Management of complex tibial and femoral nonunion using the Ilizarov technique, and its cost implications

Surgical treatment of critical size bone defects with Masquelet technique versus bone transport: a systematic review and meta-analysis of comparative studies

INTRODUCTION

To date, the management of critical-sized bone defects lacks a universally accepted approach among orthopedic surgeons. Currently, the main options to treat severe bone loss include autologous grafting, free vascularized bone transfer, bone transport and induced-membrane technique. The purpose of this study is to critically compare the outcomes of Masquelet technique and bone transport to provide a higher level of evidence regarding the indexed techniques.

MATERIAL AND METHODS

The authors conducted a systematic search on several databases according to the PRISMA guidelines. English-written reports comparing outcomes of the Masquelet technique versus the bone transport technique in patients with critical-sized defects in lower extremities were included.

RESULTS

Six observational studies involving 364 patients were included. The systematic review and meta-analysis of pooled data showed no significant difference in most outcomes, except for ASAMI bone outcomes and residual deformity, which showed better results in the bone transport group. The 64% of patients treated with Masquelet technique obtained excellent/good bone ASAMI results compared to 82.8% with bone transport (p = 0.01). Post-operative residual deformity was 1.9% with the bone transport method versus 9.7% with the Masquelet technique (p = 0.02).

CONCLUSIONS

Both the Masquelet technique and bone transport showed comparable results for the management of critical-sized bone defects of the lower limb. However, these findings must be carefully interpreted due to the high risk of bias. Further prospective randomized controlled trials are necessary to better clarify the strengths and limitations of these two techniques and to identify the variables affecting the outcomes.

Outcome analysis of ilizarov and monorail fixators in the treatment of nonunion of long bones: A systematic review and proportion meta-analysis

Introduction

Nonunion of long bones is a major complication following fractures that requires a substantial amount of investment both monetary and time from patients and surgeons. The need to comprehensively understand the complications, outcomes and distraction capability is profound, which necessitates a review of current evidence on special fixators used for distraction. The current systematic review aims to study the available literature on distraction osteogenesis using special fixators (Ilizarov and Limb Reconstruction System) in the management of nonunion (infected and non-infected).

Methods

Cochrane Library, PubMed, Scopus were searched until January 2022. The review included all original studies which used Ilizarov or Monorail Fixators/LRS in the treatment of nonunion of long bones. The quality of studies was assessed using the Modified Coleman Methodology Score.

Results

A total of 35 original studies with Ilizarov (n = 29) and LRS (n = 8) were selected including two comparative studies. The pooled data meta-analysis and the subgroup analysis of these studies found both Ilizarov and LRS fixator yield similar functional outcomes for the treatment of long bones nonunion.

Conclusion

The review was conducted to understand the scenario of nonunion in long bones. Pin tract infection is found to be the most common complication followed by adjacent joint stiffness and deformity. In our review we observed that both external fixator time and index were lower in LRS compared to Ilizarov group. Further RCT are required comparing Ilizarov and LRS fixators to effectively comment upon the superiority of the implants.

Outcomes of Intramedullary Nailing and External Fixation of Open Tibial Fractures: Three to Five-Year Follow-up of a Randomized Clinical Trial

BACKGROUND

While surgeons in low and middle-income countries have increasing experience with intramedullary nailing (IMN), external fixation (EF) continues to be commonly used for the management of open tibial fractures. We examined outcomes with extended follow-up of the participants enrolled in a clinical trial comparing these treatments.

METHODS

Adults who were ≥18 years old with acute AO/OTA type-42 open tibial shaft fractures were randomly assigned to statically locked, hand-reamed IMN or uniplanar EF. These participants were reevaluated 3 to 5 years after treatment. The primary outcome was death or reoperation for the treatment of deep infection, nonunion, or malalignment. Unresolved complications such as persistent fracture-related infection, nonunion, or malalignment were collected and analyzed. Secondary outcomes included the EuroQol-5 Dimension-3 Level (EQ-5D-3L) questionnaire, the Function IndeX for Trauma (FIX-IT) score, radiographic alignment, and the modified Radiographic Union Scale for Tibial fractures (mRUST).

RESULTS

Of the originally enrolled 240 participants,126 (67 managed with IMN and 59 managed with EF) died or returned for follow-up at a mean of 4.0 years (range, 2.9 to 5.2 years). Thirty-two composite primary events occurred, with rates of 23.9% and 27.1% in the IMN and EF groups, respectively. Six of these events (3 in the IMN group and 3 in the EF group) were newly detected after the original 1-year follow-up. Unresolved complications in the form of chronic fracture-related infection or nonunion were present at long-term follow-up in 25% of the participants who sustained a primary event. The EQ-5D-3L index scores were similar between the 2 groups and only returned to preinjury levels after 1 year among patients without complications or those whose complications resolved.

CONCLUSIONS

This observational study extended follow-up for a clinical trial assessing IMN versus EF for the treatment of open tibial fractures in sub-Saharan Africa. At a mean of 4 years after injury, fracture-related infection and nonunion became chronic conditions in nearly a quarter of the participants who experienced these complications, regardless of reintervention.

LEVEL OF EVIDENCE

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

Hexapod Circular Frame Fixation for Tibial Non-union: A Systematic Review of Clinical and Radiological Outcomes

Introduction

Tibial non-unions present with complex deformities, bone loss, infection, leg length discrepancy (LLD), and other features which influence function. Circular frame-based treatment is popular with the hexapod system used increasingly. This systematic review aims to determine the clinical and radiological outcomes of hexapod fixation when used for tibial non-unions.

Materials and methods

The review was performed in accordance with preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. The search strategy was applied to MEDLINE and Embase databases on 15 December 2021. Studies reporting either clinical or radiological outcomes following hexapod fixation on tibial non-unions were included. Primary outcomes were radiological union and patient-reported outcome measures (PROMs). Secondary outcomes included LLD, tibial alignment deformity (TAD), return to pre-injury activity and post-operative complications.

Results

After the abstract and full-text screening, 9 studies were included; there were 283 hexapod frame fixations for tibial non-unions. Infection (46.6%) and stiff hypertrophic non-union (39.2%) accounted for most non-unions treated. The average age and mean follow-up were 42.2 years and 33.1 months, respectively. The average time to union was 8.7 months with a union rate of 84.8%. A total of 90.3% of patients had TAD below 5° in all planes, with an LLD ≤1.5 cm of the contralateral leg in 90.5%. Bony and functional results were at least good in over 90% of patients when using the Association for the Study of the Method of Ilizarov (ASAMI) criteria. A total of 84% of patients returned to pre-injury activities. There were complications as follows: a total of 34% developed pin-site infection, almost 9% experienced half-pin breakage and 14% developed an equinus ankle contracture.

Conclusion

Hexapod frames for the treatment of tibial non-unions produce favourable functional outcomes. Complication rates are present and need to be discussed when this modality of treatment is proposed. Further comparative studies will allow for this option to be evaluated against that of the traditional Ilizarov frame and other methods of non-union surgery.

How to cite this article

Boksh K, Kanthasamy S, Divall P, et al. Hexapod Circular Frame Fixation for Tibial Non-union: A Systematic Review of Clinical and Radiological Outcomes. Strategies Trauma Limb Reconstr 2022;17(3):172-183.

Percutaneous Strain Reduction Screws Are a Reproducible Minimally Invasive Method to Treat Long Bone Nonunion

OBJECTIVES

(1) Evaluate whether initial results from percutaneous treatment of nonunion are reproducible (2) Estimate the relative cost of percutaneous treatment of nonunion versus traditional methods.

DESIGN

Retrospective multicentre case series.

SETTING

Four Level 1 trauma centers.

