Nonunion Research Articles

Teriparatide as a non-surgical salvage therapy for prolonged humerus fracture nonunion: A case report and literature review

BACKGROUND Fracture nonunion represents a challenging complication during fracture repair, often necessitating surgical intervention. Teriparatide, a recombinant human parathyroid hormone, has demonstrated promise in enhancing fracture healing, although its efficacy in treating established nonunion remains under investigation. CASE SUMMARY We report a case of a 27-year-old male who presented with a right humerus fracture following a traffic accident. Despite undergoing open reduction and internal fixation, the fracture resulted in a delayed union and subsequent nonunion. After 4 years of conservative management, teriparatide treatment was initiated due to persistent nonunion. Teriparatide injections were administered daily for 6 months, resulting in complete fracture healing and resolution of pain. CONCLUSION Our case demonstrates the successful use of teriparatide in treating a prolonged nonunion of a humerus fracture. Teriparatide may provide a valuable therapeutic option for established bone nonunion, even in cases that have not responded to conservative treatments.

Cancellous Grafting Versus Corticocancellous Graft With Volar Locked Plating for Scaphoid Waist Fracture Nonunion: An Evaluation of Early Bony Bridging.

Achieving bony union in scaphoid nonunion fractures is challenging. Various bone grafts have been studied using headless compression screws (HCS) fixation. However, the impact of bone graft choice on bone healing with volar locking plates (VLP) use is less clear. This study evaluates osseous bridging using packed cancellous grafting versus corticocancellous grafting when used during scaphoid waist nonunion repair with volar plating. A retrospective case series was performed of 22 consecutive patients with a scaphoid waist fracture nonunions that were treated with VLP fixation and bone autografts. Inclusion criteria required ≥90-day follow-up clinical examination and postoperative computed tomography (CT) scan. Graft types included corticocancellous or packed cancellous autograft harvested from the radius or iliac crest. Amount of bone healing and presence of residual dorsal intercalated segmental instability were determined by 3 fellowship-trained hand surgeons. Twenty-two patients with scaphoid fracture nonunions that met study inclusion criteria were evaluated. Postoperative CT scan showed osseous bridging in 95% (21/22) of patients. Despite less time between surgery and the final follow-up CT scan (102.7 ± 59 days for packed cancellous autografts vs 133.6 ± 73 days for corticocancellous autografts), the packed cancellous autograft group displayed higher osseous bridging percentages compared with the corticocancellous graft (80.7% ± 17% vs 47.8% ± 35%, P = .013). Nearly all patients displayed osseous bridging on postoperative CT scan with VLP and autograft use. However, study findings suggest that packed cancellous autograft use displayed more robust early healing.

TGFβ-1 and Healing of Bone Defects in Large Animal and Rabbit Models: A Systematic Review.

Long bone and craniofacial bone fractures amount to an overwhelming expenditure for patients and health care systems each year. Overall, 5-10% of all bone fractures result in some form of delayed or nonunion fractures. Nonunions occur from insufficient mechanical stabilization or a compromised wound environment lacking in vasculature and progenitor cells. The current standard for treating these critical-sized fractures and defects is the use of autologous bone grafts. However, advancements in tissue engineering have cultivated a shift in scientific efforts toward harnessing the body's own regenerative resources. As such, research on fracture healing has shifted as well. Transforming growth factor-beta 1 (TGFβ-1) has been studied in fracture healing for over 25 years, though many of these studies have been in vitro or in small animal models. The few studies in large animals have disagreement due to the heterogeneity within the experimental design. Because TGFβ-1 plays such a crucial role in the bone healing process, this systematic review investigates the application of TGFβ-1 in various carrier vehicles for repairing bone injuries in large animal and rabbit models. A systematic search was conducted in PubMed, Embase, and Web of Science (from database construction-October 2024). A total of 244 articles were screened, and 24 studies were included for review. Most large animal long bone studies used coated titanium implants, while most rabbit long bone studies used some form of degradable polymer constructs. TGFβ-1 doses in large animal long bone studies range from 0.005 to 750 µg, doses in large animal calvaria and mandible studies range from 1 to 5000 µg, and doses in rabbit long bone studies range from 0.05 to 120 µg. Nineteen out of 24 articles reviewed indicate successful use of TGFβ-1 for bone regeneration compared with experimental controls. It is clear that dose and controlled release of growth factor play a crucial role in defect closure, but outcome measures and success criteria were inconsistent across studies. More studies with consistent experimental designs are critical for understanding the therapeutic potential of TGFβ-1 in fracture repair, but overall, this review indicates that TGFβ-1 can be used alone or in conjunction with other growth factors to accelerate successful bone repair.

Bilateral femoral neck fractures and fixation failure due to stiff-person syndrome.

We describe a woman with stiff-person syndrome (SPS), whose muscle spasms resulted in sequential bilateral femoral neck fractures. Orthopaedic fixation of the first fracture was complicated by increased muscle spasm, fracture nonunion and ultimately metalwork fracture. SPS was diagnosed following the fracture of the contralateral femoral neck, neurology assessment and detection of high-titre antibodies to glutamic acid decarboxylase. Multidisciplinary management with high-dose benzodiazepines, intravenous immunoglobulin infusions, and bilateral total hip replacements achieved a good functional outcome. Spasms associated with SPS are a rare cause of pathological fractures and may cause orthopaedic fixation to fail. Early recognition and multidisciplinary care are essential to prevent additional morbidity.

