Healing the Index Humeral Shaft Nonunion: Risk Factors for Development of a Recalcitrant Nonunion in 125 Patients

A systematic scoping review of the latest data on orthobiologics in the surgical treatment of non-union

INTRODUCTION

Recent studies have shown a growing concern regarding the cost-effectiveness and the lack of supporting data for the biologic agents that are being increasingly used in the orthopedic field. Our aim was to conduct a systematic scoping review of recent publications (last five years) on the use of orthobiologics to treat fracture non-union and summarize the latest available data.

PATIENTS AND METHODS

The inclusion criteria for this review were articles published in English, from 2016 to 2022, and focusing on the use of orthobiologics for the surgical treatment of non-union. Searches were conducted in March 2023 using Pubmed/MEDLINE and Embase. Studies on spinal fusion or gene therapy were excluded. Reviews, case reports with five cases or less, conference proceedings, preliminary reports, pediatric or non-human studies were excluded as well.

RESULTS

The search found 1807 articles, 15 were eligible after PRISMA checklist and exclusions. The evidence was heterogenous and there was only one level II RCT. Recent data suggests that bone morphogenic protein (BMP-2) products could be effective for septic and aseptic tibial non-unions. However, the evidence was not conclusive regarding BMP-7, plasma rich platelets (PRP), stem cells or demineralized bone matrix (DBM).

DISCUSSION

Every non-union case is different in terms of bone defect, biology, mechanical stability, surgical technique and host factors, which contributes to the conflicting reports on the efficacy of orthobiologics in the literature. We might never see a level 1, high powered and robust study defining the efficacy, safety profile and cost-effectiveness of such products.

LEVEL OF EVIDENCE

IV.

Outcomes of Humerus Nonunion Surgery in Patients With Initial Operative Fracture Fixation

OBJECTIVES

To describe outcomes following humerus aseptic nonunion surgery in patients whose initial fracture was treated operatively and to identify risk factors for nonunion surgery failure in the same population.

METHODS

DESIGN

Retrospective case series.

SETTING

Eight, academic, level 1 trauma centers.

PATIENTS SELECTION CRITERIA

Patients with aseptic humerus nonunion (OTA/AO 11 and 12) after the initial operative management between 1998 and 2019.

OUTCOME MEASURES AND COMPARISONS

Success rate of nonunion surgery.

RESULTS

Ninety patients were included (56% female; median age 50 years; mean follow-up 21.2 months). Of 90 aseptic humerus nonunions, 71 (78.9%) united following nonunion surgery. Thirty patients (33.3%) experienced 1 or more postoperative complications, including infection, failure of fixation, and readmission. Multivariate analysis found that not performing revision internal fixation during nonunion surgery (n = 8; P = 0.002) and postoperative de novo infection (n = 9; P = 0.005) were associated with an increased risk of recalcitrant nonunion. Patient smoking status and the use of bone graft were not associated with differences in the nonunion repair success rate.

CONCLUSIONS

This series of previously operated aseptic humerus nonunions found that more than 1 in 5 patients failed nonunion repair. De novo postoperative infection and failure to perform revision internal fixation during nonunion surgery were associated with recalcitrant nonunion. Smoking and use of bone graft did not influence the success rate of nonunion surgery. These findings can be used to give patients a realistic expectation of results and complications following humerus nonunion surgery.

LEVEL OF EVIDENCE

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

Ultrasound assessment of humeral shaft nonunion risk: a feasibility and proof of concept study

PURPOSE

To determine the feasibility and reliability of ultrasound in the assessment of humeral shaft fracture healing and estimate the accuracy of 6wk ultrasound in predicting nonunion.

METHODS

Twelve adults with a non-operatively managed humeral shaft fracture were prospectively recruited and underwent ultrasound scanning at 6wks and 12wks post-injury. Seven blinded observers evaluated sonographic callus appearance to determine intra- and inter-observer reliability. Nonunion prediction accuracy was estimated by comparing images for patients that united (n = 10/12) with those that developed a nonunion (n = 2/12).