PATIENTS/PARTICIPANTS

Fifty-one patients (34 men and 17 women) with a median age of 51 years (range 14-81) were treated for nonunion at a median of 10 months (range 4-212) from injury.

INTERVENTION

Percutaneous strain reduction screws (PSRS).

MAIN OUTCOME MEASURED

Union rates and time to union were compared for patients treated in the developing institution versus independent units as well as with previously published results.

RESULTS

Forty-five (88%) patients achieved union at a median time of 5.2 months (range 1.0-24.7) confirming the previously published results for this technique. Comparable results were seen between the developing institution and independent units. No patients experienced adverse events beyond failure to achieve union. PSRS seems to offer savings of between £3177 ($4416) to £11,352 ($15,780) per case compared with traditional methods of nonunion surgery.

CONCLUSIONS

PSRS is a safe, efficacious treatment for long bone nonunion and may be more cost-effective than traditional nonunion treatment methods. The promising initial results of this technique have now been replicated outside of the developing institution.

LEVEL OF EVIDENCE

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

Design Strategies and Biomimetic Approaches for Calcium Phosphate Scaffolds in Bone Tissue Regeneration

Bone is a complex biologic tissue, which is extremely relevant for various physiological functions, in addition to movement, organ protection, and weight bearing. The repair of critical size bone defects is a still unmet clinical need, and over the past decades, material scientists have been expending efforts to find effective technological solutions, based on the use of scaffolds. In this context, biomimetics which is intended as the ability of a scaffold to reproduce compositional and structural features of the host tissues, is increasingly considered as a guide for this purpose. However, the achievement of implants that mimic the very complex bone composition, multi-scale structure, and mechanics is still an open challenge. Indeed, despite the fact that calcium phosphates are widely recognized as elective biomaterials to fabricate regenerative bone scaffolds, their processing into 3D devices with suitable cell-instructing features is still prevented by insurmountable drawbacks. With respect to biomaterials science, new approaches maybe conceived to gain ground and promise for a substantial leap forward in this field. The present review provides an overview of physicochemical and structural features of bone tissue that are responsible for its biologic behavior. Moreover, relevant and recent technological approaches, also inspired by natural processes and structures, are described, which can be considered as a leverage for future development of next generation bioactive medical devices.

The epidemiology and direct healthcare costs of aseptic nonunions in Germany - a descriptive report

Aims

This observational cross-sectional study aimed to answer the following questions: 1) how has nonunion incidence developed from 2009 to 2019 in a nationwide cohort; 2) what is the age and sex distribution of nonunions for distinct anatomical nonunion localizations; and 3) how high were the costs for surgical nonunion treatment in a level 1 trauma centre in Germany?

Methods

Data consisting of annual International Classification of Diseases (ICD)-10 diagnosis codes from German medical institutions from 2009 to 2019, provided by the Federal Statistical Office of Germany (Destatis), were analyzed. Nonunion incidence was calculated for anatomical localization, sex, and age groups. Incidence rate ratios (IRRs) were determined and compared with a two-sample z-test. Diagnosis-related group (DRG)-reimbursement and length of hospital stay were retrospectively retrieved for each anatomical localization, considering 210 patients.

Results

In 2019, a total of 11,840 nonunion cases (17.4/100,000 inhabitants) were treated. In comparison to 2018, the incidence of nonunion increased by 3% (IRR 1.03, 95% confidence interval (CI) 0.53 to 1.99, p = 0.935). The incidence was higher for male cases (IRR female/male: 0.79, 95% CI 0.76 to 0.82, p = 0.484). Most nonunions occurred at the pelvic and hip region (3.6/100,000 inhabitants, 95% CI 3.5 to 3.8), followed by the ankle and foot as well as the hand (2.9/100,000 inhabitants each). Mean estimated DRG reimbursement for in-hospital treatment of nonunions was highest for nonunions at the pelvic and hip region (€8,319 (SD 2,410), p < 0.001).

Conclusion

Despite attempts to improve fracture treatment in recent years, nonunions remain a problem for orthopaedic and trauma surgery, with a stable incidence throughout the last decade.

Cite this article: Bone Joint Res 2022;11(8):541–547.

Public Insurance Payment Does Not Compensate Hospital Cost for Care of Long-Bone Fractures Requiring Additional Surgery to Promote Union

OBJECTIVES

To quantify the total hospital costs associated with the treatment of lower extremity long-bone fracture aseptic and septic unhealed fracture, to determine if insurance adequately covers these costs, and to examine whether insurance type correlates with barriers to accessing care.

DESIGN

Retrospective cohort study.

SETTING

Academic Level II trauma center.

PATIENTS

All patients undergoing operative treatment of OTA/AO classification 31, 32, 33, 41, 42, and 43 fractures between 2012 and 2020 at a single Level II trauma center with minimum of 1-year follow-up.

MAIN OUTCOME MEASURES

The primary outcome was the total cost of treatment for all hospital-based episodes of care. Distance traveled from primary residence was measured as a surrogate for barriers to care.

RESULTS

One hundred seventeen patients with uncomplicated fracture healing, 82 with aseptic unhealed fracture, and 44 with septic unhealed fracture were included in the final cohort. The median cost of treatment for treatment of septic unhealed fracture was $148,318 [interquartile range(IQR) 87,241-256,928], $45,230 (IQR 31,510-68,030) for treatment of aseptic unhealed fracture, and $33,991 (IQR 25,609-54,590) for uncomplicated fracture healing. The hospital made a profit on all patients with commercial insurance, but lost money on all patients with public insurance. Among patients with unhealed fracture, those with public insurance traveled 4 times further for their care compared with patients with commercial insurance (P = 0.004).

CONCLUSIONS

Septic unhealed fracture of lower extremity long-bone fractures is an outsized burden on the health care system. Public insurance for both septic and aseptic unhealed fracture does not cover hospital costs. The increased distances traveled by our Medi-Cal and Medicare population may reflect the economic disincentive for local hospitals to care for publicly insured patients with unhealed fractures.

LEVEL OF EVIDENCE

Economic Level V. See Instructions for Authors for a complete description of levels of evidence.

Bone transport in the management of post-osteomyelitis femoral defects in children: A case series with a minimum of 10-year follow-up in Uganda

PURPOSE

The aim of this study was to evaluate the long-term outcomes of the bone transport technique in the management of post-infectious segmental femoral bone defects in children in a low-income country.

METHODS

Eleven children were included in this case series. All had a femoral defect secondary to osteomyelitis managed with the internal bone transport technique using an external fixator alone. Bone and functional results were evaluated and complications recorded after a minimum follow-up period of 10 years (range: 10-16).

RESULTS

The mean age of the patients was 7.8 years, and the average size of the bone defect was 10.8 cm. At the latest follow-up, bone results were excellent in three, good in five, and fair in three, while the functional results were excellent in three, good in four, fair in three, and poor in one. Limb length discrepancy was observed in 10 cases while hip and/or knee joint disorder was recorded in six cases. At the last follow-up, only one patient had a recurrence of infection.

CONCLUSION

The bone transport technique has proven to be a valid option for eradicating infection and filling large bone defects in children. However, it is a technically difficult and lengthy procedure that is prone to unique complications.

LEVEL OF EVIDENCE

IV-Case series.

Prospective randomized comparison of bone transport versus Masquelet technique in infected gap nonunion of tibia

AIM

The present prospective randomized study compared the bone transport technique (BT) and Masquelet technique (MT) in the treatment of infected gap non-union of the tibia.

