Aseptic Nonunion Research Articles

Biological and molecular profile of fracture non-union tissue: A systematic review and an update on current insights.

Fracture non‐union represents a common complication, seen in 5%–10% of all acute fractures. Despite the enhancement in scientific understanding and treatment methods, rates of fracture non‐union remain largely unchanged over the years. This systematic review investigates the biological, molecular and genetic profiles of both (i) non‐union tissue and (ii) non–union‐related tissues, and the genetic predisposition to fracture non‐union. This is crucially important as it could facilitate earlier identification and targeted treatment of high‐risk patients, along with improving our understanding on pathophysiology of fracture non‐union. Since this is an update on our previous systematic review, we searched the literature indexed in PubMed Medline; Ovid Medline; Embase; Scopus; Google Scholar; and the Cochrane Library using Medical Subject Heading (MeSH) or Title/ words (non‐union(s), non‐union(s), human, tissue, bone morphogenic protein(s) (BMPs) and MSCs) from August 2014 (date of our previous publication) to 2 October 2021 for non‐union tissue studies, whereas no date restrictions imposed on non–union‐related tissue studies. Inclusion criteria of this systematic review are human studies investigating the characteristics and properties of non‐union tissue and non–union‐related tissues, available in full‐text English language. Limitations of this systematic review are exclusion of animal studies, the heterogeneity in the definition of non‐union and timing of tissue harvest seen in the included studies, and the search term MSC which may result in the exclusion of studies using historical terms such as ‘osteoprogenitors’ and ‘skeletal stem cells’. A total of 24 studies (non‐union tissue: n = 10; non–union‐related tissues: n = 14) met the inclusion criteria. Soft tissue interposition, bony sclerosis of fracture ends and complete obliteration of medullary canal are commonest macroscopic appearances of non‐unions. Non‐union tissue colour and surrounding fluid are two important characteristics that could be used clinically to distinguish between septic and aseptic non‐unions. Atrophic non‐unions had a predominance of endochondral bone formation and lower cellular density, when compared against hypertrophic non‐unions. Vascular tissues were present in both atrophic and hypertrophic non‐unions, with no difference in vessel density between the two. Studies have found non‐union tissue to contain biologically active MSCs with potential for osteoblastic, chondrogenic and adipogenic differentiation. Proliferative capacity of non‐union tissue MSCs was comparable to that of bone marrow MSCs. Rates of cell senescence of non‐union tissue remain inconclusive and require further investigation. There was a lower BMP expression in non‐union site and absent in the extracellular matrix, with no difference observed between atrophic and hypertrophic non‐unions. The reduced BMP‐7 gene expression and elevated levels of its inhibitors (Chordin, Noggin and Gremlin) could potentially explain impaired bone healing observed in non‐union MSCs. Expression of Dkk‐1 in osteogenic medium was higher in non‐union MSCs. Numerous genetic polymorphisms associated with fracture non‐union have been identified, with some involving the BMP and MMP pathways. Further research is required on determining the sensitivity and specificity of molecular and genetic profiling of relevant tissues as a potential screening biomarker for fracture non‐unions.

Clinical outcomes of dual fixation of femoral shaft fracture nonunion: synchronous nailing and plate augmentation

Background The key to success in femoral shaft nonunion cases is the achievement of mechanical stability. We aimed to provide the clinical outcome of dual-fixation femoral shaft fracture nonunion using intramedullary nailing and plate augmentation in the same setting. Patients and methods This was a retrospective study of 12 patients with femoral shaft fracture aseptic nonunion operated at our university hospital between January 2017 and June 2021. All patients underwent revision surgery with synchronous nailing and plate augmentation. Demographics, comorbidities, history of previous trauma, fracture healing, and complications were recorded. We also reviewed radiological images. Results Twelve patients (nine males and three females) with a mean age of 31.1±9.8 years were included. Six patients had a previous fixation with an intramedullary nail, five with a plate, and one with an external fixator. Ten patients had atrophic nonunion, and two patients had hypertrophic nonunion. Patients achieved fracture healing after the surgical intervention, except two patients required another surgical intervention for delayed union as bone grafting (at 6 and 8 months, respectively). At the end of the study, they achieved fracture healing in all patients. The mean healing time was 6.1±2.4 months. Conclusion s Good mechanical stability and hence union can be achieved with synchronous nailing and plate augmentation as a treatment option for femoral shaft fracture aseptic nonunion.