RESULTS

The mean scan duration was 8 min (5-12) and all patients tolerated the procedure. At 6wks and 12wks, sonographic callus (SC) was present in 11 patients (10 united, one nonunion) and sonographic bridging callus (SBC) in seven (all united). Ultrasound had substantial intra- (weighted kappa: 6wk 0.75; 12wk 0.75) and inter-observer reliability (intraclass correlation coefficient: 6wk 0.60; 12wk 0.76). At 6wks, the absence of SC demonstrated sensitivity 50%, specificity 100%, positive predictive value (PPV) 100% and negative predictive value (NPV) 91% in nonunion prediction (overall accuracy 92%). The absence of SBC demonstrated sensitivity 100%, specificity 70%, PPV 40% and NPV 100% in nonunion prediction (overall accuracy 75%). Of three patients at risk of nonunion (Radiographic Union Score for HUmeral fractures < 8), one had SBC on 6wk ultrasound (that subsequently united) and the others had non-bridging/absent SC (both developed nonunion).

CONCLUSIONS

Ultrasound assessment of humeral shaft fracture healing was feasible, reliable and may predict nonunion. Ultrasound could be useful in defining nonunion risk among patients with reduced radiographic callus formation.

Tissue-Engineered Nanomaterials Play Diverse Roles in Bone Injury Repair

Nanomaterials with bone-mimicking characteristics and easily internalized by the cell could create suitable microenvironments in which to regulate the therapeutic effects of bone regeneration. This review provides an overview of the current state-of-the-art research in developing and using nanomaterials for better bone injury repair. First, an overview of the hierarchical architecture from the macroscale to the nanoscale of natural bone is presented, as these bone tissue microstructures and compositions are the basis for constructing bone substitutes. Next, urgent clinical issues associated with bone injury that require resolution and the potential of nanomaterials to overcome them are discussed. Finally, nanomaterials are classified as inorganic or organic based on their chemical properties. Their basic characteristics and the results of related bone engineering studies are described. This review describes theoretical and technical bases for the development of innovative methods for repairing damaged bone and should inspire therapeutic strategies with potential for clinical applications.

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.

Routine fixation of humeral shaft fractures is cost-effective

Aims

The primary aim was to estimate the cost-effectiveness of routine operative fixation for all patients with humeral shaft fractures. The secondary aim was to estimate the health economic implications of using a Radiographic Union Score for HUmeral fractures (RUSHU) of < 8 to facilitate selective fixation for patients at risk of nonunion.

Methods

From 2008 to 2017, 215 patients (mean age 57 yrs (17 to 18), 61% female (n = 130/215)) with a nonoperatively managed humeral diaphyseal fracture were retrospectively identified. Union was achieved in 77% (n = 165/215) after initial nonoperative management, with 23% (n = 50/215) uniting after surgery for nonunion. The EuroQol five-dimension three-level health index (EQ-5D-3L) was obtained via postal survey. Multiple regression was used to determine the independent influence of patient, injury, and management factors upon the EQ-5D-3L. An incremental cost-effectiveness ratio (ICER) of < £20,000 per quality-adjusted life-year (QALY) gained was considered cost-effective.

Results

At a mean of 5.4 yrs (1.2 to 11.0), the mean EQ-5D-3L was 0.736 (95% confidence interval (CI) 0.697 to 0.775). Adjusted analysis demonstrated the EQ-5D-3L was inferior among patients who united after nonunion surgery (β = 0.103; p = 0.032). Offering routine fixation to all patients to reduce the rate of nonunion would be associated with increased treatment costs of £1,542/patient, but would confer a potential EQ-5D-3L benefit of 0.120/patient over the study period. The ICER of routine fixation was £12,850/QALY gained. Selective fixation based on a RUSHU < 8 at six weeks post-injury would be associated with reduced treatment costs (£415/patient), and would confer a potential EQ-5D-3L benefit of 0.335 per ‘at-risk patient’.

Conclusion

Routine fixation for patients with humeral shaft fractures to reduce the rate of nonunion observed after nonoperative management appears to be a cost-effective intervention at five years post-injury. Selective fixation for patients at risk of nonunion based on their RUSHU may confer even greater cost-effectiveness, given the potential savings and improvement in health-related quality of life. Cite this article: Bone Jt Open 2022;3(7):566–572.