PATIENTS AND METHODS

Total 25 patients with infected gap non-union of the tibia with bone gap upto 6 cm were randomised into BT group (group I, 13 patients) and MT (group II, 12 patients). The mean age was 31.77 years in group I and 39.67 years in group II. The mean intra-operative bone gap was 3.92 cm in group I and 3.79 cm in group II. Monolateral fixator was applied in nine patients each in both groups, while four and three fractures were stabilized with ring fixators in group I and II, respectively. Mean follow-up was 31.62 months and 30.42 months in group I and II, respectively. Bone and functional results were compared using the association for the study and application of the method of Ilizarov (ASAMI) criteria.

RESULTS

The average fixator period was 9.42 and 16.33 months in group I and II, respectively (p < 0.001). Union was achieved in 12 (92%) patients and 6 (50%) patients in group I and II, respectively. The functional results were excellent (eight and two), good (four and six), fair (zero and three) and poor (one and one) in group I and II respectively, (p 0.23). The Bone results were excellent, good and poor in nine, three and one patients in group I, and three, three and six patients in group II respectively, (p 0.109).

CONCLUSIONS

The functional and bone results were comparable but more reliable in bone transport than the Masquelet technique. The fixator duration and incidence of non-union were higher in MT group. Ilizarov bone transport technique should be preferred in infected non-union of the tibia with bone loss upto 6 cm.

Pitfalls preventing bone union with EXOGEN Low-Intensity Pulsed Ultrasound

OBJECTIVES

To evaluate the efficacy of EXOGEN in achieving union and common pitfalls in its use within the Manchester Foundation Trust (MFT) and Salford Royal Foundation Trust (SRFT).

METHOD

Patients receiving EXOGEN therapy between 01/01/2017 and 31/12/2019 at hospitals within MFT and SRFT were identified using EXOGEN logbooks and hospital IT systems. An equal number of patients were included from both sites. Data were retrospectively collected from clinical documents detailing clinical presentation comorbidities, and radiographic images, determining the radiological union post EXOGEN therapy. In addition, local practices were observed and compared to EXOGEN's standardized guidance for clinicians.

RESULTS

Fifty-eight patients were included in the primary review, with 9 subsequently excluded based on insufficient clinical data. 47% of patients achieved radiological union following completion of EXOGEN therapy. Outcomes of the 23 patients with persistent non-union were as follows - 18 were referred for revision surgery, 5 were prescribed further EXOGEN therapy, 2 refused or were unfit for further intervention, and 1 did not have a plan documented. No significant baseline differences were present in both outcome groups. However, at MFT and SRFT, rates of union with EXOGEN are below that previously published in the literature.

CONCLUSION

EXOGEN has proven successful in facilitating union in established cases of non-union without the risk and cost associated with revision surgery. Centre outcome differences may be explained by failure to educate clinicians and patients on the correct use of the EXOGEN device, failure to standardize follow-up or monitor compliance, and must be addressed to improve current services.

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.

A Novel technique of three-ring Ilizarov fixator frame in gap non-union of tibia

INTRODUCTION

Gap non-union of tibia occurring mostly after trauma and many times complicated by infection, is a difficult problem to treat. The study aimed to assess the outcome of the three-ring construct of the Ilizarov fixator frame in the management of gap non-union of the tibia.

METHODS

This retrospective study included 30 patients of gap non-union of tibia operated from April 2016 to March 2019 with a three-ring Ilizarov fixator frame and follow-up done till March 2021. The mean age was 39.27 (range 10-66) years. The results were assessed by the Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria. MPTA, PPTA, and LDTA after removal of the frame were also measured.

RESULTS

Out of the total 30 cases, all the patients showed complete union. The Ilizarov fixator was kept for an average period of 11.43 months and the mean defect size was 7.17 (range 2-12) cm. All patients were followed up for an average period of 39.36 (range 24-54) months. According to the ASAMI score bone/radiological results, 27 were classified as excellent, 2 as good, and 1 as poor. Functionally 28 were graded as excellent and the remainder as good. The normal ranges of MPTA, LDTA & PPTA were also achieved in a majority (80%) of patients.

CONCLUSION

Our results after using only a three-ring Ilizarov fixator frame are almost equivalent to earlier studies and have advantages such as less weight, better patient compliance, superior radiographic visualization, easy mobilization, and reduced costs. Ilizarov ring fixator remains an excellent treatment modality for tibial non-union with a defect, regarding bone union, deformity correction, infection eradication, limb-length achievement, and limb function.

Biomorphic Transformations: A Leap Forward in Getting Nanostructured 3-D Bioceramics

Obtaining 3-D inorganic devices with designed chemical composition, complex geometry, hierarchic structure and effective mechanical performance is a major scientific goal, still prevented by insurmountable technological limitations. With particular respect to the biomedical field, there is a lack in solutions ensuring the regeneration of long, load-bearing bone segments such as the ones of limbs, due to the still unmet goal of converging, in a unique device, bioactive chemical composition, multi-scale cell-conducive porosity and a hierarchically organized architecture capable of bearing and managing complex mechanical loads in a unique 3D implant. An emerging, but still very poorly explored approach in this respect, is given by biomorphic transformation processes, aimed at converting natural structures into functional 3D inorganic constructs with smart mechanical performance. Recent studies highlighted the use of heterogeneous gas-solid reactions as a valuable approach to obtain effective transformation of natural woods into hierarchically structured apatitic bone scaffolds. In this light, the present review illustrates critical aspects related to the application of such heterogeneous reactions when occurring in the 3D state, showing the relevance of a thorough kinetic control to achieve controlled phase transformations while maintaining the multi-scale architecture and the outstanding mechanical performance of the starting natural structure. These first results encourage the further investigation towards the biologic structures optimized by nature along the ages and then the development of biomorphic transformations as a radically new approach to enable a technological breakthrough in various research fields and opening to still unexplored industrial applications.

Nature-Inspired Unconventional Approaches to Develop 3D Bioceramic Scaffolds with Enhanced Regenerative Ability

Material science is a relevant discipline in support of regenerative medicine. Indeed, tissue regeneration requires the use of scaffolds able to guide and sustain the natural cell metabolism towards tissue regrowth. This need is particularly important in musculoskeletal regeneration, such as in the case of diseased bone or osteocartilaginous regions for which calcium phosphate-based scaffolds are considered as the golden solution. However, various technological barriers related to conventional ceramic processing have thus far hampered the achievement of biomimetic and bioactive scaffolds as effective solutions for still unmet clinical needs in orthopaedics. Driven by such highly impacting socioeconomic needs, new nature-inspired approaches promise to make a technological leap forward in the development of advanced biomaterials. The present review illustrates ion-doped apatites as biomimetic materials whose bioactivity resides in their unstable chemical composition and nanocrystallinity, both of which are, however, destroyed by the classical sintering treatment. In the following, recent nature-inspired methods preventing the use of high-temperature treatments, based on (i) chemically hardening bioceramics, (ii) biomineralisation process, and (iii) biomorphic transformations, are illustrated. These methods can generate products with advanced biofunctional properties, particularly biomorphic transformations represent an emerging approach that could pave the way to a technological leap forward in medicine and also in various other application fields.

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.

Treatment of infected tibial non-unions using a BMAC and S53P4 BAG combination for reconstruction of segmental bone defects: A clinical case series

INTRODUCTION

Treatment of infected non-unions of the tibia is a challenging problem. The cornerstones of optimal infected non-union treatment consist of extensive debridement, fracture fixation, antimicrobial therapy and creation of an optimal local biological bone healing environment. The combination of S53P4 bioactive glass (BAG), as osteostimulative antibacterial bone graft substitute, and bone marrow aspirate concentrate (BMAC) for the implantation of mesenchymal stem cells and growth factors might be a promising combination. In this paper, preliminary results of a new treatment algorithm for infected non-unions of the tibia is presented.

