Variability in the definition and perceived causes of delayed unions and nonunions: a cross-sectional, multinational survey of orthopaedic surgeons

Does an additional attachment plate improve fixation in Vancouver type B1 and C periprosthetic femoral fractures? A retrospective comparative study

INTRODUCTION

This study compared the clinical and radiologic outcomes of well-fixed periprosthetic femoral fractures after hip arthroplasty according to the use of single plate fixation with additional attachment plate device (group 1) or not (group 2).

MATERIALS AND METHODS

Retrospective data were obtained from a single center by reviewing medical records of patients who underwent reduction and internal fixation of Vancouver type B1 and C periprosthetic femoral fractures between June 2006 and June 2021. The study analyzed patient demographics, fracture characteristics, surgical details, functional outcomes (Harris hip score [HHS] and Koval score at 1-year follow-up), reoperation rates, and radiologic findings. In this study, nonunion and malunion were defined as indicators of "healing problems."

RESULTS

Among the 32 included patients (group 1: 15; group 2: 17), fractures resulted from high-energy (six cases) and low-energy (26 cases) injuries, with no open fractures. The fractures included 21 cases of Vancouver type B1 and 11 cases of type C. One patient (6.7%) in group 1 required revision surgery. Excellent or good outcomes were observed in 100% of group 1 and 88.2% of group 2 patients according to Beals-Tower criteria (p = 0.031). Healing problems occurred in 6.7% and 41.2% of patients in groups 1 and 2, respectively (p = 0.03). HHS score, Koval score, union time, or femoral alignment did not differ significantly between the two groups (p > 0.05).

CONCLUSIONS

Using an additional plate in the treatment of well-fixed periprosthetic femoral fractures yielded better clinical outcomes compared to cases without an additional plate. Lower rates of nonunion or delayed union and improved overall healing were observed in the augmented group.

Bigger is not necessarily better - 2-ring circular frames associated with shorter duration of treatment in the management of complex tibial fractures - a retrospective cohort study

Frame configuration for the management of complex tibial fractures is highly variable and is dependent upon both fracture pattern and surgeon preference. The optimal number of rings to use when designing a frame remains uncertain. Traditionally larger, multi-ring-per-segment constructs have been assumed to offer optimal stability and therefore favourable conditions for fracture healing but there is little in-vivo evidence for this and the recent concept of reverse dynamisation challenges this approach. We compared the clinical outcomes in 302 consecutive patients with tibial fractures treated in our unit with either a stable two-ring circular frame or a three-or-more-ring (3+) frame. The primary outcome measure was time spent in frame. Secondary outcomes were the incidence of malunion and the need for further surgical procedures to achieve bone union. The mean time in frame was 168 days for the 2-ring group and 202 days for the 3+ rings group (p = 0.003). No significant differences were found in the rate of malunion or the requirement for secondary surgical intervention to achieve union. The groups were evenly matched for age, co-morbidities, energy of injury mechanism, post-treatment alignment and presence of an open fracture. This study finds that 2-ring frame constructs are a reliable option associated with shorter duration of treatment and no increase in rates of adverse outcomes compared with larger, more complex frame configurations.

Effective treatment of non-union after internal fixation of femoral neck fracture using integrated traditional Chinese and western medicine

BACKGROUND

Hip fractures, particularly femoral neck and intertrochanteric fractures, represent approximately 6.37 % of all fractures, with incidence rates showing an upward trend annually.

CASE PRESENTATION

This report presents a case of a 55-year-old female with a femoral neck fracture who underwent internal fixation. One-year post-surgery, the patient continued to experience hip pain, and computed tomography (CT) scans revealed non-union of the fracture. The patient received an integrated treatment approach combining traditional Chinese and Western medicine, involving the alternating administration of osteopeptide tablets and Guijia Jiangu capsules, a proprietary herbal formulation. No additional pharmacological or surgical interventions were employed. Seven months after initiating the treatment, digital radiography (DR) examinations showed that the fracture had largely healed. At the seven-month follow-up, and nearly four years thereafter, the patient reported no discomfort in the hip region. Subsequent DR examinations revealed no signs of avascular necrosis of the femoral head, and no adverse events were noted. The internal fixation device was removed five years post-fracture.

CONCLUSION

The results indicate that integrated traditional Chinese and Western medicine may effectively treat non-union after internal fixation of femoral neck fractures, though further studies are warranted to confirm these outcomes.

Nonunion of Fractures: A Review of Epidemiology, Diagnosis, and Clinical Features in Recent Literature

Understanding the etiology of nonunion is crucial to its effective management. Nonunion arises from a complex interplay of biological and mechanical factors. High-velocity injuries, which are becoming more prevalent, often involve extensive soft-tissue damage and stripping compromises the vascularity of bone fragments. The lack of adequate blood supply hampers the healing process and contributes to persistence of nonunion. Such injuries often result in high levels of contamination and persistent infections, making fractures particularly difficult to manage and leading to nonunion. Despite recent advances in medical techniques and interventions, managing the problem of nonunion still remains a formidable challenge. Much effort has gone into the understanding of the problem. With this review, we have made an attempt to correlate some of the known factors and looked at the future including the possible role of genetics in predicting the problem and modifying the outcome of nonunion.

Retrograde intramedullary nailing with supplemental plate and lag screws allows early weight bearing following distal end-segment femur fractures (AO/OTA 33) in a low-resource setting

PURPOSE

To underline the feasibility of achieving early weight bearing in patients with distal end-segment femur fractures (AO/OTA 33) treated with retrograde intramedullary nailing and supplemental plate or lag screws in the absence of C-arm.

METHODS

41 distal end-segment femur fractures (DFFs) included in the study were treated with SIGN nails with or without a side plate in a center that lacked intraoperative fluoroscopy and fracture table. A medial or lateral para-patellar incision was used for fracture reduction, nail insertion and side plate placement. Follow-ups were done at six weeks, 12 weeks, and six months post-operatively.

RESULTS

Distal end-segment fractures constituted 13.2% of all femur fractures treated. The patients' mean age and range were 49.6 and 23-83 years respectively. They were mostly injured in road traffic accidents. 27 were daily-income earners. By the 12th week post-operatively, 82.1% of them could flex their knee beyond 90°, all of them could bear weight fully, and 71.8% could squat & smile.

CONCLUSION

The study highlighted the procedure for retrograde nailing of DFFs in a setting without the requisite facilities for minimally-invasive surgeries. The findings demonstrated the feasibility of achieving an expedited weight bearing for the predominantly daily-income-earning victims to ensure early return to work and poverty reduction. While the small sample size is a limitation, the study does provide information that could serve as a basis for future randomized controlled trials in low-resource settings.

Efficacy of Minimally Invasive Reduction With Cerclage Fixation in Spiral or Oblique Subtrochanteric Femoral Fractures: A Retrospective Cohort Study Comparing Cables and Wires

OBJECTIVES

To compare the outcomes of a minimally invasive reduction (MIR) technique using a cable and wire in spiral or oblique subtrochanteric femoral fractures (SFFs).

METHODS

DESIGN

Retrospective cohort study.

SETTING

Two University Hospitals.

PATIENT SELECTION CRITERIA

Skeletally mature patients with spiral or oblique SFFs (OTA/AO 32A1 and 32A2) treated with intramedullary nailing and MIR with a cerclage wire passer using either a single-loop cable or cerclage wire or MIR without cable or wire between May 2016 and November 2021 were included.

OUTCOME MEASURES AND COMPARISONS

Coronal and sagittal interfragmentary gap, neck-shaft angle, coronal and sagittal angulation, fracture union, time to union, and Radiographic Union Score for Hip (RUSH) at 6 months post operation were compared.

RESULTS

A total of 46 patients were included, with 16 each in the cable and wire groups and 14 in the non-wiring group. There were no differences in demographics ( P > 0.05), fracture classification ( P = 0.710), or operative data ( P > 0.05) between the three groups. The cable group showed significantly better coronal ( P = 0.003) and sagittal ( P = 0.003) interfragmentary gap, shorter union time ( P < 0.001), and higher 6-month RUSH score ( P < 0.001) among the three groups. There were no significant differences in outcome measures between the wire and non-wiring groups (all P > 0.05). No mechanical complications or reoperations were observed in all three groups.

CONCLUSIONS

Minimally invasive reduction using a cable is more effective than wire or non-wiring reduction to improve reduction quality and promote bone union in the SFFs.

LEVEL OF EVIDENCE

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

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

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

Varus mal-alignment and residual displacement are associated with delayed union in subtrochanteric femur fracture- A retrospective observational study

Background

Subtrochanteric femoral (ST) fractures are associated with high rates of delayed and non-union. The aim of this study was to analyse the risk factors associated with delayed/non-union in ST fractures.

