Abstract
Background: Research has suggested that bone fractures can hinder the health status of patients’ life. However, limited research has examined the impact that the healing process of a fracture has on the physical health and psychological state of individuals, particularly in considering the short- and long-term impact of having a fracture that fails to heal and drops into a non-union. The aim of this systematic review is to better understand the impact of fracture non-union to physical health and to respective psychological outcomes. Methods: Electronic databases ‘PubMed’, ‘Cochrane’, ‘PsycInfo’, ‘Medline’, ‘Embase’, ‘Web of Science’, and ‘CINAHL’ were used. Search terms used were nonunion OR non-union OR “non union” OR “long bone” OR “delayed union” AND “quality of life” OR qol OR depression OR anxiety OR psycholog* OR PTSD OR “post-traumatic stress disorder”. Studies published in the years 1995 to 2018 were included. Two independent reviewers carried out screening and data extraction. Studies were included if (1) participants were adult (human) patients with a traumatic non-union secondary to fracture/s; (2) outcomes measured included physical health and psychological wellbeing (e.g., PTSD, psychological trauma, depression, anxiety, etc.). Studies received emphasis if they compared those outcomes between: (1) The “non-union” group to a normative, matched population and (2) the “non-union group” to the same group after union was achieved. However, studies that did not use comparison groups were also included. Results: Out of the 1896 papers identified from our thorough literature search, 13 met the inclusion criteria. Quality assessment was done by the Methodological Index for Non-Randomized Studies (MINORS). Findings suggested that non-unions had a detrimental impact on physical health, and psychological difficulties often after recovery. Conclusions: Patients who experience a long bone non-union are at risk of greater psychological distress and lower physical health status. There is a need for early identification of psychological distress in patients with fracture non-unions and psychological provision should become part of the available treatment.
Highlights
According to the current definition from the European Society of Tissue Regeneration in Orthopedics and Traumatology (ESTROT), a non-union is defined as a fracture that does not heal without a further intervention—independent of the length of the previous treatment [1]
Our pooled analysis showed that the physical health state of non-unions, as measured by Short Form Health Survey 12 questions (SF-12), is significantly worse compared to normal population both in its physical and mental components
Similar results were obtained from the subgroup analysis that investigated separately the impact of tibial and femoral non unions on the components of SF-12
Summary
According to the current definition from the European Society of Tissue Regeneration in Orthopedics and Traumatology (ESTROT), a non-union is defined as a fracture that does not heal without a further intervention—independent of the length of the previous treatment [1]. Factors that increase risk for developing a non-union can be classified as patient-dependent, such as older age, medical comorbidities (diabetes mellitus, vascular disease), smoking, NSAIDs use, nutritional deficiency and genetic or metabolic disorders, as well as patient–independent factors like degree of comminution, infection, fracture site (for example a base of 5th metatarsal fracture), bone loss, open fracture and quality of surgical treatment [3]. This complication does not come without a cost. We conducted a systematic review of current literature trying to ascertain the impact of non-unions on adult patients’ physical health state and on their psychological wellbeing
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