Factors Associated with Patient-Reported Outcomes Following a Humeral Shaft Fracture: Nonunion Results in a Poorer Outcome Despite Union after Surgical Fixation

OBJECTIVES

The primary aim was to assess patient-reported outcomes ≥1 year following a humeral diaphyseal fracture. The secondary aim was to compare outcomes of patients who united after initial management (operative/nonoperative) with those who united after nonunion fixation (NU-ORIF).

DESIGN

Retrospective.

SETTING

University teaching hospital.

PATIENTS AND INTERVENTION

From 2008 to 2017, 291 patients [mean age, 55 years (17-86 years), 58% (n = 168/291) female] were available to complete an outcomes survey. Sixty-four (22%) were initially managed operatively and 227 (78%) nonoperatively. After initial management, 227 (78%) united (n = 62 operative, n = 165 nonoperative), 2 had a delayed union (both nonoperative), and 62 (21%) had a nonunion (n = 2 operative, n = 60 nonoperative). Fifty-two patients (93%, n = 52/56) united after NU-ORIF.

MAIN OUTCOME MEASURES

QuickDASH, EuroQol-5 Dimension (EQ-5D)/EuroQol-Visual Analogue Scale (EQ-VAS), 12-item Short Form Physical (PCS) and Mental Component Summary (MCS).

RESULTS

At a mean of 5.5 years (range, 1.2-11.0 years) postinjury, the mean QuickDASH was 20.8, EQ-5D was 0.730, EQ-VAS was 74, PCS was 44.8 and MCS was 50.2. Patients who united after NU-ORIF reported worse function (QuickDASH, 27.9 vs. 17.6; P = 0.003) and health-related quality of life (HRQoL; EQ-5D, 0.639 vs. 0.766; P = 0.008; EQ-VAS, 66 vs. 76; P = 0.036; PCS, 41.8 vs. 46.1; P = 0.036) than those who united primarily. Adjusting for confounders, union after NU-ORIF was independently associated with a poorer QuickDASH (difference, 8.1; P = 0.019) and EQ-5D (difference, -0.102; P = 0.028).

CONCLUSIONS

Humeral diaphyseal union after NU-ORIF resulted in poorer patient-reported outcomes compared with union after initial management. Targeting early operative intervention to at-risk patients may mitigate the potential impact of nonunion on longer-term outcome.

LEVEL OF EVIDENCE

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

Treatment of a Recalcitrant Non-union of the Clavicle

Background

Plate fixation is the treatment of choice for a midshaft clavicle non-union. Those non-unions that require >1 surgical procedure to heal are termed recalcitrant non-union. Regardless of the number of previously failed procedures, our surgical strategy is aimed at achieving an optimal mechanical and biological environment to facilitate healing.

Materials and methods

We performed a retrospective analysis of 14 patients with a recalcitrant clavicle non-union treated with open reduction and plate fixation combined with graft augmentation when indicated. Healing rates after index surgery were analysed. All patients were observed for at least 12 months.

Results

All patients healed at a mean time of 193.2 days (range 90–390). Five of the 14 patients had at least one positive surprise culture, for which they received antibiotic treatment. At the latest follow-up, no patient reported pain or discomfort. Mean disability of the arm, shoulder and hand (DASH) score was 16.3 points (range 0–40), indicating only mild residual impairment. A possible link was found between the time between injury and definitive surgery and the time to healing [Pearson correlation 0.527, sig. (two-tailed) 0.000].

Conclusion

This study shows 100% bone healing and good functional outcomes after surgical revision for a recalcitrant clavicle non-union.

How to cite this article

Grewal S, Baltes TPA, Wiegerinck E, et al. Treatment of a Recalcitrant Non-union of the Clavicle. Strategies Trauma Limb Reconstr 2022;17(1):1–6.

A Composite Deferoxamine/Black Phosphorus Nanosheet/Gelatin Hydrogel Scaffold for Ischemic Tibial Bone Repair

Introduction

Bone delay union is mostly caused by lack of blood supply. Although autografts, allografts and artificial bone have been widely used to treat bone delay union, the bone regeneration fails in the ischemic site accompanied by the bone donor site complications and disease transmission. Recently, there is a growing recognition of the importance of hydrogel scaffolds which are regarded as an eligible engineer tissue for bone repair. However, hydrogel is still limited in improving neovascularization.