METHODS

In this retrospective case series patients with infected non-unions of the tibia are treated according to a new treatment algorithm. Patients are treated with extensive debridement surgery, replacement of the osteosynthesis and implantation of S53P4 BAG and BMAC in a one-stage or two-stage procedure based on non-union severity. Subsequently patients are treated with culture based antibiotic therapy and followed until union and infection eradication.

RESULTS

Five patients with an infected non-union were treated, mean age was 55, average NUSS-score was 44 and the average segmental bone defect was 4.6cm. One patient was treated in a one-stage procedure and four patients in a two-stage induced membrane-, or "Masquelet"-procedure. On average, 23 ml S53P4 BAG and 6.2 ml BMAC was implanted. The mean follow-up period was 13.6 months and at the end of follow-up all patients had clinical consolidation with an average RUST-score of 7.8 and complete eradication of infection.

DISCUSSION

These early data on the combined implantation of S53P4 BAG and BMAC in treatment of infected non-unions shows promising results. These fracture healing results and eradication rates resulted in promising functional recovery of the patients. To substantiate these results, larger and higher quality studies should be performed.

Outcome of limb reconstruction system in tibial infected non-union and open tibial diaphysial fracture with bone loss

INTRODUCTION

Incidence of open fractures of the long bones is increasing due to the increase in road traffic accidents (RTA) which leads to an increased incidence of complex non-unions of long bones. Patients are usually operated many times for fracture fixation (and healing) or to eradicate infection, which causes soft tissue scarring and devitalization of any surviving bone.

OBJECTIVE

In this study, we assess the outcome of the Limb reconstruction system in tibial infected non-union and open tibial diaphyseal fracture with bone loss.

METHOD

It is a prospective study conducted on 15 patients and patients included in this study having compound fractures of shaft tibia with bone loss classified by Gustilo-Anderson open fracture classification. With the defect in the distal tibia, proximal corticotomy 1.5 cm distal to the last screw in the proximal clamp and proximal to distal transports were done and vice versa. All patients were evaluated with the ASAMI scoring system into bone results and functional results.

RESULTS

In the majority of patients, the injury was caused by road traffic accidents 80% of cases. Out of 15 cases, 2 belong to the upper 3rd, 9 cases belong to the middle 3rd and 4 cases belong to the lower 3rd of shaft tibia. The union time ranges from 4 to 11 months but the maximum union was achieved in 7-9 months in 8 (53.33%). Pin tract infection was reported in two (13.33%) patients who became better with regular dressing. Ankle stiffness was present in one case (6.67%), most probably due to improper physiotherapy.According to ASAMI Criteria excellent radiological results were present in 11 (73.33%) cases, good results were found in 4 (26.67) cases and excellent functional results were observed in 7 cases (46.67%) and good results were found in 8 (53.33%) cases. Infection was cured in all patients and did not recur till the last follow-up.

CONCLUSIONS

Advantages of rail fixator include less invasive surgery, early weight-bearing, less infection, less blood loss, prevention of diffuse osteoporosis and atrophy, preservation of limb function, no need for bone grafting, correction of deformity during the process of healing, thus no need for a second surgery. Non-union, bone defect, and deformity can be corrected simultaneously. Hence, we recommend the use of this system (rail fixator) especially for infected non-union of long bones and compound fractures with bone loss.

Management of complex non union of tibia using rail external fixator

INTRODUCTION

Management of the complex non union of tibia is a challenging task due to infection, bony gap, deformity, poor bone quality and poor soft tissue cover at fracture site. The limb reconstruction system (LRS) or Rail fixator has emerged as a viable option for the treatment of the same as it can address most of all above problems. It is more patient friendly and easier to apply in comparison to Ilizarov ring fixator.

MATERIAL AND METHODS

Twenty two patients (17 males and 5 females) with complex non union of tibia underwent thorough debridement and resection of non viable bone followed by bone transport to fill the gap and then lengthening (8 patients) or acute docking & lengthening (14 patients) by the use of rail fixator. The average time to union, bone gap filled, lengthening achieved, treatment index were measured. The bone and functional outcome assessment was done by ASAMI score. The complications were classified according to Paley's classification.

RESULTS

Union without residual infection was achieved in 20 (90.1%) patients while 2 patients had failure. As per ASAMI criteria bone results were excellent in 12 (54.5%), good in 5 (22.7%), fair in 3 (13.6%) and poor in 2 (9.1%). Functional results were excellent in 11 (50%), good in 5 (22.72%), fair in 4 (18.18%) and failure in 2 (9%). Mean treatment duration was 8.2 months (range 7-19 months). Mean follow up duration was 11.3 months (range - 8.3 to 22 months). Average lengthening achieved was 4 cm (0-9 cm). Treatment index was 2.1 month/cm.

CONCLUSION

The monolateral rail fixator is simple, effective, easier to apply and more patient compliant with acceptable functional and radiological outcome.

Treatment of Infected Tibial Non-Unions with Ilizarov Technique: A Case Series

Background: The Ilizarov external fixation technique has been widely used for the treatment of long-bone infected non-unions. After surgical infected bone resection, to allow filling of the remaining bone gap, biomaterials with antibacterial properties could be used. The aim of this study was to report outcomes of infected tibial non-unions treated using the Ilizarov technique and antibacterial bioactive glass. Methods: Between April 2009 and December 2014, 26 patients with infected tibial non-unions were treated with the Ilizarov technique and possible use of the bioactive glass, S53P4. The Association for the Study and Application of Methods of Ilizarov (ASAMI) criteria, a clinical and radiographic evaluating tool, was used for assessing the sample. Results: The average age at the start of treatment was 51 years. The mean follow-up time was 113 weeks. According to the ASAMI Functional Scoring System, 10 excellent (38.5%) cases and 12 good (46.1%) values were recorded. According to the ASAMI Radiological System, they were excellent in 16 (61.5%) cases and good in nine (34.6%). Conclusions: Treatment of infected tibial non-unions using the Ilizarov technique was effective in bone segment regeneration. To fill the remaining bone gap, additional bioactive glass S53P4 could be used, allowing a decrease in re-interventions and minimizing complications.

Treatment of Infected Tibial Non-Unions with Ilizarov Technique: A Case Series

Background: The Ilizarov external fixation technique has been widely used for the treatment of long-bone infected non-unions. After surgical infected bone resection, to allow filling of the remaining bone gap, biomaterials with antibacterial properties could be used. The aim of this study was to report outcomes of infected tibial non-unions treated using the Ilizarov technique and antibacterial bioactive glass. Methods: Between April 2009 and December 2014, 26 patients with infected tibial non-unions were treated with the Ilizarov technique and possible use of the bioactive glass, S53P4. The Association for the Study and Application of Methods of Ilizarov (ASAMI) criteria, a clinical and radiographic evaluating tool, was used for assessing the sample. Results: The average age at the start of treatment was 51 years. The mean follow-up time was 113 weeks. According to the ASAMI Functional Scoring System, 10 excellent (38.5%) cases and 12 good (46.1%) values were recorded. According to the ASAMI Radiological System, they were excellent in 16 (61.5%) cases and good in nine (34.6%). Conclusions: Treatment of infected tibial non-unions using the Ilizarov technique was effective in bone segment regeneration. To fill the remaining bone gap, additional bioactive glass S53P4 could be used, allowing a decrease in re-interventions and minimizing complications.

Comparison of Clinico-radiological Outcomes of Monolateral Fixator in Infected Non-union of Tibia Based on Bone Gap Quantification

INTRODUCTION

Monolateral rail fixators are more comfortable to the patients and have a lesser learning curve compared to ring fixators. Guidelines are still lacking for rational use of monolateral fixator for bone transport. This retrospective study aimed to analyze and compare the clinico-radiological outcomes of monolateral fixator in infected non union of tibia based on bone gap quantification.