Methods

All patients with surgical stabilisation of ST fractures during the period 2014 to 2019 were identified in an electronic patient records database in two trauma centres. Exclusion criteria were incomplete clinical/radiological data, pathological fractures and loss to follow-up. Radiographs at about 6 months post-surgery were assessed for fracture union using Radiographic Union Score for Hip (RUSH). Fracture was deemed to be un-united if RUSH score was <18. CCD (caput-collum-diaphyseal) angle of operated and uninjured hip, residual displacement at fracture site and 3-point relationship was calculated on operative or immediate post-operative images in both groups. Student's t-test was used to compare CCD angle difference between operated and uninjured sides and the residual fracture displacement between delayed union and united fractures group. Chi-square test was used for 3-point relationship. Observational analysis was performed on implant failure rates including distal screw breakage.

Results

During the study period, there were total of 278 patients. 193 with inadequate data and 22 with pathological fractures were excluded. Advanced age and female sex had significantly higher rate of delayed union (p value of 0.043 and 0.003 respectively). Delayed union group (26) had a mean RUSH score of 14.1 and united group (37) had a mean RUSH score of 26.3 (p = 0.019). The mean CCD angle difference between operated and uninjured sides was -5.77° for delayed union and -2.33° for united fractures (p = 0.03). Residual displacement at fracture site showed statistically significant difference between delayed union and united fractures on anteroposterior and lateral views (p = 0.001 each). There was no statistical difference in 3-point relationship of implant in two groups (p = 0.775). 10 revision procedures were performed for implant failures. Distal screw failure (3 cases) was not a precursor for non-union in this study.

Conclusion

This study confirms varus alignment of hip and residual fracture displacement after fracture fixation of subtrochanteric fracture are surgeon associated significant risk factors for delayed union at 6 months. Fracture contact and alignment are key to reduce failures in these group of fractures. Among patient factors, advancing age and female sex predisposes to higher rate of delayed union.

Open Access Redefined: Survey Data and Literature Study on the Impact of Sci-Hub in Orthopaedic Research

BACKGROUND

Since Alexandra Elbanyan founded Sci-Hub in 2011, the website has been used by a growing number of researchers worldwide. Sci-Hub is a so-called shadow library or guerrilla open access format bypassing publishers' paywalls, giving everyone free access to scientific papers. Until today, there have been no publications about usage by orthopaedic and trauma surgeons of Sci-Hub or other "pirate sites" and how it may influence their work.

MATERIALS AND METHODS

Orthopaedic and trauma surgeons of four university hospitals in Germany and Europe were consulted using a standardised questionnaire containing multiple items about the use and evaluation of Sci-Hub. In addition, the Medline and Cochrane databases were screened for all studies related to Sci-Hub. Two reviewers independently reviewed all articles and the references of these articles.

RESULTS

Of all orthopaedic surgeons consulted, 69% knew of Sci-Hub and 66.7% used it on a regular basis. Of the younger participants (< 45 years old), 77% knew the webpage, while only 25% of older participants (> 45 years old) knew the webpage. Ninety percent found the quality of their citation and research had been enhanced since using Sci-Hub. On a scale of 1 to 10, user-friendliness was rated with a mean rating of 7.58 (95% CI: 7.262-7.891). Ethical or legal concerns among users seem mixed. On a scale of 1 (no concerns) to 5 (many concerns), the mean score was 2.39 (95% CI: 2.154-2.615). Of doctors using Sci-Hub, 89% would recommend it to other colleagues.

CONCLUSION

The quality and number of articles in Sci-Hub is outstanding, and the rate of young researchers using the website is high. The most important shift in literature research for decades is a phenomenon mostly used by young researchers and is not the subject of current research itself. Sci-Hub may have already changed how orthopaedic research works.

Familial Analysis of Nonunion in a Genealogic Population Database Demonstrates No Evidence of Heritable Risk

OBJECTIVE

To determine whether there is evidence of heritable risk for nonunion using a large, state-wide population database.

DESIGN

Database.

SETTING

Level 1 Trauma Center.

POPULATION

All Utah residents from 1996 to 2021 who sustained a long bone fracture and their family members were included.

OUTCOMES

The primary outcome was nonunion and the prevalence of nonunion among the patients' first-, second-, and third-degree relatives. The secondary objective was to identify demographic, injury, and socioeconomic risk factors associated with nonunion.

RESULTS

In total, 150,263 fractures and 6577 nonunions (4.4%) were identified. This was highly refined to a 1:3 matched cohort of 4667 nonunions of 13,981 fractures for familial clustering analysis. Cox proportional hazards did not demonstrate excessive risk of nonunion among first- ( P = 0.863), second- ( P = 0.509), and third-degree relatives ( P = 0.252). Further analysis of the entire cohort demonstrated that male sex (relative risk [RR] = 1.15; P < 0.001), Medicaid enrollment (RR = 2.64; P < 0.001), open fracture (RR = 2.53; P < 0.001), age group 41-60 years (RR = 1.43; P < 0.001), and a history of obesity (RR = 1.20; P < 0.001) were independent risk factors for nonunion.

CONCLUSIONS

Our results demonstrate no evidence of heritable risk for nonunion. Independent risk factors for nonunion were male sex, Medicaid enrollment, open fracture, middle age, and a history of obesity. Although it is important to identify modifiable and nonmodifiable risk factors, these results continue to support that the risk of nonunion is multifactorial, relating to injury characteristics, operative techniques, and patient-specific risk factors.

LEVEL OF EVIDENCE

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

The double-plate fixation technique prevents varus collapse in AO type C3 supra-intercondylar fracture of the distal femur

INTRODUCTION

Varus collapse followed by osteosynthesis for distal femoral fractures with conventional implants has been well documented but is seldom mentioned in fractures managed with locking plates. The purpose of this study was to assess the incidence of varus collapse after treating complex supra-intercondylar fractures of the distal femur (AO type C3) using a Single Plate (SP) or Double Plate (DP) fixation technique.

MATERIALS AND METHODS

We retrospectively reviewed 357 patients with distal femoral fractures who were treated at our hospital between 2006 and 2017. After excluding cases of infection, malignancy, periprosthetic fracture, revision surgery, pediatric fracture, and extra-articular fracture, 54 patients were included in the study. All demographic data and radiological and clinical outcomes were reviewed and analyzed.

RESULTS

There were 54 patients enrolled into this study with age from 15 to 85 years old (mean 41.6, SD = 19.9), and 32 of them were open fractures (59%). The patients were further divided into either an SP (n = 15) or a DP group (n = 39). Demographics, including age, sex, injury severity score, and open fracture type, were all compatible between the two groups. The overall nonunion rate was 25.9% (n = 14; 6 from the SP and 8 from the DP group; p = 0.175). The varus collapse rate was 9.3% (n = 5; 4 from the SP and 1 from the DP group (p = 0.018).

CONCLUSIONS

The varus collapse rate after osteosynthesis with a single lateral locking plate could be as high as 26.7% in AO type C3 fractures of the distal femur, which would be decreased to 2.6% by adding a medial buttress plate. Surgeons should consider DP fixation to avoid varus collapse in severely comminuted complete intra-articular fractures of the distal femur.

Assessment of Bone Healing: Opportunities to Improve the Standard of Care

➤ Bone healing is commonly evaluated by clinical examination and serial radiographic evaluation. Physicians should be mindful that personal and cultural differences in pain perception may affect the clinical examination. Radiographic assessment, even with the Radiographic Union Score, is qualitative, with limited interobserver agreement.➤ Physicians may use serial clinical and radiographical examinations to assess bone healing in most patients, but in ambiguous and complicated cases, they may require other methods to provide assistance in decision-making.➤ In complicated instances, clinically available biomarkers, ultrasound, and magnetic resonance imaging may determine initial callus development. Quantitative computed tomography and finite element analysis can estimate bone strength in later callus consolidation phases.➤ As a future direction, quantitative rigidity assessments for bone healing may help patients to return to function earlier by increasing a clinician's confidence in successful progressive healing.

Combined dynamized nailing with partial fibulectomy for aseptic diaphyseal tibial nonunion in adults

Background and aim of the study

Mechanical stability of hypertrophic nonunion remains the goal for treatment leading to bony bridging and remodeling. Partial fibulectomy or dynamization was reported with a wide range of clinical and radiological results. This study aims at assessment of combined dynamically locked nailing with partial fibulectomy technique to reach biological and mechanical stability with shorter healing time.