Methods

In this work, black phosphorus nanosheet and deferoxamine (BPN-DFO) were loaded in the gelatin hydrogel to overcome the high risk of bone delay union and systemically investigated the regeneration capability of BPN-DFO hydrogel in vitro and vivo.

Results

The resulting BPN-DFO hydrogel scaffold showed superior swollen, degradation and release rate, as well as satisfied biocompatibility. BPN-DFO hydrogel shown the significant up-expression of mRNA related to bone regeneration and cell proliferation. In vivo, the proposed BPN-DFO hydrogel significantly improved osteogenesis and neovascularization in the ischemic tibial bone site of SD rats with acute femoral artery occlusion. Both macroscopic and histological evaluation of new regenerated bone showed newly formed blood vessel and collagen using BPN-DFO hydrogel. The immunohistochemistry and RT-PCR revealed that the bone regeneration could be improved via BMP/Runx2 pathway.

Conclusion

The BPN-DFO hydrogel possesses potential tissue engineer material for ischemic bone defect treatment. However, furthermore studies are needed to testify the safety and efficacy of BPN-DFO hydrogel.

Return to work and sport after a humeral shaft fracture

Aims

The primary aim of this study was to determine the rates of return to work (RTW) and sport (RTS) following a humeral shaft fracture. The secondary aim was to identify factors independently associated with failure to RTW or RTS.

Methods

From 2008 to 2017, all patients with a humeral diaphyseal fracture were retrospectively identified. Patient demographics and injury characteristics were recorded. Details of pre-injury employment, sporting participation, and levels of return post-injury were obtained via postal questionnaire. The University of California, Los Angeles (UCLA) Activity Scale was used to quantify physical activity among active patients. Regression was used to determine factors independently associated with failure to RTW or RTS.

Results

The Work Group comprised 177 patients in employment prior to injury (mean age 47 years (17 to 78); 51% female (n = 90)). Mean follow-up was 5.8 years (1.3 to 11). Overall, 85% (n = 151) returned to work at a mean of 14 weeks post-injury (0 to 104), but only 60% (n = 106) returned full-time to their previous employment. Proximal-third fractures (adjusted odds ratio (aOR) 4.0 (95% confidence interval (CI) 1.2 to 14.2); p = 0.029) were independently associated with failure to RTW. The Sport Group comprised 182 patients involved in sport prior to injury (mean age 52 years (18 to 85); 57% female (n = 104)). Mean follow-up was 5.4 years (1.3 to 11). The mean UCLA score reduced from 6.9 (95% CI 6.6 to 7.2) before injury to 6.1 (95% CI 5.8 to 6.4) post-injury (p < 0.001). There were 89% (n = 162) who returned to sport: 8% (n = 14) within three months, 34% (n = 62) within six months, and 70% (n = 127) within one year. Age ≥ 60 years was independently associated with failure to RTS (aOR 3.0 (95% CI 1.1 to 8.2); p = 0.036). No other factors were independently associated with failure to RTW or RTS.

Conclusion

Most patients successfully return to work and sport following a humeral shaft fracture, albeit at a lower level of physical activity. Patients aged ≥ 60 yrs and those with proximal-third diaphyseal fractures are at increased risk of failing to return to activity.

Cite this article: Bone Jt Open 2022;3(3):236–244.

Technical Considerations and Early Results of Magnetic Compressive Intramedullary Nailing for Humeral Shaft Delayed Unions and Nonunions

Background

Expandable magnetic rods and intramedullary nails are being used in a number of innovative ways, including limb length discrepancy and scoliosis correction. However, recently, the full complement of these devices has been further explored, with the utilization of their compressive capacity to improve fracture healing. The purpose of the present study was to report on early results of compressive magnetic intramedullary nailing for humeral shaft delayed unions and nonunions.

Methods

This retrospective case series was completed at a level 1 trauma center, with adult patients who underwent compressive intramedullary nailing from 2017 to 2021 for humeral shaft nonunion or delayed union. The primary indication for this procedure was nonunion in the setting of previous conventional fixation, but a subset of patients with atrophic nonunions and risk factors for recalcitrant nonunion were also included.