Repair of critical diaphyseal defects of lower limbs by 3D printed porous Ti6Al4V scaffolds without additional bone grafting: a prospective clinical study

The repair of critical diaphyseal defects of lower weight-bearing limbs is an intractable problem in clinical practice. From December 2017, we prospectively applied 3D printed porous Ti6Al4V scaffolds to reconstruct this kind of bone defect. All patients experienced a two-stage surgical process, including thorough debridement and scaffold implantation. With an average follow-up of 23.0 months, ten patients with 11 parts of bone defects were enrolled in this study. The case series included three females and seven males, their defect reasons included seven parts of osteomyelitis and four parts of aseptic nonunion. The bone defects located at femur (five parts) and tibia (six parts), with an average defect distance of 12.2 cm. Serial postoperative radiologic follow-ups displayed a continuous process of new bone growing and remodeling around the scaffold. One patient suffered tibial varus deformity, and he underwent a revision surgery. The other nine patients achieved scaffold stability. No scaffold breakage occurred. In conclusion, the implantation of 3D printed Ti6Al4V scaffold was feasible and effective to reconstruct critical bone defects of lower limbs without additional bone grafting.Graphical abstract

The efficacy of augmentative anti-rotational plating plus decortication and autogenic bone grafting for aseptic nonunion after intramedullary nailing of femoral shaft fracture

Abstract Background: Femoral interlocking intramedullary (IM) nailing fixation is an effective method for the treatment of femoral shaft fractures. Aseptic nonunion of femoral shaft fracture after IM nailing is uncommon. Currently, the treatment for aseptic femoral shaft nonunion is controversial. The aim of this study was to investigate the clinical effect of augmentative antirotational plating plus decortication and autogenic bone grafting for aseptic femoral shaft nonunion after IM nailing failure. Methods: A retrospective study was conducted on 25 cases of aseptic femoral shaft fracture nonunion treated with IM nailing from January 2015 to August 2019. All patients were treated by leaving the nail in situ, debridement of nonunion sites, decortication, autogenous iliac bone grafting, and augmentative antirotational plating fixation. The time to fracture union and complications were recorded. Results: All patients were followed up for 12–18 months. The union rate after revision surgery was 100%. The average union time was 5.5 months (range, 4-10). Subjective pain symptoms had disappeared in all patients. There were no incision infections or internal fixator fatigue fractures. Average scores of the physical function and bodily pain components of the SF-36 were 95.5 (range, 91-98) and 94.1 (range, 90-97), respectively. No other obvious complications occurred postoperatively. Conclusion: Augmentative antirotational plating plus decortication and autogenic bone grafting is an excellent choice for treating femoral shaft fracture nonunion after IM nailing; this approach has an overall high union rate and few complications.