Patients and methods

This study included seventeen skeletally mature patients with aseptic diaphyseal hypertrophic tibial nonunion after nailing or external fixator. Patients with infected nonunion, atrophic nonunion, skeletally immature, and those with incomplete follow-up were excluded. Included patients were allocated into two groups, and final functional and radiological outcome regards healing time, union, limb alignment and rotation, knee and ankle rage of motions were reported.

Results

The mean follow-up period was 33.3 ± 6.2months. All nonunions healed successfully within 11.9 ± 1.5weeks (range: 10–16 weeks). One patient had tibial plafond injury that necessitated nail removal. The mean angle of coronal angulation was 1.4 ± 1.4°. The rotational difference between both limbs as per the thigh-foot angle was 2.5 ± 1.7°. The average functional outcome as per the Karlström-Olerud scale score was 30.9 ± 3. A significant difference was evident between the external fixator group and the nailing group in terms of functional grading scale (P=0.03).

Conclusion

The combined dynamically locked nailing with partial fibulectomy technique is a biology-preserving technique that provides mechanical stability, allows early return to functional activity with complete bone healing and no need for further surgeries.

Biophysical Enhancement in Fracture Healing: A Review of the Literature

Bone healing constitutes a complex process involving cellular and pathophysiological mechanisms. Despite progress in osteosynthesis techniques, fracture union continues to be challenging. In some cases, it is not ultimately achieved or is delayed relative to the expected time resulting in economic and social outcomes for the patient and the health system. In addition to surgical treatment, biophysical methods have been developed to assist in fracture healing used in combination or individually. Biophysical stimulation is a non-invasive therapy used in orthopedic practice to increase and enhance tissue's reparative and anabolic activities. This study reviewed the existing literature, including electromagnetic fields, ultrasound, laser, extracorporeal shockwave therapy, and electrical stimulation, and revealed the efficacy of biophysical stimulation for bone healing. This study aims to define if these methods are helpful, especially in cases of non-union. Biophysical stimulation requires care and precision in use to ensure the success expected of it by physicians and patients.

Return to sport after forearm fractures in children: A scoping review and survey

Purpose

A common question faced by clinicians is when a child may return to sport after treatment for a pediatric forearm fracture. There are few published recommendations and fewer supported by evidence. The aims of this study were to summarize existing published recommendation for return to sport after pediatric forearm fractures and to conduct a survey to determine usual clinical recommendations.

Methods

A scoping review was performed on Ovid MEDLINE, Cochrane Central Register of Controlled Trials, Embase, Scopus, and Google Scholar in accordance with the Joanna Briggs Institute guidelines. In addition, 64 orthopedic surgeons were anonymously surveyed asking for recommendations regarding return to sport after pediatric forearm fractures. Participants were to assume children were 9 years old and played a sport with an average risk of forearm injury.

Results

Twenty-two publications for return to sport were retrieved. Children with distal radius buckle fractures safely commonly returned to sport by 4 weeks after initial injury, while survey respondents recommended over 6 weeks. Survey respondents valued fracture stability the highest when making return to sport recommendations. Children with simple, metaphyseal, single-bone fractures were usually allowed to return to sport at 8-10 weeks post-injury. Diaphyseal and complete fractures were prescribed longer return to sport intervals. Australian respondents also prescribed longer return to sport intervals.

Conclusion

Children with distal radius buckle fractures may return to sport by 4 weeks after initial injury, sooner than recommended. Published recommendations remain limited for other fractures. However, our survey suggests children with simple, metaphyseal, single-bone fractures may return to sport at 8-10 weeks. Children with diaphyseal and complete fractures should abstain from sport for longer than metaphyseal and greenstick fractures, respectively.

Level of evidence

level V.

Individualized herbal prescriptions for delayed union: A case series

Background Bone fractures are important clinical events for both patients and professionals. Active treatment options are limited for delayed unions and for nonunions; surgery is common but not entirely risk-free. This report describes three cases of delayed union successfully treated with herbal decoction. Participants Three patients had trapezoid and 3rd metacarpal bone fractures, 2nd, and 5th metatarsal bone fractures, respectively. All three patients were diagnosed with delayed union by an independent orthopedic surgeon based on computed tomography (CT) scan/radiographic imaging and fracture duration without a healing process. Patients took herbal decoction, Jeopgol-tang, with individually added herbs based on symptom manifestations, twice daily for 56, 85 and 91 days with no additional interventions except for a splint that they had been wearing since fracture diagnosis. Outcomes Improvement of delayed union was evaluated using radiographic imaging or CT during treatment with Jeopgol-tang. Results After taking herbal medicine, callus and bony bridging were confirmed on follow-up imagings and the patients described their experience with pain reduction at an interview after recovery. Conclusions This case series suggests that the herbal decoction Jeopgol-tang warrants further investigation to establish its role as a complementary and integrative medicine treatment option for delayed unions.

"Fragment Width Ratio" as a Predictor of Nonunion for Femoral Shaft Fracture With Third Fragments

Previous studies have reported that large fracture fragment with displacement might cause nonunion of femoral shaft fractures. We therefore intended to delineate significant risk factors for developing a nonunion predisposed by a major fracture fragment. We analyzed 61 patients who were operated on using interlocking nails for femoral shaft fractures from 2009 to 2018. We classified patients with modified Radiographic Union Scale for Tibia fractures scores of less than 11 or needing reoperations by 1 year postoperatively as nonunion. We thereafter measured parameters of the displaced fracture fragment and fracture site to identify the significant difference between the union and non-union groups. We also applied the receiver operating characteristic curve to demonstrate a threshold value for the fragment width (FW) ratio. Among 61 patients with complete follow-up, no significant difference was found regarding length, displacement, and angulation of fragments between patients with and without union. Except for higher mean FW (P=.03) and the FW ratio (P=.01) in patients with nonunion, the logistic regression analysis demonstrated that FW ratio significantly affected union (P=.018; odds ratio, 0.21; 95% CI, 0.001-0.522). Although a fracture fragment greater than 4 cm with displacement greater than 2 cm was reported to significantly cause nonunions, our study showed that an FW ratio greater than 0.55 instead of fragment size or displacement was predictive for the occurrence of nonunion adjoining to the fracture site. Fixation of the third fracture fragment should not be ignored for preventing a nonunion. More attention should be paid to achieve a better fixation for a major fracture fragment with an FW ratio greater than 0.55 to avoid the development of non-union following the use of interlocking nail for femoral shaft fracture. [Orthopedics. 202x;xx(x):xx-xx.].

Endosteal plating for the treatment of malunions and nonunions of distal femur fractures

PURPOSE

To describe the surgical technique and the outcome of a case series of nonunion and malunion of distal femur fractures treated with an endosteal medial plate combined with a lateral locking plate and with autogenous bone grafting.

METHODS

We retrospectively analyzed a series of patients with malunion or nonunion of the distal femur treated with a medial endosteal plate in combination with a lateral locking plate, in a period between January 2011 and December 2019, Database from chart review was obtained including all the clinical relevant available baseline data (demographics, type of fracture, mechanism of injury, time from injury to surgery, number of previous surgical procedures, type of bone graft, and type of lateral plate). Time to bone healing, limb alignment at follow-up and complications were documented.

RESULTS

Ten patients were included into the study: 7 male and 3 female with mean age of 48.3 years (range 21-67). The mechanism of trauma was in 8 cases a road traffic accident and in 2 cases a fall from height. According to AO/OTA classification 5 fractures were 33 A3, 3 were 33 C1, 1 was 33 C2 and 1 was 33 C3. The average follow up was 13.5 months. In all cases but one bony union was achieved. Bone healing was observed in average 3.3 months after surgery. No intraoperative or postoperative complications were reported.

CONCLUSION

A medial endosteal plate is a useful augmentation for lateral plate fixation in nonunion or malunion following distal femur fractures, particularly in cases of medial bone loss, severe comminution, or poor bone quality.

LEVEL OF EVIDENCE

Level IV (retrospective case series).

Solid locked intramedullary nailing for expeditious return of bone-setting-induced abnormal fracture union victims to work in South-western Nigeria

Wage earning in low- and middle-income countries (LMICs) is predominantly through physical labour. Consequently, limb-related disabilities caused by abnormal fracture unions (AFUs) preclude gainful employment and perpetuate the cycle of poverty. Many AFUs result from traditional bone-setting (TBS), a pervasive treatment for long bone fractures in LMICs. The objective of this study was to accentuate the expediency of solid locked intramedullary nail in the early restoration of victims of TBS-induced abnormal fracture unions (AFUs) to their pre-injury functioning, including work. One hundred AFUs in 98 patients treated with a solid locked intramedullary nail in our center over a period of 7 years were prospectively studied. We found the mean age to be 47.97 years. Males constituted 63.9% of the patients' population. Atrophic non-union accounted for 54.1% of the AFUs. The mean fracture-surgery interval was 21.30 months. By the 12th post-operative week, more than 75% of the fractures had achieved knee flexion/shoulder abduction beyond 90°, were able to squat and smile (or do shoulder abduction-external rotation), and were able to bear weight fully. The study demonstrated the expediency of solid locked nail in salvaging TBS-induced abnormal fracture unions in a way that permitted early return to pre-injury daily activities and work, thereby reducing fracture-associated poverty.

