Abstract
AimAlthough 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. MethodsA 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. ResultsAlthough 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. ConclusionIn 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.
Highlights
In the current orthopaedic literature, we found a lack of consensus with regard to the definition of long-bone nonunions
In high energy open fractures, the risk of nonunion increases significantly and has been reported to be 19-fold higher when compared to closed fractures [5]; this may be explained by the extent of the soft-tissue injury, comminuted fracture patterns and elevated rate of fracture-related infection (FRI)
Orthopaedic trauma surgeons and experts in the field utilize a wide variety of nonunion definitions
Summary
Agnosed with nonunion are estimated to be more than double the cost of those with uneventful fracture healing [2]. The overall risk for nonunion is 5%, whereas for certain fractures in specific age groups the risk may increase up to 9% [3,4]. Mills et al observed relatively higher nonunion rates in a large national cohort for tibial and clavicular fractures, especially in young and middle-aged adults [3]. In high energy open fractures, the risk of nonunion increases significantly and has been reported to be 19-fold higher when compared to closed fractures [5]; this may be explained by the extent of the soft-tissue injury, comminuted fracture patterns and elevated rate of fracture-related infection (FRI)
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