Abstract
PurposeTo evaluate the available tibial fracture non-union prediction scores and to analyse their strengths, weaknesses, and limitations.MethodsThe first part consisted of a systematic method of locating the currently available clinico-radiological non-union prediction scores. The second part of the investigation consisted of comparing the validity of the non-union prediction scores in 15 patients with tibial shaft fractures randomly selected from a Level I trauma centre prospectively collected database who were treated with intramedullary nailing.ResultsFour scoring systems identified: The Leeds-Genoa Non-Union Index (LEG-NUI), the Non-Union Determination Score (NURD), the FRACTING score, and the Tibial Fracture Healing Score (TFHS). Patients demographics: Non-union group: five male patients, mean age 36.4 years (18–50); Union group: ten patients (8 males) with mean age 39.8 years (20–66). The following score thresholds were used to calculate positive and negative predictive values for non-union: FRACTING score ≥ 7 at the immediate post-operative period, LEG-NUI score ≥ 5 within 12 weeks, NURD score ≥ 9 at the immediate post-operative period, and TFHS < 3 at 12 weeks. For the FRACTING, LEG-NUI and NURD scores, the positive predictive values for the development of non-union were 80, 100, 40% respectively, whereas the negative predictive values were 60, 90 and 90%. The TFHS could not be retrospectively calculated for robust accuracy.ConclusionThe LEG-NUI had the best combination of positive and negative predictive values for early identification of non-union. Based on this study, all currently available scores have inherent strengths and limitations. Several recommendations to improve future score designs are outlined herein to better tackle this devastating, and yet, unsolved problem.
Highlights
Non-union of long bones is a relatively frequent and most devastating complication of trauma with an incidence ranging from 5 to 10% [1, 2]
There is no accepted universal definition of “non-union”, the U.S Food and Drug Administration (FDA) defines it as a fracture that is at least nine months old and has not shown any signs of healing for three consecutive months [5]
The FRACTING score was prospectively developed by a collaboration of 41 trauma centres throughout Italy in 2018 [9], and it has been designed to predict tibial fracture healing time when applied in the immediate post-operative period
Summary
Non-union of long bones is a relatively frequent and most devastating complication of trauma with an incidence ranging from 5 to 10% [1, 2]. There is no accepted universal definition of “non-union”, the U.S Food and Drug Administration (FDA) defines it as a fracture that is at least nine months old and has not shown any signs of healing for three consecutive months [5]. These are inappropriately long intervals and it is of utmost importance to be able to predict early which fractures will advance into non-unions in order to intervene promptly and, optimally, within 12 weeks after initial fracture fixation to prevent the aforementioned severe and multifaceted consequences.
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