Non-Union Scoring System (NUSS): Is It Enough in Clinical Practice?

INTRODUCTION

Bone consolidation defects represent a real orthopedic challenge because of the absence of validated treatment guidelines that can assist the surgeon in his choices. The aim of this study is to evaluate the appropriateness of the Non-Union Scoring System NUSS treatment protocol in the management of long bone non-unions by comparing it to the experience-based therapeutic approach carried out in our facility.

MATERIALS AND METHODS

We conducted a comparative outcome study of a retrospective series of 89 patients surgically treated for long bone non-union in our facility vs. clinical results reported by Calori et al. obtained following the NUSS treatment protocol.

RESULTS

Radiographic healing was reached in 13/13 non-unions (100%) in group NUSS 1, in 58/62 (93.5%) in group NUSS 2, and in 13/14 (92.9%) in group NUSS 3. The mean time to radiographic healing was 5.69 ± 2.09 months in group 1, 7.38 ± 3.81 months in group 2 and 9.23 ± 2.31 months in group 3. 91% of patients in group I, 69% in group II and 48% in group III received what would be considered by the NUSS treatment protocol an "overtreatment", especially from a biological stand point. The comparative outcome analysis shows that our case series achieved significantly higher global healing rates (p value = 0.017) and shorter radiological healing times in groups NUSS 1 and 2 (p value < 0.001).

CONCLUSION

From the results obtained, we can assume that the NUSS treatment protocol might underestimate the necessary therapies, particularly from a biological point of view.

Primary cilia: The central role in the electromagnetic field induced bone healing

Primary cilia have emerged as the cellular “antenna” that can receive and transduce extracellular chemical/physical signals, thus playing an important role in regulating cellular activities. Although the electromagnetic field (EMF) is an effective treatment for bone fractures since 1978, however, the detailed mechanisms leading to such positive effects are still unclear. Primary cilia may play a central role in receiving EMF signals, translating physical signals into biochemical information, and initiating various signalingsignaling pathways to transduce signals into the nucleus. In this review, we elucidated the process of bone healing, the structure, and function of primary cilia, as well as the application and mechanism of EMF in treating fracture healing. To comprehensively understand the process of bone healing, we used bioinformatics to analyze the molecular change and associated the results with other studies. Moreover, this review summarizedsummarized some limitations in EMFs-related research and provides an outlook for ongoing studies. In conclusion, this review illustrated the primary cilia and related molecular mechanisms in the EMF-induced bone healing process, and it may shed light on future research.

The perceptions of clinicians using low-intensity pulsed ultrasound (LIPUS) for orthopaedic pathology: A national qualitative study

INTRODUCTION

Low-intensity pulsed ultrasound (LIPUS) is a non-invasive treatment modality for delayed union or non-union of acute fractures. We aimed to assess the current use of LIPUS at a national level in the United Kingdom, why and how clinicians use it, what treatment protocols are followed, and what the current perceptions are on this technology.

METHODOLOGY

Using a detailed online survey compromised of 20 questions delivered to known LIPUS users, we were able to collect qualitative data on indication of use, type of machine used, personal views on the technology, frequency of usage, and treatment protocols. Each question was peer-reviewed to exclude bias.

RESULTS

A total of 70 respondents completed the survey. LIPUS was used by most clinicians for cases of non-union (N = 55, 78.5%) and delayed union (N = 51, 72.8%). The majority of respondents personally used a LIPUS device between 1 and 5 times in 12 months (N = 38, 54.3%). Most considered LIPUS a failure after three to six months of treatment without clinical improvement (N = 39, 55.7%). A total of 32 respondents (45.7%) mentioned the need for funding approval before accessing LIPUS technology. Poor revision surgery candidates (N = 48, 68.6%) and atrophic non-union (N = 46, 65.7%) were the most frequently cited reasons for using LIPUS technology as treatment. Most participants (N = 48, 68.6%) considered LIPUS to be cost-effective. Despite most clinicians being comfortable with the use of LIPUS, some respondents did not understand the basic science underpinning the technology nor could explain the need for LIPUS to patients comfortably.

CONCLUSION

LIPUS technology may have a significant role to play in the treatment of orthopaedic fracture related pathology. Regular users perceived the technology to be cost-effective and efficacious. Further research should standardize treatment protocols and aim to establish a national LIPUS registry.

Medium-Term Outcomes of a Forward-Striking Technique to Reduce Fracture Gaps during Long Cephalomedullary Nailing in Subtrochanteric Femoral Fractures

INTRODUCTION

A residual fracture gap after intramedullary nailing is a known risk factor for delayed union and non-union. This study aimed to report the outcomes of a forward-striking technique to reduce fracture gaps during long cephalomedullary nailing in subtrochanteric femoral fractures (SFFs).

METHODS

A retrospective cohort study was conducted on patients with SFFs treated in a single institution between February 2013 and October 2018. A total of 58 patients treated via long cephalomedullary nailing with a forward-striking technique were included. The width of the fracture gap, location of the cephalic screw, tip-apex distance (TAD), and time to bone union were evaluated using intraoperative and postoperative radiographs. Complication rates, including fixation failure, non-union, implant breakage, and infection, were assessed. The mean follow-up duration was 4 (range, 2‒8) years.

RESULTS

Of the 58 patients (mean age, 67.9 years), 38 (65.5%) were female. Thirty-two cases (55.2%) were classified as atypical femoral fractures. The mean fracture gap reduced from 5.1 mm to 1.6 mm by forward striking (P<0.001). The reduced fracture gap was significantly greater in atypical SFFs (mean, 4.9 mm vs. 1.7 mm; P<0.001). The lag screw was located in the center-center or center-inferior zones of the femoral head in 54 patients (93.1%). The mean TAD was 14.2 mm and was under 25 mm in 55 patients (94.8%). Bone union was achieved in all cases without reoperation at a mean of 5.4 months. One incident of lag screw breakage was noted at 5 months, but bone union was achieved at 7 months.

CONCLUSIONS

The forward-striking technique with a long cephalomedullary nail demonstrated a 100% bone union rate in a consecutive series of 58 SFFs. This technique is effective in reducing the fracture gap as well as placing the cephalic screw into the optimal position. The forward-striking technique was particularly effective in reducing atypical SFFs with a transverse or short oblique configuration.

Radiographic Evaluation of Distal Radius Fracture Healing by Time: Orthopedist versus Qualitative Assessment of Image Processing

Distal radius fractures are among the most prevalent long-bone fractures in the body. Fracture healing assessment is based on clinical evaluation and radiological examinations. A lack of consensus exists regarding the radiographic criteria for fracture union. Our work examined the commonly used criteria for the assessment of fracture healing. Thirty-two patients, conservatively treated for distal radius fracture, participated in a prospective study. Enrolled patients followed protocol for 26 weeks. Four orthopedic surgeons with similar ranks were asked to evaluate three parameters of radiographic measurements for each set of radiographs, including callus formation, the presence of a fracture line, and bridging of fracture sites or sites of fracture edges in 70 radiographs. Ten patients were eligible for the study. The degree of agreement among surgeons was “good” (Cronbach’s alpha): callus formation—0.8, bridging of fracture sites—0.775, blurring of fracture line gap—0.795. A timeline based on the specific week and grading system was made. Radiographic detection of callus formation was seen after the second film, between 6 and 9 weeks, and an agreement among surgeons was achieved for more than half of the patients for the blurring of the fracture gap. The radiographic healing progression of the distal radius can be detected after 6 and 9 weeks in all three parameters with good agreement between different surgeons. A timeline graph such as the one that was made in this model can be used for the follow-up of patients’ fracture healing or early detection of non-union.

Effect of non-steroidal anti-inflammatory drugs on fracture healing in children: A systematic review

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most commonly prescribed medications in the United States. Although they are safe and effective means of analgesia for children with broken bones, there is considerable variation in their clinical use due to persistent concerns about their potentially adverse effect on fracture healing.

AIM

To assess whether NSAID exposure is a risk factor for fracture nonunion in children.