MATERIALS AND METHODS

This retrospective study included 35 patients of post traumatic infected osteocutaneous defects of tibia operated from May 2013 to May 2016. Group I having bone gap of 6 cm or less (n = 20) and group II with > 6 cm bone gap (n = 15). The mean age was 29.56 (range 18-62) years in group I and 29.67 (range 20-65) years in group II. The mean bone gap was 4.62 (2-6 cm) in group I and 7.6 cm (6.5-10 cm) in group II (P < 0.00001, Mann-Whitney test). The results were assessed by Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria.

RESULTS

Union was achieved primarily in 90% (n = 18) cases in group I and 73.34% (n = 11) cases in group II. The bone result was excellent, good, fair/poor in 14, 5, 1 in group I; and in 4, 6, 5 in group II, respectively (P = 0.020, Chi-square test). The functional results were excellent, good, fair/poor in 15, 4, 1 in group I; and 5, 8, 2 in group II, respectively (P = 0.0479, Chi-square test).

CONCLUSION

We recommend use of monolateral fixator in patients with infected diaphyseal non union of tibia with bone gap ≤ 6 cm. Use of monolateral fixator in patients with bone gap > 6 cm is associated with higher incidence of residual problems and complications.

Hardware considerations in infection and nonunion management: When and how to revise the fixation

The occurrence of both nonunion and fracture-related infection provides challenges for both the patient and the treating orthopaedic surgeon, with the potential need for complex reconstructive procedures to achieve union and/or eradicate infection. In addition to addressing the multiple different factors that often contribute to nonunion, surgeons are often forced to deal with difficult hardware issues at the time of revision surgery including infected hardware, loose or failing hardware, malaligned hardware, or inappropriate hardware constructs. This article reviews common causes of nonunions with emphasis on infection management and provides indications and techniques for hardware removal in the context of an algorithmic approach to nonunion management with illustrative case examples.

Use of Masquelet technique in treatment of septic and atrophic fracture nonunion

BACKGROUND

Treatment of atrophic non-unions and large bone defects or infections remains a challenging task for the treating surgeon. In the herein study, we present our experience of the 'Masquelet technique' according to the 'diamond concept' for the treatment of complex long bone reconstruction procedures.

METHODS

Between February 2010 and March 2015, 150 patients (mean age 51.4) with atrophic and- /or infected non-unions were included in this prospective study. All patients received autologous bone graft, a graft expander (TCP (tricalcium phosphate)) and BMP (bone morphogenic protein). Clinical and radiological parameters were assessed at 6 weeks, and at 3, 6 and 12 months. The SF-12 questionnaire was used to evaluate the subjective health of patients.

RESULTS

A successful bony consolidation of the non-unions was observed in 120 (80%) cases with a median healing time of 12.1 months. The mean defect gap was 4.4cm. Initial infection was documented in 54 cases. The most frequently identified pathogen was staphylococcus epidermidis and staphylococcus aureus. A successful removal of microorganisms with subsequent healing was achieved in 39 cases (72%). The SF-12 scores of subjective physical and mental health increased from PCS 31.5 preoperatively to 36.7 one year postoperatively, while MCS increased from 45.5 to 48.7.

CONCLUSIONS

Our study showed that the Masquelet technique according to the 'diamond concept' is a valid method to treat complex atrophic non-unions with large bone defects and associated infection. Following the principles of the 'diamond concept' (targeted optimization of tissue engineering and bone regeneration) a high rate of success can be expected in these difficult reconstruction cases.

Fracture Non-Union: A Review of Clinical Challenges and Future Research Needs

Non-union of bone following fracture is an orthopaedic condition with a high morbidity and clinical burden. Despite its estimated global prevalence of nine million annually, the limit of bone regeneration therapy still results in patients living with pain, a reduced quality of life and associated psychological, social and financial repercussions. This review provides an overview of the current epidemiological and aetiological data, and highlights where the clinical challenges in treating non-union lie. Current treatment strategies are discussed as well as promising future research foci. Development in biotechnologies to treat non-union provides exciting scope for more effective treatment for this debilitating condition.

The 'diamond concept' for long bone non-union management

Long bone non-union continues to be a significant worldwide problem. Since its inception over a decade ago, the ‘diamond concept’, a conceptual framework of what is essential for a successful bone healing response, has gained great acceptance for assessing and planning the management of fracture non-unions. Herein, we discuss the epidemiology of non-unions, the basic science of bone healing in the context of the diamond concept, the currently available results and areas for future research.

Percutaneous Strain Reduction Screws-A Safe and Simple Surgical Option for Problems With Bony Union. A Technical Trick

This article describes percutaneous strain reduction screws, a technical trick, to provide effective stability in a simple manner and at low cost. Percutaneous strain reduction screws are an option when a surgeon has decided that further intervention is indicated for a fracture that has not united.

Genomewide Association Study of Fracture Nonunion Using Electronic Health Records

Nonunion is a clinically significant complication of fracture associated with worse outcomes, including increased pain, disability, and higher healthcare costs. The risk for nonunion is likely to be complex and multifactorial, and as such, the biology underlying such risk remains poorly understood. Genetic studies represent one approach to identify implicated biology for further investigation, but to date the lack of large cohorts for study has limited such efforts. We utilized the electronic health records of two large academic medical centers in Boston to identify individuals with fracture nonunion and control individuals with fracture but no evidence of nonunion. We conducted a genomewide association study among 1760 individuals of Northern European ancestry with upper or lower extremity fracture, including 131 with nonunion, to examine whether common variants were associated with nonunion in this cohort. In all, one locus in the Calcyon (CALY) gene exceeded a genomewide threshold for statistical significance (p = 1.95e-8), with eight additional loci associated with p < 5e-7. Previously reported candidate genes were not supported by this analysis. Electronic health records should facilitate identification of common genetic variations associated with adverse orthopedic outcomes. The loci we identified in this small cohort require replication and further study to characterize mechanism of action, but represent a starting point for the investigation of genetic liability for this costly outcome.

Primary ilizarov external fixation in open grade III type C distal femur fractures: Our experience

INTRODUCTION

Open comminuted distal femur fractures are notorious for septic or aseptic non-union. The recommended fixed angle distal femur locking plate in such situations can lead to a septic non-union due to its extensive approach and further periosteal stripping. Supracondylar nails, though have a minimally invasive approach, are not suitable for type C2 and C3 (AO/ASIF) fractures. A monolateral fixator as damage control followed by plating may be recommended. But if wound healing is delayed it results in difficult articular reduction, poor alignment and a stiff knee. We therefore used ilizarov circular external fixators (ICEF) for such open fractures (type C1, C2 and C3) and analysed its radiological and functional outcomes.

MATERIALS AND METHODS

25 male patients, with a mean age of 31.04 ± 6.62 years (range, 22-44 years), with open grade III type C distal femoral fractures were treated with ICEF. There were 7 fractures of type C1and C3 each, 11 were of type C2. Articular reduction and compression was achieved with inter-fragmentary screws through minimal open technique by extending the open wound and then stabilising the fracture with ICEF. The main outcomes evaluated were union, range of motion, final shortening, Knee Society scoring and ASAMI scoring system for radiological and functional outcomes.

RESULTS

The mean follow-up period was 19.12 ± 1.14 months. All fractures except two united at a mean period of 30 ± 3.02 weeks, without the need of bone grafts. The bony assessment (according to ASAMI score) was excellent in 8 cases (33.33%), good in 9 cases (37.5%) and fair in 5 cases (20.83%), while there were 2 poor clinical end results. The functional results were excellent in 6 cases (25%), good in 9 cases (37.5%) fair in 6 cases (25%) poor in 3 cases (12.5%). The complications included shortening, extension lag and pin tract infections.