Results

Fourteen patients, with a mean age of 51 ± 17 years, underwent compressive magnetic intramedullary nailing. Nine patients had previously underwent surgery, 6 of which had undergone multiple prior procedures. Five others were initially treated nonoperatively and underwent surgery 4.1 ± 2.9 months out from injury. Ten patients went on to union at a mean of 2.9 ± 2.4 months. One patient experienced hardware failure with nail cut-out at 2 weeks, and one required revision surgery for a wound infection. Three other patients were lost to follow-up, one of which was deceased for reasons unrelated to surgery.

Conclusion

Compressive magnetic intramedullary nails are a viable solution for complex humeral shaft nonunions, particularly in the setting of previously well-fixed fractures and those at risk of recalcitrant nonunion. However, comparative and prospective studies looking at union rates and secondary procedures are needed to more clearly define their role in treatment and assure their safety, given recent concerns regarding osteolysis at the nail modular junction.

Surgical management of humeral shaft nonunions. Success of a consistent protocol over 17 years

INTRODUCTION

Surgical treatment of humeral shaft nonunions is characterized by variability of fixation methods, graft choices, and rates of union and iatrogenic radial nerve palsy. The aim of the current study is to evaluate the union rate of humeral shaft aseptic nonunions and the rate of postoperative complications following a consistent management protocol.

PATIENTS AND METHODS

This is a retrospective review of 41 consecutive adult patients (23 female and 18 male with a mean age of 42 years) with aseptic nonunions of the humeral shaft treated by the senior author in our institution over a 17-year period. Nonunions were located in the middle third of the diaphysis in 33 patients, in the distal third in 6, and in the proximal third in 2 patients. Comorbidities were present in 49% of patients and the most common were smoking in 27% and diabetes mellitus in 17% of patients. Patients were treated at an average of 24 months after their injury. Surgical protocol consisted of careful dissection of the radial nerve, debridement of the nonunion site, stable plate fixation and augmentation of local biology.

RESULTS

Thirty-eight patients had mean clinical and radiographic follow-up of 9.4 months. All 38 nonunions healed at a mean time of 3.5 months. There were no persistent nonunions and no failures of fixation. None of the 40 patients with an intact radial nerve preoperatively developed any signs of radial nerve compromise after surgery. Complications consisted of one superficial infection (2%) that resolved with oral antibiotics and one deep infection (2%) that required implant removal and debridement. The mean pain score on the visual analog scale was 0.7. Mean elbow range of motion was 125 degrees with a mean extension deficit of 5 degrees and mean flexion of 130 degrees.

CONCLUSIONS

Our surgical protocol achieved consistent healing of nonunions of the humeral shaft with a low complication rate and no iatrogenic radial nerve palsy, even in long-standing nonunions in patients with comorbidities.

Risk Factors for Development of a Recalcitrant Femoral Nonunion: A Single Surgeon Experience in 122 Patients

OBJECTIVES

The goals of the study were (1) to document the healing rates of femoral nonunions stratified by those that healed as intended, healed after a subsequent intervention, and those that did not heal; (2) to report the prevalence of recalcitrant femoral nonunions and (3) to identify specific demographic, injury, and treatment-related risk factors for the development of a recalcitrant nonunion.

DESIGN

Longitudinal observational cohort study.

SETTING

Academic Level 1 trauma center.

PATIENTS/PARTICIPANTS

One hundred twenty-two femoral nonunions treated with either a plate or intramedullary nail by a single surgeon between 1991 and 2018.

INTERVENTION

Bivariate and multivariate regression analysis were performed to identify specific demographic, injury, and treatment factors in patients who developed a recalcitrant nonunion.

RESULTS

Although 83.6% of the femoral nonunions eventually healed, only 66% "healed as intended" with 17.2% requiring 1 or more additional procedures to consolidate and 16.4% of nonunions failing to unite. There were no statistically significant differences in the recalcitrance rate when we compared treatment with conventional versus locked plates or primary versus exchange nailing. Risk factors for developing a recalcitrant nonunion were deep infection, current smokers, metabolic bone disease, and patients who had undergone 3 or more prior surgical procedures.

CONCLUSIONS

The use of both intramedullary nails and modern plates were associated with a high rate of recalcitrance. Infection, current smokers, metabolic bone disease, and 3 or more prior surgical procedures were predictors for the development of a recalcitrant nonunion.

LEVEL OF EVIDENCE

Therapeutic Leve IV. See Instructions for Authors for a complete description of levels of evidence.