METHODS

We systematically reviewed the literature reporting the effect of NSAIDs on bone healing. We included all clinical studies that reported on adverse bone healing complications in children with respect to NSAID exposure. The outcomes of interest were delayed union or nonunion. Study quality was assessed using the Newcastle-Ottawa scale for non-randomized studies. A final table was constructed summarizing the available evidence.

RESULTS

A total of 120 articles were identified and screened, of which 6 articles were included for final review. Nonunion in children is extremely rare; among the studies included, there were 2011 nonunions among 238822 fractures (0.84%). None of the included studies documented an increased risk of nonunion or delayed bone healing in those children who are treated with NSAIDs in the immediate post-injury or peri-operative time period. Additionally, children are likely to take these medications for only a few days after injury or surgery, further decreasing their risk of adverse side-effects.

CONCLUSION

This systematic review suggests that NSAIDS can be safely prescribed to pediatric orthopaedic patients absent other contraindications without concern for increased risk of fracture non-union or delayed bone healing. Additional prospective studies are needed focusing on higher risk fractures and elective orthopaedic procedures such as osteotomies and spinal fusion.

Bone Healing Monitoring in Bone Lengthening Using Bioimpedance

The most common technique of orthopedic surgical procedure for the correction of deformities is bone lengthening by “distraction osteogenesis,” which requires periodic and ongoing bone assessment following surgery. Bone impedance is a noninvasive, quantitative method of assessing bone fracture healing. The purpose of this study was to monitor bone healing and determine when fixation devices should be removed. The left tibia of eight male New Zealand white rabbits (2.4 ± 0.4 kg) undergoing osteotomy was attached with a mini-external fixator. The bone length was increased by 1 cm one week after surgery by distracting it 1 mm per day. Before and after osteotomy, as well as every week after, bone impedance was measured in seven frequency ranges using an EVAL-AD5933EBZ board. Three orthopedic surgeons analyzed the radiographs using the Radiographic Union Scale for Tibial (RUST) score. The Kappa Fleiss coefficient was used to determine surgeon agreement, and the Spearman rank correlation coefficient was used to find out the relationship between impedance measurements and RUST scores. Finally, the device removal time was calculated by comparing the bone impedance to the preosteotomy impedance. The agreement of three orthopedic surgeons on radiographs had a Fleiss' Kappa coefficient of 49%, indicating a moderate level of agreement. The Spearman rank correlation coefficient was 0.43, indicating that impedance and radiographic techniques have a direct relationship. Impedance is expected to be used to monitor fractured or lengthened bones in a noninvasive, low-cost, portable, and straightforward manner. Furthermore, when used in conjunction with other qualitative methods such as radiography, impedance can be useful in determining the precise time of device removal.

Design considerations for piezoelectrically powered electrical stimulation: The balance between power generation and fatigue resistance

Quality and timing of bone healing from orthopedic surgeries, especially lumbar spinal fusion procedures, is problematic for many patients. To address this issue, clinicians often use electrical stimulation to improve surgery success rates and decrease healing time in patients with increased risk of pseudarthrosis, including smokers and diabetics. Current invasive electrical stimulation devices require an implantable battery and a second surgery for removal. Piezoelectric composites within an interbody implant generate sufficient power under physiologic loads to deliver pulsed electrical stimulation without a battery and have demonstrated promising preclinical bone growth and fusion success. The objective of the current study was to assess the power generation and fatigue resistance of three commercially manufactured piezocomposite configurations in a modified implant design to demonstrate efficacy as a robust biomaterial within osteogenic implants. The three configurations were electromechanically assessed under physiological lumbar loading conditions, and all configurations produced sufficient power to promote bone healing. Additionally, electrical and mechanical fatigue performance was assessed under high load, low cycle conditions. All configurations demonstrated runout with no gross mechanical failure and two configurations demonstrated electrical fatigue resistance. Future piezoelectric implant design decisions should be based on power generation needs to stimulate bone growth, as mechanical fatigue efficacy was proven for all piezocomposite configurations tested.

Bone Union Assessment with Computed Tomography (CT) and Statistical Associations with Mechanical or Histological Testing: A Systematic Review of Animal Studies

Objective and accurate assessment of bone union after a fracture, arthrodesis, or osteotomy is relevant for scientific and clinical purposes. Bone union is most accurately imaged with computed tomography (CT), but no consensus exists about objective assessment of bone union from CT images. It is unclear which CT-generated parameters are most suitable for bone union assessment. The aim of this review of animal studies is to find which CT-generated parameters are associated most strongly with actual bone union. Scientific databases were systematically searched. Eligible studies were studies that (1) were animal studies, (2) created a fracture, (3) assessed bone union with CT, (4) performed mechanical or histological testing as measure of actual bone union, and (5) associated CT-generated outcomes to mechanical or histological testing results. Two authors selected eligible studies and performed risk of bias assessment with QUADAS-2 tool. From 2567 studies that were screened, thirteen studies were included. Most common CT parameters that were investigated were bone mineral density, bone volume, and total callus volume. Studies showed conflicting results concerning the associations of these parameters with actual bone union. CT-assessed torsional rigidity (assessed by three studies) and callus density (assessed by two studies) showed best results. The studies investigating these two parameters reported moderate to strong associations with actual bone union. CT-assessed torsional rigidity and callus density seem the most promising parameters to represent actual bone union after a fracture, arthrodesis, or osteotomy.Prospero trial registration number: CRD42020164733.

Progression of Tibia Fracture Healing Using RUST: Are Early Radiographs Helpful?

OBJECTIVES

To report the progression of radiographic healing after intramedullary nailing of tibial shaft fractures using the Radiographic Union Score for Tibial fractures (RUST) and determine the ideal timing of early postoperative radiographs.

DESIGN

Retrospective case series.

SETTING

Urban academic Level 1 trauma center.

PATIENTS/PARTICIPANTS

Three hundred three patients with acute tibial shaft fractures underwent intramedullary nailing between 2006 and 2013, met inclusion criteria, and had at least 3 months of radiographic follow-up.

INTERVENTION

Baseline demographic, injury, and surgical data were recorded for each patient. Each set of postoperative radiographs were scored using RUST and evaluated for implant failure.

MAIN OUTCOME MEASUREMENTS

Postoperative time distribution for each RUST score, RUST score distribution for 4 common follow-up time points, and the presence and timing of implant failure.

RESULTS

The fifth percentile and median times, respectively, for reaching "any radiographic healing" (RUST = 5) was 4.0 weeks and 8.4 weeks, "radiographically healed" (RUST = 9) was 12.1 and 20.9 weeks, and "healed and remodeled" (RUST = 12) was 23.5 weeks and 47.7 weeks. At 6 weeks, 84% of radiographs were scored as RUST ≤ 6 (2 or fewer cortices with callus). No implant failure occurred within the first 8 weeks after surgery, and the indication for all 7 reoperations within this period was apparent on physical examination or immediate postoperative radiographs.

CONCLUSIONS

The median time to radiographic union (RUST = 9) after tibial nailing was approximately 20 weeks, and little radiographic healing occurred within the first 8 weeks after surgery. Routine radiographs in this period may offer little additional information in the absence of clinical concerns such as new trauma, malalignment, or infection.

LEVEL OF EVIDENCE

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

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.

Success Story of Ilizarov in Chronic Non-union of Tibia with 18 Years of Morbidity: A Case Report

Introduction:

When the fracture fails to heal for more than 12 months, it is called chronic non-union. Surgical intervention becomes mandatory to get this type of fracture healed. We are reporting our results in a case of congenital pseudoarthrosis of the tibia (CPT) having chronic non-union of 18 years duration with superadded infection following attempted surgery, using Ilizarov technology. We shall highlight the problems found during the course of treatment and different strategies to tackle them.

Case Presentation:

An 18-year-old female, born with CPT of the right tibia with neurofibromatosis, presented as Type 1 infected non-union following three unsuccessful surgeries. She had neurofibromatic nodules all over the body including the face. The leg had multiple active draining sinuses, with evidence of healed sinuses and operating scars, adherent to underlying bone. She had 20 cm of limb shortening. Prolonged morbidity made her socially isolated. Being poor, they could not manage her medical expenses. They started believing that amputation would be a viable option and with that feeling in mind, they approached us. After few sittings of counseling, they somehow agreed to give it a try. After preparing the patient, a radical excision of the infected and dead tissue was done. A 3 ring Ilizarov assembly was mounted as the distal fragment was very small. A corticotomy was done to fill up 10 cm of gap following excision and subsequent limb lengthening. She developed hyporegenerate, pin-tract infections (PTIs) during the course of treatment which were tackled accordingly. She also developed psychological problems due to nature of treatment that was taken care of too. The fracture united and she could start walking unaided. There was no recurrence of infection. The ring was kept in situ for about 700 days.