CONCLUSION

With the encouraging results, the use of ICEF with minimal internal fixation in grade III open comminuted distal femur fractures as a primary definitive treatment is a valuable alternative.

The PRECICE magnetic IM compression nail for long bone nonunions: a preliminary report

INTRODUCTION

The magnetic intramedullary (IM) compression nail is capable of providing sustained compression for the treatment of nonunions of long bones. This ability was previously only possible with the use of external fixation. We asked the following questions: How effective is the IM compression nail at achieving union? How do we know when adequate compression has been attained? Which types of nonunions are good candidates for this treatment?

MATERIALS AND METHODS

Fourteen patients with nonunions of the tibia (5) or femur (9) were treated with the PRECICE IM compression nail. The average age was 49 years number of previous surgeries was 1.9, 7 were atrophic and 7 normotrophic, 3 were metaphyseal and 11 diaphyseal. All PRECICE IM nails were pre-distracted prior to implantation. Compression was applied post-operatively until the locking bolts were seen on X-ray to be bending or the nail was no longer shortening despite applying the external magnet.

RESULTS

Union was achieved in 13/14 cases. The time to union was 24.5 weeks (range 11-60). The two proximal tibia metaphyseal nonunions, both deformed into varus (4°) and flexion (10°) after compression was applied with one failing to unite. The distal tibia metaphyseal and diaphyseal nonunions did not deform upon compression. Three patients had positive cultures and were treated with IV antibiotics for 6 weeks followed by 3 months of oral suppression without subsequent infection. No mechanical nail failures were seen.

CONCLUSIONS

The IM compression nail was successful at applying compression, preventing deformity, and obtaining union in all diaphyseal and in distal tibia metaphyseal nonunions. Signs of active compression are bending of the locking bolts and failure of the nail to shorten. Proximal tibia metaphyseal nonunion may not be suited for this treatment.

Open Supracondylar-Intercondylar Fractures of the Femur Treatment With Taylor Spatial Frame

OBJECTIVES

To evaluate the Taylor spatial frame (TSF) for primary and definitive fixation of open supracondylar-intracondylar femoral (SIF) fractures.

DESIGN

Retrospective.

SETTING

Level I trauma center.

PATIENTS

Subset of 20 SIF open fractures treated with TSF extracted from a consecutive series of 80 SIF fractures treated between 2007 and 2013.

INTERVENTION

Eighteen (90%) fractures underwent definitive fixation with the TSF; 2 were treated primarily within 24 hours of injury. Mean time interval between primary treatment and secondary TSF was 5 days.

MAIN OUTCOME MEASUREMENTS

Clinical and radiological.

RESULTS

Complete union was obtained in 17 (85%) fractures without additional surgery at an average of 33 weeks. Three nonunions and 1 malunion occurred. No deep infection occurred. Results based on Association for the Study and Application of the Method of Ilizarov criteria: 37% excellent, and 63% good for bone outcomes; 5% excellent, 58% good, and 37% fair for functional outcomes. Neer knee scores were 21% excellent, 68% good, and 11% fair. The mechanical lateral distal femoral angle and anatomic posterior distal femoral angle values were within normal range in 80% and 90% of patients, respectively. Abnormal mechanical axis deviation was observed in 4 (20%) cases (2 had associated tibia fractures).

CONCLUSIONS

Primary and definitive fixation with the TSF are effective. Advantages include continuity of device until union, reduced risk of infection, early mobilization, restoration of primary defect caused by bone loss, easy and accurate application, convertibility and versatility, and improved union rate and range of motion for SIF open fractures.

LEVEL OF EVIDENCE

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

The risk of non-union per fracture: current myths and revised figures from a population of over 4 million adults

Background and purpose - Fracture non-union remains a major clinical problem, yet there are no data available regarding the overall risk of fractures progressing to non-union in a large population. We investigated the rate of non-union per fracture in a large adult population. Methods - National data collected prospectively over a 5-year period and involving just under 5,000 non-unions were analyzed and compared to the incidence of fracture in the same period. Results and interpretation - The overall risk of non-union per fracture was 1.9%, which is considerably less than previously believed. However, for certain fractures in specific age groups the risk of non-union rose to 9%. As expected, these higher rates of non-union were observed with tibial and clavicular fractures, but-less expectedly-it was in the young and middle-aged adults rather than in the older and elderly population. This study is the first to examine fracture non-union rates in a large population according to age and site, and provides more robust (and lower) estimates of non-union risk than those that are frequently quoted.

Outcomes of the Ilizarov frame use in elderly patients

AIM

The use of circular frame is widely accepted. This is an outcome review on use of circular Ilizarov frame in elderly patients.

MATERIALS & METHODS

Data from all patients treated with an Ilizarov circular frame between January 2002 and December 2014, who were 65 years of age or over at surgery was collected. Seventy Ilizarov circular frames were applied during this period in our unit at a mean age of 71.2 years. Clinical, radiological and quality of life questionnaire (SF-12) data were gathered. Mortality, complication and revision data were also collected.

RESULTS

Indications of application of Ilizarov frame were fractures (53%), non-unions (19%), deformity correction (7%) and ankle fusions (21%). Mean period of time in the frame was 184.4 ± 84.2 days. Mortality and complication rates were low (5-7%) at a mean follow-up 4.2 years. There was no case of septic arthritis or newly induced deep infection. Physical and Mental components of SF-12 questionnaire returned to normal for that age group. There was no difference between the subgroups (tibia plateau fractures, pilon fractures, ankle fusions, non-unions, deformity correction and miscellaneous trauma) concerning the physical and mental subjective (PCS and MCS SF-12 component) outcomes (p > 0.05).

CONCLUSIONS

Ilizarov circular frame as a definitive treatment of many kinds of trauma and orthopaedic conditions can be safely and reliably used in the elderly with good quality of life results.

Masquelet technique versus Ilizarov bone transport for reconstruction of lower extremity bone defects following posttraumatic osteomyelitis

OBJECTIVE

This study was to compare the effectiveness of Masquelet technique versus Ilizarov bone transport in the treatment of lower extremity bone defects following posttraumatic osteomyelitis.

PATIENTS AND METHODS

We retrospectively reviewed 39 patients who had been treated at our department for lower extremity bone defects following posttraumatic osteomyelitis. They were 30 males and 9 females with a mean age of 39.18 (range, 12-63 years). The infected bone defects involved 26 tibias and 13 femurs. The mean length of the bone defects after radical debridement was 6.76cm (range, 2.7-15.7cm). Masquelet technique (MT, group A) was used in 20 patients and Ilizarov bone transport (IBT, group B) in 19 ones. The measurements were bone outcomes (union, deformity, infection and leg-length discrepancy) and functional outcomes (significant limping, joint contracture, soft tissue dystrophy, pain and inactivity).

RESULTS

The mean follow-up after removal of the apparatus was 25.26 months (range, 14-51 months). The mean finite fixator time was 10.15 months (range, 8-14 months) in group A versus 17.21 months (range, 11-24 months) in group B. The bone outcomes were similar between groups A and B [excellent (5 vs. 7), good (10 vs.9), fair (4 vs. 2) and poor (1 vs. 1)]; group A showed better functional outcomes than group B [excellent (8 vs. 3), good (9 vs. 6), fair (3 vs. 8) and poor (0 vs. 2)].

CONCLUSIONS

In the treatment of segmental lower extremity bone defects following posttraumatic osteomyelitis, both IBT and MT can lead to satisfactory bone results while MT had better functional results, especially in femoral cases. IBT should be preferred in cases of limb deformity and MT may be a better choice in cases of periarticular bone defects.