Resorbable polylactide membrane for the treatment of segmental bone defects

IntroductionSegmental bone defects are a challenging clinical problem. In animal studies and craniomaxillofacial surgery, resorbable polylactide membrane (OrthoMesh; DePuy Synthes, West Chester, PA) shows promise for treatment of bone defects. This study presents the results of the treatment of segmental bone defects with resorbable polylactide membrane, bone morphogenic protein-2 (BMP-2), and autograft. MethodsThis study was approved by the institutional review board. All patients with a segmental bone defect treated with a resorbable polylactide membrane by a single surgeon from 2010 to 2019 were retrospectively reviewed. Data related to demographic variables, surgical details, and union were collected. ResultsEleven patients with median age of 37 years (range 22–62 years) were included in the study with segmental bone defects in the tibia (n = 3), femur (n = 4), or forearm (n = 4). Median bone defect size was 6 cm (range 3–12 cm). Etiology of bone defects included osteomyelitis (n = 7), oncologic resection (n = 3), and post-traumatic aseptic nonunion (n = 1). Flap coverage was performed in two patients. Median radiographic follow-up was 24 months (range 5–75 months). Ten patients (10/11) achieved union at a median of 17 months (range 5–46 months). Seven patients required reoperation for any reason with six patients requiring repeat grafting. ConclusionsTo our knowledge, this study is the largest series of patients with segmental bone defects treated with resorbable polylactide membrane. Resorbable polylactide membrane in combination with BMP-2 and autograft represents a safe and effective method of bone graft containment in segmental bone defects measuring up to 12 cm in this series. Ten of 11 patients achieved union at a median time of 16 months with 6 patients requiring repeat grafting. These results compare favorably with the induced membrane technique. This study is limited by its retrospective design, absence of control and comparison groups, and low patient numbers. Future prospective randomized study of the induced membrane technique and resorbable polylactide membrane should be undertaken to determine preferred approaches for treatment of segmental bone defects.

Оценка роли первичной фиксации переломов костей голени в развитии асептических несращений большеберцовой кости

Рассмотрены виды первичного остеосинтеза и оценена их значимость как причины развития несращения у 76 больных с асептическими несращениями костей голени. Сформулированы основы применения различных видов фиксации в различных клинических ситуациях, принципы профилактики несращений костей голени. Первичный остеосинтез переломов костей голени является очень важным, но не единственным фактором, который детерминирует развитие несращения. Анализ результатов проведенного комплексного лечения при переломах костей голени свидетельствовал о существующих возможностях улучшения результатов и уменьшения процента несращений. При высокоэнергетических, а тем более открытых поражениях методом выбора (первичным и заключительным) могло быть применение кольцевых фиксаторов спицестержневого типа.

Conversion total hip arthroplasty for early failure following unstable intertrochanteric hip fracture: what can patients expect?

To report surgical outcomes in patients treated with conversion total hip arthroplasty (CTHA) for early failure of cephalomedullary nails (CMNs). A retrospective review was conducted of CTHA for treatment of failed CMN within 1year of initial surgery for intertrochanteric (IT) hip fractures. The cohort was matched 1:5 to patients who underwent elective primary THA (PTHA). Patient demographics, mechanism of CMN failure, surgical outcomes, and complication rates were assessed. 22 patients met criteria with a mean time to failure of 145days. Modes of failure included: lag screw cut-out with superior migration (9, 40.9%), or medialization (8, 36.4%), and aseptic nonunion with implant failure (2, 9.0%) and without implant failure (3, 13.6%). Fourteen of the patients (63.6%) had acetabular-sided damage secondary to lag screw penetration, all in the screw cut-out groups. Patient demographics were similar between cohorts. Compared to PTHA, CTHA patients had increased operative time, blood loss, LOS, and readmission rates. After IMN failure, the operative leg was shorter than the contralateral leg in all cases. CTHA restored leg lengths to < = 10mm in 15 (68.1%) of patients, with an average leg length discrepancy after CTHA of 6.7mm. CTHA patients had increased rates of overall surgical complications and medical complications, specifically anemia (all p < 0.01). Tranexamic acid was used less often in the CTHA group (p < 0.01). Rate of periprosthetic joint infection (PJI), dislocation, and revision were all higher in the CTHA, though did not reach statistical significance. The majority (77.3%) of CMN implant failure for nonunion within 1year was due to screw cut-out. CTHA is a salvage option for early failed IT hip fracture repair, but expected surgical outcomes are more similar to revision THA than primary THA, with increased risk of readmission, longer surgery and LOS, increased blood loss, and higher complication rates. III, Retrospective comparative study.

Complications and Soft-Tissue Coverage After Complete Articular, Open Tibial Plafond Fractures.