Conclusion:

Chronic non-union associated with neurofibromatosis and infection is a very challenging situation. Radical debridement is the key to prevent recurrence of both. Ilizarov system plays the most significant role in forming regenerate by distraction. Hyporegenerate and PTIs could be tackled meticulously to prevent complications and attain the desired result. The patient could achieve painless unaided walking after the treatment. Probably instilling self-confidence in the patient was one of the most important aspects to sustain such an arduous journey.

Definition of long-bone nonunion: A scoping review of prospective clinical trials to evaluate current practice

AIM

Although nonunions are among the most common complications after long-bone fracture fixation, the definition of fracture nonunion remains controversial and varies widely. The aim of this study was to identify the definitions and diagnostic criteria used in the scientific literature to describe nonunions after long-bone fractures.

METHODS

A comprehensive literature search was performed in PubMed, Cochrane Library, Web of Science, and Embase. Prospective clinical studies, in which adult long-bone fracture nonunions were investigated as main subject, were included in this analysis. Data on nonunion definitions described in each study were extracted and collected in a database.

RESULTS

Although 148 studies met the inclusion criteria, only 50% (74/148) provided a definition for their main study subject. Nonunion was defined in these studies based on time-related criteria in 85% (63/74), on radiographic criteria in 62% (46/74), and on clinical criteria in 45% (33/74). A combination of clinical, radiographic and time-related criteria for definition was found in 38% (28/74). The time interval between fracture and the time point when authors defined an unhealed fracture as a nonunion showed considerable heterogeneity, ranging from three to twelve months.

CONCLUSION

In the current orthopaedic literature, we found a lack of consensus with regard to the definition of long-bone nonunions. Without valid and reliable definition criteria for nonunion, standardization of diagnostic and treatment algorithms as well as the comparison of clinical studies remains problematic. The lack of a clear definition emphasizes the need for a consensus-based approach to the diagnosis of fracture nonunion centred on clinical, radiographical and time-related criteria.

High-energy extracorporeal shockwave therapy in humeral delayed and non-unions

INTRODUCTION

Within the last few decades, focused high-energy extracorporeal shockwave therapy (ESWT) has proven to be an effective alternative to standard of care revision surgery in delayed healing fractures or manifest non-unions in various anatomical regions.

MATERIALS AND METHODS

A retrospective multi-variant analysis of an open prospective, single-armed clinical study was conducted. Patients receiving focused high-energy ESWT for a delayed healing or an apparent non-union of a humeral fracture between January 1999 and December 2015 at a single trauma center were included in the study. Bony healing was defined as cortical continuity in three of four cortices and pain-free force loading and evaluated using CT scans and clinical examination at three- and six-month follow-ups after ESWT.

RESULTS

A total of 236 patients were included. N = 93 (43.8%) showed bony consolidation three months after ESWT and n = 105 (52.5%) after six months. Sub-group analysis showed significantly better healing for the proximal metaphyseal humerus (66.7% after six months, n = 42) compared to the diaphyseal region (48.1%, n = 133) and distal metaphyseal humerus (48.1%, n = 25). Regression analysis indicated significantly increased healing rates for patients of younger ages (p = 0.001) and a fracture diastasis of less than 5 mm (p = 0.002).

CONCLUSION

The findings of this study indicate that ESWT can be considered as a treatment option for a well-selected patient population despite the lower healing rates compared to other anatomical regions.

Open tibial fractures: An overview

Open tibial fractures are complex injuries with multifactorial outcomes and variable prognosis. The close proximity of the tibia to the skin makes it prone to extensive soft tissue damage and subsequent detrimental complications, such as infection and non-union. Thus, they were historically associated with high rates of amputation, sepsis, or even death. The advancement of surgical instruments and techniques, along the emergence of evidence-based guidance, have resulted in a significant reduction in complications. Peculiarly though, modern management strategies have a strong foundation in practices described in the ancient times. Nevertheless, post-operative complications are still a challenge in the management of open tibial fractures. Efforts are actively being made to refine the surgical approaches used, while noteworthy is the emergence of the Orthoplastic approach. The aim of this review is to summarise and discuss the historical perspective of the management of open tibial fractures, their epidemiology and classification, up-to-date principles of surgical management and outcomes following injury.

Management of Chronic Osteomyelitis by an Orthoplastic Team: 7-Year Experience of a University Hospital

BACKGROUND

Treating chronic osteomyelitis of the lower extremities is challenging. The treatment of acute lower limb trauma by orthoplastic teams has shown good results over the past few decades. This study aimed to characterize surgical outcomes of leg and heel chronic osteomyelitis by an orthoplastic team.

METHODS

The cases of 113 consecutive leg and heel chronic osteomyelitis patients undergoing soft-tissue reconstruction with an orthopedic procedure were reviewed in this retrospective single-center observational study. The main objective was to assess surgical outcomes of skin healing and gait recovery at the 1-year follow-up. The secondary objective was to evaluate the global success rate at the last follow-up.

RESULTS

The median follow-up was 19.7 months. A free flap was performed for 33 patients (29.2 percent) and a locoregional flap was used in 79 patients (69.9 percent). Seventy-two patients (63.7 percent) had chronic osteomyelitis on continuous bone. The others had a septic pseudarthrosis with a mean bone defect length of 42.9 mm. Forty-four patients (38.9 percent) underwent curettage only, eight (7.1 percent) underwent curettage and cement, 20 (17.7 percent) underwent curettage and bone fixation, and 39 (34.5 percent) underwent the Masquelet technique. At the 1-year follow-up, 72 patients (63.7 percent) had achieved skin healing and had recovered their gait. The success rate at all follow-up time points was 82.3 percent. The median time to achieve skin healing was 6.5 months and that to bone union in cases of septic pseudarthrosis was 7.9 months.

CONCLUSION

Orthoplastic management of leg and heel chronic osteomyelitis patients with combined soft-tissue reconstruction using an orthopedic procedure was a viable strategy that offered good results even though the time to complete healing was long.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Restoration of Stiffness During Fracture Healing at the Distal Radius, Using HR-pQCT and Finite Element Methods

Finite element analysis (FE) coupled with high-resolution peripheral quantitative computed tomography (HR-pQCT) allows for noninvasive in vivo assessment of fracture stiffness at peripheral locations including the distal radius. Previous studies have reported the ability of FE analysis to capture significant longitudinal changes in fracture stiffness. We hypothesized that continuum-based FE methods are necessary to capture significant changes in FE-estimated stiffness in men and women, with closed reductions and casting, over the course of their fracture healing process. The primary aim of the study was to evaluate the performance of 3 micro-FE (μFE) methods, 2 density-based (continuum) methods, and a homogeneous method. A total of 30 participants with stable distal radius fractures completed follow-ups at 2, 4, 6, 8, 12, and 26 weeks postfracture. Participants had their fractured wrist scanned using HR-pQCT at each follow-up; the contralateral wrist was also scanned at the initial assessment to represent baseline conditions. Images were used to generate continuum and homogeneous µFE models. Uniaxial compression and torsional tests were completed, with apparent stiffness determined as the primary outcome measure. Stiffness of the fractured wrist was compared to stiffness of the uninjured contralateral wrist to quantify the change in stiffness. Days since fracture significantly predicted change in stiffness for continuum and homogeneous µFE methods (p < 0.05). Continuum µFE methods appeared to account for partially mineralized tissues, resulting in a graduated recovery of stiffness (1% per week). Homogeneous µFE methods were more sensitive to stages of healing progression, resulting in a faster recovery of stiffness (3% per week). Our findings demonstrate the capability of µFE to capture the restoration of stiffness at the fractured side to prefracture stiffness in men and women, up to 6 months postfracture.

Exposure to 16 Hz Pulsed Electromagnetic Fields Protect the Structural Integrity of Primary Cilia and Associated TGF-β Signaling in Osteoprogenitor Cells Harmed by Cigarette Smoke

Cigarette smoking (CS) is one of the main factors related to avoidable diseases and death across the world. Cigarette smoke consists of numerous toxic compounds that contribute to the development of osteoporosis and fracture nonunion. Exposure to pulsed electromagnetic fields (PEMF) was proven to be a safe and effective therapy to support bone fracture healing. The aims of this study were to investigate if extremely low frequency (ELF-) PEMFs may be beneficial to treat CS-related bone disease, and which effect the duration of the exposure has. In this study, immortalized human mesenchymal stem cells (SCP-1 cells) impaired by 5% cigarette smoke extract (CSE) were exposed to ELF-PEMFs (16 Hz) with daily exposure ranging from 7 min to 90 min. Cell viability, adhesion, and spreading were evaluated by Sulforhodamine B, Calcein-AM staining, and Phalloidin-TRITC/Hoechst 33342 staining. A migration assay kit was used to determine cell migration. Changes in TGF-β signaling were evaluated with an adenoviral Smad2/3 reporter assay, RT-PCR, and Western blot. The structure and distribution of primary cilia were analyzed with immunofluorescent staining. Our data indicate that 30 min daily exposure to a specific ELF-PEMF most effectively promoted cell viability, enhanced cell adhesion and spreading, accelerated migration, and protected TGF-β signaling from CSE-induced harm. In summary, the current results provide evidence that ELF-PEMF can be used to support early bone healing in patients who smoke.