The Non-Union Scoring System: an interobserver reliability study

PURPOSE

The Non-Union Scoring System (NUSS) aims to classify non-unions according to their severity and relate them to four treatment categories. The main purpose of this study was to evaluate the reliability of the NUSS. In addition we assessed its clinical validity.

METHODS

Forty-four Patients with a tibia non-union between 2005 and 2015 were included in this study. Data from all included patients were scored independently by three observers according to the NUSS criteria. The interobserver agreement was evaluated using the intraclass correlation coefficient (ICC). The interobserver agreement of the Weber-Cech system was assessed using Fleiss' kappa. Finally, the clinical validity of the NUSS was analysed by comparing outcomes of the actual treatment groups to the proposed treatment groups following from the NUSS scores.

RESULTS

Forty-four patients were included. The comparison of NUSS scores between observers showed substantial agreement [ICC; 0.78 (0.67-0.86)]. The comparison of the Weber-Cech classification between observers showed only fair agreement [Fleiss κ; 0.30 (0.17-0.42)]. The χ² test for the treatment groups according to the NUSS and the treatments at index procedure showed an independent relation (χ² = 5.794, 6 degrees of freedom, p: 0.447). In contrast, the proposed treatment strategy corresponds well to the definitive treatment (χ² = 29.963, 9 degrees of freedom, p < 0.001).

CONCLUSION

We conclude that the NUSS is both a reliable and valid system to classify non-unions.

Current treatment of infected non-union after intramedullary nailing

Non-union is a devastating consequence of a fracture. Non-unions cause substantial patient morbidity with patients suffering from loss of function of the affected extremity, increased pain, and a substantial decrease in the quality of life. The management is often associated with repeated, unsuccessful operations resulting in prolonged hospital stays, which has social and economic consequences to both the patient and the healthcare system. The rates of non-union following intramedullary (IM) nailing vary according to anatomical location. There is currently no consensus regarding the treatment of infected non-unions following IM nailing, but the most common procedures reported are; exchange IM nail with antibiotic suppression or excision of the non-union, (stabilisation with external fixation or less commonly plate or IM nail) and then reconstruction of the bone defect with distraction osteogenesis or the Masquelet technique. This article explores the general principles of treatment, fixation modalities and proposes a treatment strategy for the management of infected non-unions following intramedullary nailing.

Three-stage treatment protocol for recalcitrant distal femoral nonunion

INTRODUCTION

In this study, we proposed a three-stage treatment protocol for recalcitrant distal femoral nonunion and aimed to analyze the clinical results.

MATERIALS AND METHODS

We retrospective reviewed 12 consecutive patients with recalcitrant distal femoral nonunion undergoing our three-stage treatment protocol from January 2010 to December 2014 in our institute. The three-stage treatment protocol comprised debridement of the nonunion site, lengthening to eliminate leg length discrepancy, deformity correction, stabilization with a locked plate, filling of the defect with cement spacer for inducing membrane formation, and bone reconstruction using a cancellous bone autograft (Masquelet technique) or free vascularized fibular bone graft. The bone union time, wound complication, lower limbs alignment, amount of lengthening, knee range of motion, and functional outcomes were evaluated.

RESULTS

Osseous union with angular deformity <5° and leg length discrepancy <1 cm were achieved in all the patients. The average amount of lengthening was 5.88 cm (range 3.5-12 cm). Excellent or good outcomes were obtained in 9 patients.

CONCLUSIONS

Although the current study involved only a small number of patients and the intervention comprised three stages, we believe that such a protocol may be a valuable alternative for the treatment of recalcitrant distal femoral nonunion.

Prospective randomised comparison of ring versus rail fixator in infected gap nonunion of tibia treated with distraction osteogenesis

AIMS

This is a prospective randomised study which compares the radiological and functional outcomes of ring and rail fixators in patients with an infected gap (> 3 cm) nonunion of the tibia.

PATIENTS AND METHODS

Between May 2008 and February 2013, 70 patients were treated at our Institute for a posttraumatic osseocutaneous defect of the tibia measuring at least 3 cm. These were randomised into two groups of 35 patients using the lottery method. Group I patients were treated with a ring fixator and group II patients with a rail fixator. The mean age was 33.2 years (18 to 64) in group I and 29.3 years (18 to 65) in group II. The mean bone gap was 5.84 cm in group I and 5.78 cm in group II. The mean followup was 33.8 months in group I and 32.6 months in group II. Bone and functional results were assessed using the classification of the Association for the Study and Application of the Method of Ilizarov (ASAMI). Functional results were also assessed at six months using the short musculoskeletal functional assessment (SMFA) score.

RESULTS

The bone result was excellent, good, fair and poor in 21, 12, 0 and 2 in group I; and 14, 15, 3, and 3 in group II, respectively. The functional results were excellent, good, fair, poor and failure in 16, 17, 1, 0 and 1 in group I; and 22, 10, 0, 3 and 0 in group II, respectively. Both fixator systems achieved comparable rates of union and functional outcomes. The rate of deep pintract infection was significantly higher in the rail fixator group but patients found it more comfortable.

CONCLUSION

We recommend the use of a ring fixator in patients with a bone gap of more than 6 cm. Patients with a bone gap up to 6 cm can be managed with either a ring or rail fixator. Cite this article: Bone Joint J 2016;98B:1399-1405.

The multifactorial aetiology of fracture nonunion and the importance of searching for latent infection

Objectives

A successful outcome following treatment of nonunion requires the correct identification of all of the underlying cause(s) and addressing them appropriately. The aim of this study was to assess the distribution and frequency of causative factors in a consecutive cohort of nonunion patients in order to optimise the management strategy for individual patients presenting with nonunion.

Methods

Causes of the nonunion were divided into four categories: mechanical; infection; dead bone with a gap; and host. Prospective and retrospective data of 100 consecutive patients who had undergone surgery for long bone fracture nonunion were analysed.

Results

A total of 31% of patients had a single attributable cause, 55% had two causes, 14% had three causes and 1% had all four. Of those (31%) with only a single attributable cause, half were due to a mechanical factor and a quarter had dead bone with a gap. Mechanical causation was found in 59% of all patients, dead bone and a gap was present in 47%, host factors in 43% and infection was a causative factor in 38% of patients.

In all, three of 58 patients (5%) thought to be aseptic and two of nine (22%) suspected of possible infection were found to be infected. A total of 100% of previously treated patients no longer considered to have ongoing infection, had multiple positive microbiology results.

Conclusion

Two thirds of patients had multiple contributing factors for their nonunion and 5% had entirely unexpected infection. This study highlights the importance of identifying all of the aetiological factors and routinely testing tissue for infection in treating nonunion. It raises key points regarding the inadequacy of a purely radiographic nonunion classification system and the variety of different definitions for atrophic nonunion in the current mainstream classifications used for nonunion.

Cite this article: L. Mills, J. Tsang, G. Hopper, G. Keenan, A. H. R. W. Simpson. The multifactorial aetiology of fracture nonunion and the importance of searching for latent infection. Bone Joint Res 2016;5:512–519. DOI: 10.1302/2046-3758.510.BJR-2016-0138.

Fracture healing in the elderly: A review

Older patients are commonly at a higher risk of experiencing a bone fracture. Complications during fracture healing, including delayed union and non-union, can arise as a result of a multitude of patient and treatment factors. This review describes those factors which contribute to a greater risk of delayed union and non-union with particular reference to the elderly population and discusses therapies that may enhance the fracture healing process in the hope of reducing the incidence of delayed union and non-union. Increasing age does seem to increase the risk of delayed union or non-union. In addition, smoking and the treatment of post-fracture pain with non-steroidal anti-inflammatory drugs (NSAIDs) put the patient at the greatest risk, while ultrasound therapy appears to be a non-invasive, effective treatment option to reduce the risk of delayed union or non-union. The use of growth factors and of stem cells and the role of surgery are also discussed.