To evaluate the incidence of nonunion and wound complications after open, complete articular pilon fractures. Second, to study the effect that both timing of fixation and timing of flap coverage have on deep infection rates. Retrospective case series. Three Academic Level 1 Trauma Centers. One hundred sixty-one patients with open OTA/AO type 43C distal tibia fractures treated with open reduction internal fixation (ORIF) between 2002 and 2018. The mean (SD) age was 46 (14) years, 70% male, with median (interquartile range) follow-up of 2.1 (1.3-5.0) years (minimum 1 year). There were 133 (83%) type 3A and 28 (17%) type 3B open fractures. Fracture fixation: acute, primary (<24 hours) versus delayed, staged ORIF (>24 hours). Soft-tissue coverage: rotational or free flap. Primary outcomes included deep infection and nonunion. Secondary outcomes included rates of soft-tissue coverage and reoperation. Acute fixation (<24 hours) was performed in 36 (22%) patients; 125 (78%) underwent delayed, staged fixation. Deep infection occurred in 27% patients and was associated with men (33% vs. 16%, P = 0.029), smoking (38% vs. 23%, P = 0.047), and type 3B fractures (39% vs. 25%, P = 0.046). Acute fixation of type 3A fractures demonstrated a higher rate of infection (38% vs. 20% P = 0.036) than delayed, staged fixation. In type 3B fractures, early flap coverage (<1 week) demonstrated a lower rate of infection (18% vs. 53%, P = 0.066) and 20% (vs. 43%) with a single-staged "fix and flap" procedure (P = 0.408). Nonunion occurred in 36 (22%) and was associated with deep infection (43% vs. 15%, P < 0.001). Fifteen (42%) were septic nonunions. Twenty-nine of the 36 (81%) nonunions achieved radiographic union after median (interquartile range) 27 (20-41) weeks and median (range) 1 (1-3) revision ORIF procedures. There was no difference in the rate of secondary union between septic and aseptic nonunions (85% vs. 86%, P = 1.00). There was a high rate of secondary procedures (47%): revision ORIF (17%), irrigation and debridement (15%), and removal of implants (11%). Complete articular, open pilon fractures are associated with a high rate of complications after ORIF. Early fixation carries a high risk of deep infection; however, early flap coverage for 3B fractures seems to play a protective role. We advocate for aggressive management including urgent surgical debridement and very early soft-tissue cover combined with definitive fixation during single procedure if possible. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Reconstruction of Massive Segmental Distal Femoral Metaphyseal Bone Defects After Open Injury: A Study of 20 Patients Managed with Intercalary Gamma-Irradiated Structural Allografts and Autologous Cancellous Grafts.

Our aim was to examine the outcome of gamma-irradiated intercalary structural allografts combined with autologous cancellous grafts in treating large metaphyseal bone defects of the distal femur following open injuries. We prospectively included 20 consecutive patients with large metaphyseal bone defects of >4 cm located in the region of the distal femur following open injuries treated between 2010 and 2018, with a mean follow-up of 2 years (range, 2 to 10 years). Of these patients,18 were men and 2 were women. The mean age was 39 years (range, 22 to 72 years). The mean length of the bone defects was 10.1 cm (range, 5.5 to 14.5 cm), and all were in the metaphysis of the distal femur. The surgical technique included initial early debridement and external fixation followed by reconstruction of the bone defect using structural allograft combined with autologous cancellous bone graft harvested from the iliac crest and locking plate fixation. Definitive fixation was performed at an average period of 22.5 days (range, 3 to 84 days) after injury. Osseous union, rate of infection, complications, need for secondary procedures, and functional outcome using the Lower Extremity Functional Scale (LEFS) at the final follow-up were assessed. After excluding 1 patient who was lost to follow-up, 19 patients with complete follow-up were available for analysis. Of those, 13 patients (68%) achieved complete union at both ends of the allograft with host bone without any further intervention. Three patients (16%) developed aseptic nonunion of the proximal end of the allograft requiring 1 additional procedure each to achieve union. Four patients (21%) developed a deep surgical site infection. Of those, 1 elderly patient required above-the-knee amputation following uncontrolled diabetes and infection. A second patient required 2 additional procedures, and a third patient needed 4 additional procedures to achieve union. The fourth patient developed infection after achieving union, and the infection subsided after debridement and implant removal. The mean LEFS score for all 19 patients was 55 (range, 41 to 75). Use of allograft was a reasonable single-stage alternative solution for massive distal femoral bone defects, which united without additional surgery in two-thirds of the patients and without limb-length discrepancy. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Greffe autologue de fibula non vascularisée pour le traitement des pseudarthroses récidivantes de la diaphyse humérale: étude rétrospective de cas