Factors associated with humeral shaft nonunion

BACKGROUND

The primary aim was to identify patient and injury factors independently associated with humeral diaphyseal fracture nonunion after nonoperative management. The secondary aim was to determine the effect of management (operative/nonoperative) on nonunion.

METHODS

From 2008-2017, a total of 734 humeral shaft fractures (732 consecutive skeletally mature patients) were retrospectively identified from a trauma database. Follow-up was available for 663 fractures (662 patients, 90%) that formed the study cohort. Patient and injury characteristics were recorded. There were 523 patients (79%) managed nonoperatively and 139 (21%) managed operatively. Outcome (union/nonunion) was determined from medical records and radiographs.

RESULTS

The median age at injury was 57 (range 16-96) years and 54% (n = 359/662) were female. Median follow-up was 5 (1.2-74) months. Nonunion occurred in 22.7% (n = 119/524) of nonoperatively managed injuries. Multivariate analysis demonstrated preinjury nonsteroidal anti-inflammatory drugs (NSAIDs; odds ratio [OR] 20.58, 95% confidence interval [CI] 2.12-199.48; P = .009) and glenohumeral arthritis (OR 2.44, 95% CI 1.03-5.77; P = .043) were independently associated with an increased risk of nonunion. Operative fixation was independently associated with a lower risk of nonunion (2.9%, n = 4/139) compared with nonoperative management (OR for nonoperative/operative management 9.91, 95% CI 3.25-30.23; P < .001). Based on these findings, 5 patients would need to undergo primary operative fixation in order to avoid 1 nonunion.

CONCLUSIONS

Preinjury NSAIDs and glenohumeral arthritis were independently associated with nonunion following nonoperative management of a humeral diaphyseal fracture. Operative fixation was the independent factor most strongly associated with a lower risk of nonunion. Targeting early operative fixation to at-risk patients may reduce the rate of nonunion and the morbidity associated with delayed definitive management.

Healing the Index Tibial Nonunion: Risk Factors for Development of a Recalcitrant Nonunion in 222 Patients

OBJECTIVES

To compare and stratify the healing rates after our index nonunion surgery using contemporary methods of fixation, report the prevalence of recalcitrant non-union, and identify specific demographic, injury, and treatment-related risk factors for the development of a recalcitrant nonunion.

DESIGN

Retrospective analysis of a prospectively collected database.

SETTING

Academic Level 1 Trauma Center.

PATIENTS/PARTICIPANTS

Two hundred twenty-two tibial nonunions treated with internal fixation by a single surgeon.

INTERVENTION

Bivariate and multivariate regression analysis were performed to compare healing rates by the type of fixation and graft augmentation and to identify specific demographic, injury, and treatment-related risk factors for the development of a recalcitrant nonunion.

RESULTS

Of the 222 patients, 162 (73%) healed as intended and 51 (23%) required 1 or more subsequent interventions to achieve union (96%). Nine fractures (4%) failed to unite. The 60 fractures (27%) that required a subsequent intervention(s) or failed to consolidate were defined as recalcitrant nonunions. There were no statistically significant differences in the recalcitrant rate when we compared plates versus nails or types of bone graft. Risk factors for developing a recalcitrant nonunion were multifactorial and included grade III open fractures, compartment syndrome, deep infection, and 2 or more prior surgical procedures.

CONCLUSIONS

Internal fixation remains a successful method of treatment for most tibial nonunions. However, 27% of patients required a subsequent intervention because of failure to heal our index nonunion procedure. Factors that are associated with recalcitrant nonunions were a grade III open fracture, compartment syndrome, deep infection, and 2 or more or more prior surgical procedures.

LEVEL OF EVIDENCE

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

Repair of Humeral Shaft Nonunion With Plate and Screw Fixation and Iliac Crest Bone Graft

A 58-year-old woman with a proximal 1/3 humeral shaft nonunion presented 2 years after initial injury. We present a technique for nonunion repair, including nonunion site preparation, direct compression of the fracture site using plate osteosynthesis, and iliac crest bone graft harvest and utilization. The purpose of this video is to review humeral shaft nonunion literature and describe our management technique.

