in at least one time point postoperatively. These were included in multivariate models that revealed nonunion location (p=0.035) was predictive of pain 3 months postoperatively, smoking status was predictive of pain 3 months (p=0.012) and 6 months (p<0.0005) postoperatively, and days from injury to nonunion surgery at our institution was predictive of pain 6 months (p=0.024) and 12 months (p=0.004) postoperatively.

CONCLUSION

Healed patients have improved pain levels after lower extremity nonunion surgery. Orthopedic surgeons should stress smoking cessation programs and minimize delay to nonunion surgery, in order to maximize pain relief in this patient cohort.