IntroductionThere is a great surgical challenge when humeral diaphyseal fractures are initially open, complex, or associated with segmental bone loss. The challenge becomes even greater with previous multiple unsuccessful surgeries. The question of this study was: Does combining locked compression plating with non-vascularized fibular autograft in cases of resistant humeral diaphyseal nonunion yield reliable bony union and satisfactory functional outcome? HypothesisThe use of non-vascularized fibular autograft in conjunction with locked compression plating will provide stable construct, enhance bony union and improve functional outcome in cases of resistant humeral diaphyseal nonunion. Materials and methodsthirty three patients with resistant humeral diaphyseal nonunion who were surgically managed combining non-vascularized fibular autograft fixed with locked compression plating in the period from January 2011 to June 2017, were retrospectively studied. All patients were followed-up for a minimum of 24 months. The time to union, the postoperative disability of arm, shoulder and hand (DASH) score, in addition to the possible complications including infection or nonunion were reported and analyzed. ResultsTwenty nine patients have achieved union at the final follow-up with a mean time to radiological union of 7.5±2.6 months (range: 3-12). The mean postoperative DASH score was 7.7±8.9 (range: 0-38.8) which was significantly better than the preoperative value (p<0.001) and superior in the patients of aseptic nonunion (p=0.04). Eight patients showed complications in the form of infection (four), nonunion (two cases), transient radial nerve palsy (one case) and one case of septic nonunion that was managed by two stage reconstruction using vascularized fibular autograft. There were comparable results in patients with either open or closed fractures. However, patients with septic nonunion experienced more significant complications (p=0.02). DiscussionThe use of non-vascularized fibula autograft in cases of resistant humeral diaphyseal nonunion provides adequate fracture stability, quadrilateral screw purchase, enhances bony union in addition to promoting satisfactory functional outcome particularly in aseptic nonunion. Level of evidenceIV; retrospective case series.

Bone marrow aspirate: a viable source of stem cells for bone regeneration. A systematic review

This systematic review evaluated the effectiveness of bone marrow aspirate (BMA) to enhance bone repair in humans. Comprehensive survey of ramdomized clinical trials published up to June 2021 and listed in PubMed/MEDLINE, EMBASE, and Cochrane Library databases following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Two reviewers independently searched eligible studies, made a final article selection, and extracted the data of the selected studies to evaluate it qualitatively. Overall, 13 studies were included in the review. Experimental models involved Posttraumatical aseptic nonunions of long bones of the upper limb, alveolar ridges following tooth extraction, atrophic mandibular fracture, benign bone lesions, bilateral tibial lengthening, fracture of intracapsular neck femur, maxillary horizontal ridge augmentation, non-traumatic femoral head necrosis, and sinus maxillary augmentation. The analyses included radiography, tomography, biopsies, and clinical evaluations. Ten studies reported enahanced bone formation (primary outcome) with combined use or not of BMA with other biomaterials and three studies found no benefit resulting from the use of BMA to treat bony defects. Secundary outcomes related to the healing process were also evaluated and positive, such as postoperative complications and pain visual analogue score. Within the limits of the present study, it can be concluded that BMA can improve the early stages of bone healing process.