Open Reduction and Internal Fixation for Humeral Shaft Nonunion: Bone Grafting Is Not Routinely Required and Avoids Donor Site Morbidity

OBJECTIVES

To document union rate, complications and patient-reported outcomes after open reduction and internal fixation (ORIF), with and without bone grafting (BG), for humeral diaphyseal nonunion after failed nonoperative management.

DESIGN

Retrospective.

SETTING

University teaching hospital.

PATIENTS AND INTERVENTION

From 2008 to 2017, 86 consecutive patients [mean age 59 years (range 17-86), 71% (n = 61/86) women] underwent nonunion ORIF (plate and screws) at a mean of 7 months postinjury (range 3-21.5). Eleven (13%) underwent supplementary BG.

MAIN OUTCOME MEASUREMENTS

Union rate and complications for 83 patients (97%) at a mean of 10 months (3-61). Patient-reported outcomes (QuickDASH, EQ-5D, EQ-VAS, SF-12, satisfaction) for 53 living, cognitively-intact patients (78%) at a mean of 4.9 years (0.3-9.2).

RESULTS

Ninety-three percent (n = 77/83) achieved union after nonunion ORIF. Complications included recalcitrant nonunion (7%, n = 6/83), iatrogenic radial nerve palsy (6%, n = 5/83), infection (superficial 7%, n = 6/83; deep 2%, n = 2/83), and iliac crest donor site morbidity (38%, n = 3/8). The union rate with BG was 78% (n = 7/9) and without was 95% (n = 70/74; P = 0.125), and was not associated with the nonunion type (atrophic 91%, n = 53/58; hypertrophic 96%, n = 24/25; P = 0.663). Median QuickDASH was 22.7 (0-95), EQ-5D 0.710 (-0.181-1), EQ-visual analog scale 80 (10-100), SF-12 physical component summary 41.9 (16-60.5), and mental component summary 52.6 (18.7-67.7). Nineteen percent (n = 10/53) were dissatisfied with their outcome.

CONCLUSIONS

ORIF for humeral diaphyseal nonunion was associated with a high rate of union. Routine BG was not required and avoided the risk of donor site morbidity. One in 5 patients were dissatisfied despite the majority achieving union.

LEVEL OF EVIDENCE

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

Fracture nonunion in long bones: A literature review of risk factors and surgical management

Nonunion following a long bone fracture causes considerable morbidity when it occurs. Risk factors depend on specific fractures but there is a complex interplay of injury severity, comorbidities, patient medication and infection. The majority of nonunions occur after long bone fractures with the tibia, femur, forearm, humerus and clavicle predominating. Despite interest in the biological augmentation of fracture healing, the majority of nonunions can be effectively managed with conventional surgical techniques. In this review we present a review of risk factors for nonunion and the outcome following surgical management.

Lipoteichoic Acid Accelerates Bone Healing by Enhancing Osteoblast Differentiation and Inhibiting Osteoclast Activation in a Mouse Model of Femoral Defects

Lipoteichoic acid (LTA) is a cell wall component of Gram-positive bacteria. Limited data suggest that LTA is beneficial for bone regeneration in vitro. Thus, we used a mouse model of femoral defects to explore the effects of LTA on bone healing in vivo. Micro-computed tomography analysis and double-fluorochrome labeling were utilized to examine whether LTA can accelerate dynamic bone formation in vivo. The effects of LTA on osteoblastogenesis and osteoclastogenesis were also studied in vitro. LTA treatment induced prompt bone bridge formation, rapid endochondral ossification, and accelerated healing of fractures in mice with femoral bone defects. In vitro, LTA directly enhanced indicators of osteogenic factor-induced MC3T3-E1 cell differentiation, including alkaline phosphatase activity, calcium deposition and osteopontin expression. LTA also inhibited osteoclast activation induced by receptor activator of nuclear factor-kappa B ligand. We identified six molecules that may be associated with LTA-accelerated bone healing: monocyte chemoattractant protein 1, chemokine (C-X-C motif) ligand 1, cystatin C, growth/differentiation factor 15, endostatin and neutrophil gelatinase-associated lipocalin. Finally, double-fluorochrome, dynamic-labeling data indicated that LTA significantly enhanced bone-formation rates in vivo. In conclusion, our findings suggest that LTA has promising bone-regeneration properties.