Percutaneous Reduction and 2.7-mm Cortical Screw Fixation for Low-Energy Lisfranc Injuries

To use the advantages of transarticular screw fixation while minimizing iatrogenic involved joint damage and screw irritation, it is important to determine the screw size. The aim of this study was to analyze the outcomes of percutaneous reduction and 2.7-mm cortical screw fixation for low-energy Lisfranc injuries and determine whether the procedure is a safe alternative to traditional screw fixation using a larger screw size. A review was performed for all patients who underwent percutaneous reduction and 2.7-mm cortical screw fixation for low-energy Lisfranc injuries at a single institution over a 6-year period. Thirty-one patients were enrolled in this study. Patients were assessed clinically and radiographically for demographics, foot function index (FFI), numerical rating scale (NRS) for pain, patient satisfaction, and complication rates. Factors affecting screw breakage and its clinical relevance were also analyzed. The FFI and NRS for pain were 17.2 ± 14.7 (range 0.8 to 57.8) and 3.1 ± 2.3 (range 0 to 8) points, respectively, at the 12-month follow-up visit. One patient (3.2%) underwent arthrodesis for the development of posttraumatic arthritis; all other patients recovered without sequelae. Screw breakage was identified in 7 patients (22.6%). There was no significant difference between patients with and without screw breakage in terms of FFI, NRS for pain, patient satisfaction, or complication rate. Body mass index (BMI) was significantly higher in patients with screw breakage than in those without screw breakage. Receiver operator characteristics curve analysis demonstrated a strong relationship between BMI and screw breakage (area under the curve = 90%, p < .001), and the potential BMI cutoff value was 27.8 kg/m². After considering the incidence of screw breakage, percutaneous reduction and 2.7-mm cortical screw fixation can be a viable option for treating low-energy Lisfranc injuries in nonobese patients, especially those with BMI <27.8 kg/m².

Monitoring of fracture healing. Update on current and future imaging modalities to predict union

Fracture nonunion causes considerable patient morbidity and an associated burden to society. Traditional reliance on radiographs to monitor union has limitations as bridging callus of long bone fractures can take three or more months to occur. Computed Tomographic (CT) scanning is becoming increasingly popular and can evaluate bridging callus in the late stages of healing to confirm union. The use of dynamic contrast enhanced Magnetic Resonance Imaging (MRI) and advances in nuclear imaging may yield benefits in the assessment of the infected nonunion. Emerging evidence supports the use of ultrasound to detect bridging callus prior to radiographic confirmation and it may be of use to predict patients at high risk of nonunion. This paper is part of a Supplement supported by The Osteosynthesis and Trauma Care Foundation (OTCF).

The use of low intensity pulsed ultrasound in the foot and ankle

Low intensity pulsed ultrasound (LIPUS) therapy has demonstrated clinical effectiveness in achieving union in a variety of fracture situations.Few studies have investigated the effectiveness of LIPUS therapy in foot and ankle surgery.The overall rate of union in all published studies relating to the use of LIPUS in a variety of foot and ankle fracture and fusion situations is 95%.Some studies suggest lower healing rates (~ 67%) when LIPUS therapy is used to treat hindfoot fusion nonunion.A well-powered, high-quality, randomized controlled trial is needed to demonstrate the clinical and cost effectiveness of LIPUS therapy in foot and ankle surgery. Cite this article: EFORT Open Rev 2021;6:217-224. DOI: 10.1302/2058-5241.6.200045.

Clavicle nonunion: plate and graft type do not affect healing rates-a single surgeon experience with 71 cases

BACKGROUND

Clavicle nonunions often result after nonoperative treatment for the acute fracture. Those that require >1 surgical procedure in order for a nonunion to heal are termed recalcitrant. The aims of the present study were to (1) determine healing rates of clavicle nonunions after plate osteosynthesis using either a conventional or locked plate, (2) compare iliac crest bone graft vs. bone morphogenetic protein on nonunion healing, and (3) identify risk factors for the development of a recalcitrant nonunion.

METHODS

We performed a retrospective analysis of a prospectively collected database of 78 clavicle nonunions treated with open reduction and plate fixation with or without graft augmentation by a single surgeon over 25 years. Seventy-one patients over the age of 18 with at least 12 months of follow-up comprised the study group. We analyzed healing rates after the index clavicle nonunion surgery comparing plate type and graft technique as well as identifying risk factors for developing a recalcitrant nonunion.

RESULTS

A total of 62 patients (87.3%) healed after their index nonunion surgery at our institution. Three patients (4.2%) required additional surgery but healed, and 6 patients (8.5%) remain un-united; these 9 patients (12.7%) were defined as recalcitrant. There was no statistically significant difference in healing rates between plate type (P = .633) or type of bone graft (P = .157). There were no identifiable risk factors for the development of a recalcitrant nonunion.

CONCLUSIONS

Plate fixation of clavicle nonunions remains a successful method of treatment. The type of plate or the method of bone graft did not produce different results. There were no demographic, patient, or injury characteristics associated with the development of a recalcitrant nonunion.

The AMANDUS Project PART II-Advanced Microperfusion Assessed Non-Union Diagnostics with Contrast-Enhanced Ultrasound (CEUS): A Reliable Diagnostic Tool for the Management and Pre-operative Detection of Infected Upper-Limb Non-unions

The management of upper-limb non-unions can be challenging, especially when infection is existent. Thus, pre-operative detection of infection plays a relevant role in non-union treatment. This study investigated in a large cohort the diagnostic potential of contrast-enhanced ultrasound (CEUS) as stand-alone method for differentiating between aseptic and infected upper-limb non-unions. Osseous perfusion of 50 upper-extremity non-unions (radius/ulna, n = 20; humerus, n = 22; clavicle, n = 8) was prospectively assessed with CEUS before revision surgery. The perfusion was quantified via time-intensity curves and peak enhancement (in arbitrary units). Significant perfusion differences between aseptic and infected non-unions could be detected (peak enhancement, p < 0.001). The sensitivity and specificity for the detection of infected upper-limb non-unions were 80% and 94.3% (cutoff peak enhancement: 130.8 arbitrary units). CEUS reliably differentiates between aseptic and infected upper-limb non-unions. Consequently, CEUS should be integrated into the daily diagnostic routine algorithm to plan non-union revision surgery more precisely as a single- or multi-step procedure.

Semi-quantitative CT scoring of nailed shaft fractures during normal healing and in non-unions: comparison with radiographic scoring

PURPOSE

To compare tomographic (TUS) with radiographic (RUS) union scores in nailed shaft fractures during normal healing and in non-unions.

METHODS

Two radiologists blinded to fracture age separately determined RUS and TUS in nailed femoral or tibial shaft fractures by analyzing the radiographic and CT examinations obtained in 47 patients during normal healing (early fracture group; 24 study participants, 17 men,19 tibias, mean fracture-CT delay 109 ± 57 days [42-204 days]) and in surgically proven non-united fractures (late fracture group, 23 patients, 14 men, 12 tibias, mean fracture-CT delay 565 ± 519 days[180-1983 days]). In both study groups, we determined the inter- and intra-observer agreement of RUS and TUS and compared TUS with RUS.

RESULTS

Intra- and inter-observer agreement of RUS and TUS was very good in the early fracture group and good in the late fracture group for both readers. TUS correlated with RUS substantially in the early fracture group and only weakly in the late fracture group. TUS was statistically significantly lower than RUS in study participants with RUS ≥ 8 or 9 for R2 only and ≥ 10 for both readers in the early fracture group and in patients with RUS ≥ 8, 9 or 10 in the late fracture group for both readers.

CONCLUSION

RUS and TUS of nailed shaft fractures during normal healing or in non-unions are both feasible and reproducible. They yield similar values in fractures with no or limited callus. TUS yields lower values than RUS in fractures with callus.