Autogenous Onlay Graft with Compression Plate for Treatment of Persistent Humeral Shaft Aseptic Non-union with Failed Previous Surgery

BACKGROUND: The humeral shaft fractures have a good rate of union, despite this fact, still there is a significant rate of nonunion after nonoperative treatment and more often after operative treatment. AIM: The aim of the study is to evaluate the autogenous onlay graft with compression plate for treatment of persistent humeral shaft non-union with failed previous surgery both radiological and functional outcome. MATERIALS AND METHODS: A prospective study on twenty patients having persistent aseptic non-union age between 20 and 60 years old, after failed surgical treatment of fractures humeral shaft in Al-Zahra teaching and Al-Kindy teaching hospitals, while infected nonunion, diabetes mellitus, secondary metastasis, smoking, alcoholism, and patients on long medication with corticosteroid were excluded from the study. All our patients were treated with corticocancellous onlay bone grafting harvesting from the ipsilateral upper tibia and compression plating (graft parallel to plate) and follow-up for at least 18 months post-operative to evaluate both radiology and functional using Mayo elbow performance index. RESULTS: All the patients ended with a solid union without hardware failure, and no one patient needs further surgery, even with significant resorption of the graft, there is a good chance of graft re-calcification and solid union with good to excellent functional outcome. CONCLUSION: Very successful solid union results achieve in those patients with established aseptic nonunion and pseudoarthrosis of the humerus.

Evaluation of the Accuracy of the Fluorodeoxyglucose-Positron Emission Tomography ([18F] FDG-PET CT) in the Diagnosis of Chronic Osteomyelitis

Background: Chronic Osteomyelitis is an infection of bone and bone marrow. Diagnosis is based mainly on correlation between history, clinical picture, lab analysis, bacteriological, pathological, and imaging studies. Bone biopsy for culture and sensitivity is the gold standard for the correct identification of the causative organism. The present retrospective study aims to evaluate the accuracy of FDG PET-CT in the diagnosis of COM. Methods: 18 patients who underwent FDG-PET/CT scanning for clinically or radiologically suspected COM of the lower extremity. Patients were 16 males and 2 females.14 patients had septic nonunion, 3 patients with aseptic nonunion, and 1 with chronic diffuse sclerosing OM of Garre. 7 patients had implants at site of examination at the time of scan. Diagnosis of COM was confirmed by surgical deep cultures and pathological analysis following PET/CT scanning. FDG-PET uptake was measured by SUV max, and we compared SUV max at the infected site and at the contralateral side (SUV ratio). Results: the sensitivity, specificity, accuracy, PPV and NPV of PET SUV max were 100%, 66.7%, 94.44%, 93.75% and 100% respectively in diagnosis of COM at a cut-off value of (4.46). The present study included 15 true positive, 2 true negative and 1 false-positive PET/CT results. Conclusion: 18F-FDG PET/CT is a highly sensitive and specific method for the evaluation of chronic osteomyelitis in patients with or without trauma. PET/CT provides anatomical localisation and characterization of the infected area and has a very important role in preoperative planning with a high degree of accuracy.

Revision with Locking Compression Plate by Compression Technique for Diaphyseal Nonunions of the Femur and the Tibia: A Retrospective Study of 54 Cases.

Nonunion after diaphyseal fracture of the femur or the tibia is a common but difficult complication for treatment. Currently, the main treatment modalities include nail dynamization, exchange nailing, and bone transport, but revision with compression plating in these nonunions was rarely reported. To evaluate the outcomes of compression plating in the treatment of femur and tibia shaft nonunions, we retrospectively reviewed 54 patients with diaphyseal nonunion of the tibia or the femur treated with locking compression plate (LCP) by compression technique. There were 46 aseptic and 8 septic nonunions in the case series. Patient's history, fracture characteristics, previous interventions, and types of nonunion were recorded. The possible reason which might lead to nonunion was also analyzed for each case. Patients with aseptic nonunions were revised by hardware removal and compression plating with or without bone grafting. For septic nonunions, a two-stage surgery strategy was used. Compression plating with iliac crest bone grafting (ICBG) or free vascularized fibular grafting (FVFG) was used as the final treatment for septic nonunions. The compression technique and bone grafting method were individualized in each case according to the patient's history and architecture of the nonunion. Each patient finished at least a two-year follow-up, and all cases achieved healing uneventfully. Our study showed that compression plating with LCP was an effective method to treat diaphyseal nonunions of the tibia and the femur. It is compatible with different bone grafting methods for both infected and noninfected nonunions and is a good alternative to the current treatment methods for these nonunions.