The management of tibial fracture non-union using the Taylor Spatial Frame

We reviewed 40 complex tibial non-unions treated with Taylor Spatial Frames. 39 healed successfully. Using the ASAMI scoring, we obtained 33 excellent, 5 good, 1 fair and 1 poor bone results. The functional results were excellent in 29 patients, good in 8, fair in two and poor in one. Mean patient satisfaction score was 95%. All but one patient would have the same treatment again. 28 of the 36 patients in work when injured, returned to work at the time of their final review. Four patients had an adverse event requiring significant intervention. Average treatment cost was approximately £26,000/patient.

Exchange nailing for nonunion of diaphyseal fractures of the tibia

Aims

The aim of this study was to identify risk factors for the failure of exchange nailing in nonunion of tibial diaphyseal fractures.

Patients and Methods

A cohort of 102 tibial diaphyseal nonunions in 101 patients with a mean age of 36.9 years (15 to 74) were treated between January 1992 and December 2012 by exchange nailing. Of which 33 (32%) were initially open injuries. The median time from primary fixation to exchange nailing was 6.5 months (interquartile range (IQR) 4.3 to 9.8 months). The main outcome measures were union, number of secondary fixation procedures required to achieve union and time to union. Univariate analysis and multiple regression were used to identify risk factors for failure to achieve union.

Results

Multiple causes for the primary nonunion were found for 28 (27%) tibiae, with infection present in 32 (31%). Six patients were lost to follow-up. Further surgical procedures were required in 35 (36%) nonunions. Other fixation modalities were required in five fractures. A single nail exchange procedure achieved union in 60/96 (63%) of all nonunions. Only 11 out of 31 infected nonunions (35.4%) healed after one exchange nail procedure. Up to five repeated exchange nailings, with or without bone grafting, ultimately achieved union in 89 (93%) fractures. The median time to union after exchange nailing was 8.7 months (IQR 5.7 to 14.0 months). Univariate analysis confirmed that an oligotrophic/atrophic pattern of nonunion (p = 0.002), a bone gap of 5 mm or more (p = 0.04) and infection (p < 0.001), were predictive for failure of exchange nailing Multiple regression analysis found that infection was the strongest predictor of failure (p < 0.001).

Conclusion

Exchange nailing is an effective treatment for aseptic tibial diaphyseal nonunion. However, in the presence of severe infection with a highly resistant organism, or extensive sclerosis of the bone, other fixation modalities, such as Ilizarov treatment, should be considered. Take home message: Exchange nailing is an effective treatment for aseptic tibial diaphyseal nonunion. Cite this article: Bone Joint J 2016;98-B:534–41.

Outcome of distraction osteogenesis by ring fixator in infected, large bone defects of tibia

BACKGROUND

Salvage of large, infected bone defects in tibia poses a formidable problem. The present prospective study aimed to evaluate radiologic and functional outcome of ring fixator in infected, large (≥6 cm) bone defects of tibia treated with distraction osteogenesis.

MATERIALS AND METHODS

The study included 35 patients (30 males and 5 females) who had minimum of 6 cm gap after radical resection of necrotic bone and presence or history of active infection. Mean age was 36.1 years. Mean bone gap was 7.27 cm. Mean follow-up period was 25.4 months.

RESULTS

Fracture united primarily in 17 cases and after fixator adjustment with freshening of fracture margins in 15 cases. Fixator adjustment with bone grafting was done in one patient to achieve union. One patient had nonunion and another had amputation. The bone result was excellent, good, and poor in 19, 13, and 3 patients, respectively. The functional results were excellent, good, fair and failure in 14, 19, 1, and one patient, respectively. 24 patients had superficial pin tract infection and 18 patients had ankle stiffness.

CONCLUSION

Ring fixator systems reliably achieve union in infected, large bone defects of tibia and help in treating infection, shortening, bone and soft tissue loss simultaneously. We advocate early freshening of fracture ends and removal of interposed soft tissue at docking sites to achieve union. Superficial pin tract infection and ankle stiffness are common problems in managing large tibial defects. But good to excellent functional outcomes can be achieved in majority of patients.

Exchange nailing for femoral diaphyseal fracture non-unions: Risk factors for failure

The aim of this study was to identify risk factors for failure of exchange nailing for femoral diaphyseal fracture non-unions. The study cohort comprised 40 patients with femoral diaphyseal non-unions treated by exchange nailing, of which six were open injuries. The median time to exchange nailing from primary fixation was 8.4 months. The main outcome measures were union, number of secondary fixation procedures required to achieve union and time to union. Multiple causes for non-union were found in 16 (40%) cases, with infection present in 12 (30.0%) patients. Further surgical procedures were required in nine (22.5%) cases, one of whom (2.5%) required the use of another fixation modality to achieve union. Union was ultimately achieved with exchange nailing in 34/37 (91.9%) patients. The median time to union after the exchange nailing was 9.4 months. Cigarette smoking and infection were risk factors for failure of exchange nailing. Multivariate analysis found infection to be the strongest predictor of exchange failure (p<0.05). Exchange nailing is an effective treatment for aseptic femoral diaphyseal fracture non-union. However, 50% of patients undergoing exchange nailing in the presence of infection required at least one further procedure. It is important to counsel patients of this so that they can plan for it and do not consider that the first exchange operation has failed.

Profiling microRNA expression in fracture nonunions: Potential role of microRNAs in nonunion formation studied in a rat model

MicroRNAs (miRNAs ) are small non-coding RNAs that regulate gene expression. We hypothesised that the functions of certain miRNAs and changes to their patterns of expression may be crucial in the pathogenesis of nonunion. Healing fractures and atrophic nonunions produced by periosteal cauterisation were created in the femora of 94 rats, with 1:1 group allocation. At post-fracture days three, seven, ten, 14, 21 and 28, miRNAs were extracted from the newly generated tissue at the fracture site. Microarray and real-time polymerase chain reaction (PCR) analyses of day 14 samples revealed that five miRNAs, miR-31a-3p, miR-31a-5p, miR-146a-5p, miR-146b-5p and miR-223-3p, were highly upregulated in nonunion. Real-time PCR analysis further revealed that, in nonunion, the expression levels of all five of these miRNAs peaked on day 14 and declined thereafter. Our results suggest that miR-31a-3p, miR-31a-5p, miR-146a-5p, miR-146b-5p and miR-223-3p may play an important role in the development of nonunion. These findings add to the understanding of the molecular mechanism for nonunion formation and may lead to the development of novel therapeutic strategies for its treatment.

Ilizarov bone transport for the treatment of fibular osteomyelitis: a report of five cases

Background

The objective of this study was to evaluate the effectiveness of the treatment of fibular osteomyelitis by Ilizarov bone transport.

Methods

We retrospectively reviewed 5 patients with fibular osteomyelitis treated by Ilizarov bone transport. Our study included 4 males and 1 female with a mean of age 29.2 years. The average length of the bone defects after radical debridement was 7.6 cm (range 6.5-10 cm).

Results

The mean follow-up was 24.8 months (range 14–34 months). No patient was lost to follow-up. All the patients had bone union and no recurrence of infection was observed. The mean external fixation time was 8.8 months (range 8-10 months), and the mean external fixation index was 1.18 months/cm (range 0.90-1.43 months/cm). There was no sign of knee or ankle instability by clinical examination in all the patients. According to Association for the Study and Application of the Method of Ilizarov (ASAMI) classification, bone results were excellent in 3 patients, good in 2 patients; functional results were excellent in 3 patients, good in 2 patients.

Conclusions

Our study suggested that Ilizarov bone transport may be a good choice for the treatment of fibular osteomyelitis, especially for the patient with distal fibular loss.