Improvements in radiographic and clinical assessment of distal radius fracture healing by FE-estimated bone stiffness

Bone strength determined from finite element (FE) modelling provides an estimate of fracture healing progression following a distal radius fracture (DRF), but how these measures relate to patient-reported outcomes and functional outcomes remains unknown. We hypothesized that changes in bone stiffness and bone mineral density measured using high-resolution peripheral quantitative computed tomography (HR-pQCT) are associated with clinically available measures of functional and patient-reported outcomes. We also aimed to identify which clinical outcome measures best predict fracture stiffness and could therefore be used to inform cast removal.

Participants (n = 30) with stable distal radius fractures were followed for two week intervals from the time of fracture until two months post-fracture, then at three months and six months post-fracture. At each follow-up, participants underwent clinical, radiographic, and functional assessments, as well as had their fractured wrist scanned using HR-pQCT. Recovery of bone stiffness during fracture healing was determined from micro-FE (μFE) models generated from HR-pQCT image data.

During the DRF healing process, significant longitudinal changes were found in μFE-estimated stiffness, patient-reported outcomes, grip strength, range of motion (ROM), tenderness, number of cortices healed based on radiographs, and fracture line visibility (p < 0.05); however, no significant change was detected in HR-pQCT based total bone mineral density. Patient-reported outcomes, such as the Patient-Rated Wrist Evaluation (PRWE) and the Quick Disability of the Arm, Shoulder and Hand (QuickDASH) questionnaire, correlated strongly with μFE-estimated stiffness (0.61 ≥ r_m ≥ 0.66). Based on μFE-estimated stiffness, PRWE and QuickDASH are the best predictors of stiffness recovery (p < 0.05) and may be used to guide duration of cast immobilization in the clinical setting.

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Recovery of fracture stiffness may inform time required for cast immobilization.

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Patient reported outcomes predict rate of fracture stiffness recovery.

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Radiographic outcomes correlate weakly with fracture stiffness.

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Patient reported outcomes may inform duration of cast immobilization.

External fixator combined with three different fixation methods of fibula for treatment of extra-articular open fractures of distal tibia and fibula: a retrospective study

Background

To compare the efficacy of three different fixation methods of fibula combined with external fixation of tibia for the treatment of extra-articular open fractures of distal tibia and fibula.

Methods

From January 2017 to July 2019, 91 cases of open fractures of distal tibia and fibula were treated with external fixator, and the fibula was fixed with non-fixation (group A, n = 35), plate-screw (group B, n = 30) and Kirschner wire (group C, n = 26). The operation time, intraoperative blood loss, surgical and implants costs, fracture healing time, postoperative complications, and American Orthopaedic Foot and Ankle surgery (AOFAS) scores were compared among the groups.

Results

Four patients were lost to follow-up, and 87 patients were followed up for 5–35 months (average, 14.2 months). The operation time of group C (114.92 ± 36.09 min) was shorter than that of group A (142.27 ± 47.05 min) and group B (184.00 ± 48.56 min) (P < 0.05). There was no difference in intraoperative blood loss among the three groups (P > 0.05). The surgical and implants costs in group C (5.24 ± 1.21, thousand dollars) is lower than that in group A (6.48 ± 1.11, thousand dollars) and group B (9.37 ± 2.16, thousand dollars) (P < 0.05). The fracture healing time of group C (5.67 ± 1.42 months) was significantly less than that of group A (6.90 ± 1.33 months) and group B (6.70 ± 1.12 months) (P < 0.05). The postoperative complications such as fractures delayed union and nonunion in group C (2 cases, 8.00%) is less than that in group A (13 cases, 39.39%) and group B (11cases, 37.93%) (P < 0.05). The wound infection and needle-tract infection did not differ among the three groups (P > 0.05). The excellent or good rate of ankle function was 69.70% in group A, 72.41% in group B and 84.00% in group C, with no statistical difference among the three groups (P > 0.05).

Conclusion

Compared with simple external fixator fixation and external fixator combined with plate-screw osteosynthesis, external fixator combined with K-wire intramedullary fixation shortens the operative time and fracture healing time, reduced costs and complications of fracture healing, while the blood loss, infection complications and ankle function recovery showed no difference with the other two groups. External fixator combined with plate-screw osteosynthesis had no advantage in treating extra-articular open fractures of distal tibia and fibula when compared with simple external fixation.

Nonunion and Reoperation After Ulna Shortening Osteotomy

Background: The primary purpose of our study was to identify factors associated with reoperation after ulna shortening osteotomy. Our secondary aims were to determine the rate and type of reoperation procedures. Methods: In this retrospective study, we included patients older than 18 years of age who underwent an ulna shortening osteotomy between January 2003 and December 2015. Medical records of patients were assessed for our explanatory variables, reoperations, and reporting of symptoms. We used bivariate and multivariable analyses to identify factors associated with reoperation after ulna shortening osteotomy. Results: Among 94 patients who underwent 98 ulna shortening osteotomies, there were 34 reoperations (35%). Nineteen patients (19%) underwent removal of hardware, 6 (6.1%) had a nonunion, and 9 (9.2%) underwent additional surgeries. Surgery on their dominant limb, trauma, and prior surgery to the ipsilateral wrist were associated with reoperation. In multivariable analysis, factors independently associated with reoperation were the dominant side being affected (odds ratio = 3.9; 95% confidence interval [CI] = 1.36-11) and traumatic origin (odds ratio = 3.4; 95% CI = 1.1-11). Bivariate analysis identified younger age and prior surgery of the affected wrist as factors associated with hardware removal. More operations for refixation due to nonunion of osteotomy were performed in patients with a transverse osteotomy compared with patients with an oblique osteotomy. Conclusions: One in 3 patients will undergo a reoperation after ulna shortening osteotomy, most often due to hardware irritation or nonunion of osteotomy. Awareness of these rates and predictive factors may be helpful for preoperative discussions and surgical decision making.

Vascularization Strategies in the Prevention of Nonunion Formation

Delayed healing and nonunion formation are major challenges in orthopedic surgery, which require the development of novel treatment strategies. Vascularization is considered one of the major prerequisites for successful bone healing, providing an adequate nutrient supply and allowing the infiltration of progenitor cells to the fracture site. Hence, during the last decade, a considerable number of studies have focused on the evaluation of vascularization strategies to prevent or to treat nonunion formation. These involve (1) biophysical applications, (2) systemic pharmacological interventions, and (3) tissue engineering, including sophisticated scaffold materials, local growth factor delivery systems, cell-based techniques, and surgical vascularization approaches. Accumulating evidence indicates that in nonunions, these strategies are indeed capable of improving the process of bone healing. The major challenge for the future will now be the translation of these strategies into clinical practice to make them accessible for the majority of patients. If this succeeds, these vascularization strategies may markedly reduce the incidence of nonunion formation. Impact statement Delayed healing and nonunion formation are a major clinical problem in orthopedic surgery. This review provides an overview of vascularization strategies for the prevention and treatment of nonunions. The successful translation of these strategies in clinical practice is of major importance to achieve adequate bone healing.

Effectiveness of Pulsed Electromagnetic Fields on Bone Healing: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

The effect of pulsed electromagnetic field (PEMF) on bone healing is still uncertain and it has not been established as a standardized treatment. The aim of this systematic review and meta-analysis is to evaluate the effect of PEMF on bone healing in patients with fracture. We searched CNKI, Wan Fang, VIP, EMbase, PubMed, CENTRAL, Web of Science, Physiotherapy Evidence Database, and Open Grey websites for randomized controlled trials (published before July 2019 in English or Chinese) comparing any form of PEMF to sham. Reference lists were also searched. Related data were extracted by two investigators independently. The bias risk of the articles and the evidence strength of the outcomes were evaluated. Twenty-two studies were eligible and included in our analysis (n = 1,468 participants). The pooled results of 14 studies (n = 1,131 participants) demonstrated that healing rate in PEMF group was 79.7% (443/556), and that in the control group was 64.3% (370/575). PEMF increased healing rate (RR = 1.22; 95% confidence interval [CI] = 1.10-1.35; I²  = 48%) by the Mantel-Haenszel analysis, relieved pain (standardized mean difference (SMD) = -0.49; 95% CI = -0.88 to -0.10; I²  = 60%) by the inverse variance analysis, and accelerated healing time (SMD = -1.01; 95% CI = -2.01 to -0.00; I²  = 90%) by the inverse variance analysis. Moderate quality evidence suggested that PEMF increased healing rate and relieved pain of fracture, and very low-quality evidence showed that PEMF accelerated healing time. Larger and higher quality randomized controlled trials and pre-clinical studies of optimal frequency, amplitude, and duration parameters are needed. © 2020 Bioelectromagnetics Society.