Radiological union analysis of femoral shaft aseptic nonunion after failed plate and screw convert to reaming intramedullary solid locking nail

Background: Non-united fracture shaft of the femur after plate fixation is a common problem. Management of this problem is still controversial. There are many methods for treating femoral shaft aseptic nonunions with a broken implant which conversion to reaming solid intramedullary nail is one of the procedures. However, the reported success rate varies. This study aimed to evaluate bone healing, especially callus formation, radiologically after nonunion reconstruction using intramedullary nailing reamingMethod: This study is a cross-sectional retrospective case analysis presenting 22 patients with the patient's age was 15 to 50 years old who underwent operation procedures managed by removing the hardware and converting to reaming solid intramedullary locking nail with or without autogenous iliac bone graft for at least six months. The bone healing process was assessed by serial plain radiography every six weeks using the Callus Index method.Results: Conversion to reaming solid intramedullary nailing after nonunion with broken implant gives union rate 95%. Among 22 patients, one patient persisted in nonunion, and two patients experience delayed union. The Callus index of Fracture location (P=0,043) significantly affected index callus formation (P&lt;0.05); The fracture location, whereas fracture classification (P=0,365), nonunion type (P=0,398), and bone graft (P=0,510) did not significantly affect index callus formation (P&gt;0.05). There was no significant difference in time to the solid union between patients with or without iliac autogenous bone graft. Proximal third nonunion affects the time to solid union. No significant complications were noted.Conclusion: Nonunion reconstruction using solid reaming nail at both types nonunion gives a solid union. Solid union achieves with or without bone graft.

TIBIAL BONE NONUNION PLASTIC WITH THE USE OF MONOLOCAL OSTEOSYNTHESIS BY RING FIXATORS

Abstract. Actuality. Monolocal extrafocal osteosynthesis by ring fixators (RF) of tibial nonunion is not a generally accepted method, there are no systematic guidelines for its implementation. These issues need to be further studied. Task. Formulate situational predominant properties of RF; features of application in different condi-tions. To offer a method of nonunion plastics and features of monolocal osteosynthesis of RF and to study its efficiency. Materials and methods. The data of treatment of 16 patients with aseptic nonunion of tibia, who required complex comprehensive specialized medical care with a possible positive result (scores from 51 to 75 according to the evaluation system Non-Union Scoring System - NUSS). Implementation of monolocal extrafocal osteosynthesis of RF nonunion of shin bones after fractures was performed by us taking into account the features that distinguished it from that by fractures. The principal requirement of surgical intervention was the need to treat the center of nonunion, local stimulation of repara-tive processes. The technical features of all components of the intervention in the future were of great im-portance. The so-called blood-saving tactics were used, which were carried out using squeezing and hemostatic tourniquets, tranexamic acid. The results obtained. The results of treatment of victims with nonunion of the tibia with the use of RF in monolocal mode were as follows. Taking in consideration the severity of the lesion, we consider this result to be good. Given the insufficient number of observations, it is necessary to continue the use of the proposed method of treatment and to investigate its effectiveness. Conclusions. 1. The use of monolocal RF in patients with nonunion of tibia after fractures has the advantage of use in cases with episodes of septic inflammation in the past, extensive scarring of soft tissues, short distal fragment and osteoporosis. 2. The peculiarities of monolocal osteosynthesis of RF were the use of thick Ilizarov needles Ø 2.0 mm with their conduction at an angle of two planes. The obtained results of treatment of victims with nonunion of the tibia with the use of RF in the monolocal mode should be considered encouraging.

Outcomes of Fast-Track Primary Internal Fixation of Open Fractures in Ballistic Injuries – A Single-Center Experience

Background: Open fractures due to ballistic injuries (bullets and/or splinters due to grenade blasts) have increased in the last decade. Outcome of management of such injuries depends on various factors. Purpose of this study was to frame a management protocol for primary internal fixation of such fractures without significant complications. Materials and Methods: 105 patients (117 fractures) of ballistic injuries evacuated to the trauma care center of this hospital from July 2018 to July 2019 were enrolled. After initial evaluation and optimal resuscitation, patients were considered for primary internal fixation of the fractures followed by multidepartmental rehabilitation involving a physiotherapist, a psychiatrist, and a psychotherapist. Follow-up was done at 3 months, 6 months, and 1 year after the surgery. Results: 74 fractures were due to gunshot-related injuries and 43 due to splinters from grenade blasts. Average interval between time of injury and surgery was 5.68 h. Seventeen patients required repeat debridement after initial surgery, and the subsequent wound healing was uneventful. All fractures united except 15 patients who underwent bone grafting for aseptic nonunion (6–9 months after index surgery). Only six patients were followed telephonically, else there was no loss to follow-up. The study did not encounter any mortality or infection. Conclusions: Open fractures occurring due to ballistic injuries pose a unique challenge in management. Fast-track evaluation and urgent management of the fractures by careful wound debridement and primary internal fixation have shown excellent results, with absolute zero infection rate in 1-year follow-up.

Forearm reconstruction by induced-membrane technique after sarcoma resection in children: technique and functional outcome in three cases

Forearm sarcoma is rare in children. Here, we report three cases. One child presented undifferentiated soft-tissue sarcoma involving the ulna, another had Ewing's sarcoma of the ulna, and the third had Ewing's sarcoma of the proximal radius. In the first case, there were episodes of iterative aseptic nonunion, treated surgically. At last follow-up (respectively 11, 9 and 8 years postoperatively), the mean Musculoskeletal Tumor Society (MSTS) score was 80%, 90% and 77% respectively, and all cases were in remission. The induced membrane technique to reconstruct bone defect after sarcoma resection in children is a possible limb-salvage strategy.

Novel Technique for the Treatment of a Tongue-Type Calcaneal Fracture in the Setting of Chronic Osteomyelitis.

Osteomyelitis of the calcaneus combined with a pathologic fracture is a rare and difficult presentation for any practicing foot and ankle surgeon. Treatment for achieving an aseptic nonunion involves a variety of steps, including surgical debridement, antibiotic administration, and fracture stabilization. In this case series, we report a novel technique for the treatment of a tongue-type calcaneal fracture in the setting of chronic osteomyelitis using the Biomet JuggerLoc bone-to-bone system for fixation.

Results of revision intramedullary nailing with and without auxillary plate in aseptic trochanteric and subtrochanteric nonunion

PurposeAim of this study was to investigate whether limited open auxiliary angle stable plate fixation has an effect on functional and radiologic outcomes one year after revision intramedullary nailing in aseptic trochanteric and subtrochanteric fracture nonunion.MethodsIn a retrospective analysis, surgically revised aseptic trochanteric and subtrochanteric nonunion was evaluated in a total of 190 consecutive patients ranging from 18 to 94 years between 12/2005 and 10/2018.ResultsOne year after revision intramedullary nailing, nonunion healing was assessed in 129 out of 136 patients (95%) in group 1 without auxiliary plate fixation and in 51 out of 54 patients (94%) in group 2 with auxiliary plating (p = 0.23). In group 1, range of motion (ROM) was unrestricted in 88 patients and still restricted in 48 patients. In group 2, ROM was free in 34 patients and restricted in 20 patients (p = 0.25). The mean Lower Extremity Functional Scale (LEFS) was 56 points in group 1 and 55 points in group 2 (p = 0.55).ConclusionThis study did not demonstrate significant differences in functional and radiologic outcomes following revision intramedullary nailing of aseptic trochanteric and subtrochanteric fracture nonunion. Limited open auxiliary plate fixation might be a reasonable option especially in cases of relevant varus axis deviation and comminuted or atypical fracture configurations, regardless of patients’ age.Retrospectively registered with the German Clinical Trials Register (01/25/2021; ID: DRKS00024112).