Postoperative outcome of screw fixation with autogenous bone grafting for the management of hallux sesamoid fracture nonunion

Postoperative outcome of screw fixation with autogenous bone grafting for the management of hallux sesamoid fracture nonunion

Demographic Patterns and Surgical Trends in Radius and Ulnar Fracture Nonunion: A TriNetX Database Review 2017-2022

Objectives Understanding the population and demographic factors in the face of a rapidly changing demographic in the United States is critical to ensuring high-quality patient care and effectively guiding operative management of fracture nonunion. This study explores the underlying demographic factors of radius and ulna shaft fractures nonunion and subsequent operative management. Methods International Classification of Disease-10 (ICD-10) diagnostic codes were used to query the TriNetX database for all patients who suffered radius or ulna shaft fractures from 2017 to 2022. Current Procedure Terminology (CPT) codes for surgical intervention of radius or ulna shaft fracture nonunion were used to stratify patients into surgical or nonsurgical cohorts. Results The overall number of radius shaft fractures have fractured from 4,399 in 2017 to 4,878 in 2022, while overall rates of radius shaft fracture nonunion have slightly decreased from 0.68% to 0.64% during this period. The number of ulna shaft fractures increased from 7,728 in 2017 to 8,244 in 2022, with an overall nonunion rate of 0.08%. The incidence rate of nonunion was higher in females with radius (0.80%) and ulna shaft fracture (0.10%) than in males with radius (0.73%) or ulna shaft fracture (0.08%). The highest rates of nonunion amongst age groups were in the 40-64 age group for radius (2.2%) and ulna (0.27%) shaft fracture, with the lowest in the 0-17 age group among patients with radius shaft fracture (0.33%). The highest overall number of radius shaft fractures from 2017 to 2022 was among white patients. Still, the highest rates of fracture nonunion were seen among Black (1.7%) and Asian (3.1%) patients with radius fractures than white patients (0.77%). Overall rates of nonunion surgery were 54% in radius shaft fracture patients and 28% in ulna shaft fracture patients. Patients who smoked had higher rates of nonunion (4.0%) than those who did not smoke (0.61%) among all patients with radius shaft fractures, but both groups had similar rates of nonunion surgical management. Among radius shaft fracture patients, rates of nonunion surgical management have increased from 50% in 2017 to 71% in 2022. Conclusion Demographic disparities were noted regarding radius and ulna shaft fracture nonunion and their subsequent management, which could challenge ensuring equitable care for all and provide an opportunity to explore ways to improve patient care regardless of demographic background.

Arthrodesis in the treatment of ankle osteoarthritis due to neglected malleolar fractures in the elderly.

Neglected malleolus fracture cases, among other conditions in which arthrodesis is inevitable, usually present with pseudoarthrosis of the malleolus and impaired ligament balancing. The study aimed to summarize the clinical data results of neglected malleolus fractures accompanied by ankle instability. The retrospective study was conducted at Adana City Training and Research Hospital. The files of the patients diagnosed with nonunion malleolus fractures admitted between January 1, 2018, and July 30, 2023, were analyzed. In addition to the demographics, the type of malleolus fracture, the technique used in arthrodesis surgery, use of graft, union status, presence of early and late complications, visual analog scale (VAS), and Maryland Foot Score (MFS) scores at preoperative, 3-, 6-, and 12-month postoperative visits were recorded. There was a total of 11 files available for analysis. The mean age of the cases was 70.55 ± 5.03, ranging between 65 and 82. The records showed that the patients ignored the need for surgical treatment for an average of 10.64 ± 3.5 months. In terms of the technique, 4 were treated using the Ilizarov only, 3 with the intramedullary nails, 3 with plates and screws, and the remaining Ilizarov and plate. The average duration of the union was 6.27 ± 2.99 months. The mean VAS scores for preoperative, postoperative 3rd, postoperative 6th, and postoperative 12th months were 7.55 ± 0.78, 5.55 ± 2.31, 3.45 ± 2.27, and 2.45 ± 1.44, respectively. The mean Maryland Foot Scores (MFS) for preoperative, postoperative 3rd, postoperative 6th, and postoperative 12th months were 21.82 ± 6.85, 51.27 ± 15.39, 61.18 ± 20.21, and 70.82 ± 5.27, respectively. This study has shown that no matter how difficult the case, if the appropriate implant and basic arthrodesis principles are followed, the union can be achieved, albeit late, in cases with osteoarthritis due to neglected ankle malleolus fracture. Especially in the presence of infection, it should be kept in mind that union may be delayed compared to the regular arthrodesis recovery duration, requiring the team performing the surgery to be familiar with the Ilizarov technique.

Treatment of High-Grade Chronic Osteomyelitis and Nonunions with PerOssal®: A Retrospective Analysis of Clinical Efficacy and Patient Perspectives.

Background/Objectives: Traditional autologous bone grafts as a treatment for bone defects have drawbacks like donor-site morbidity and limited supply. PerOssal®, a ceramic bone substitute, may overcome those drawbacks and could offer additional benefits like prolonged, local antibiotic release. This study investigates the clinical and radiological outcomes, including patient-reported outcomes, of using PerOssal® in nonunions (NU) and high-grade chronic osteomyelitis (COM). Methods: A single-center, retrospective study, investigating patients treated with PerOssal® between January 2020 and December 2023. Collected data include patient characteristics as well as various surgical and outcome parameters including the Lower Extremity Functional Scale (LEFS). Results: A total of 82 patients were analyzed. Reinfection occurred in 19.5% of cases. Osseous integration of PerOssal® was achieved in 89% of cases, higher in cavitary defects (91.5%) than segmental defects (72.7%). The revision rate was 32.9%, mainly due to wound healing disorders and reinfections. Mean LEFS score was 53.4 which was heavily influenced by sex (male: 50.7 vs. female: 63.4), revision surgery (no: 55.7 vs. yes: 49.1), reinfection (no: 56.6 vs. yes: 39.4), and osseous integration of PerOssal® (yes: 55.8 vs. no: 38.4). Conclusions: PerOssal® demonstrates promising outcomes in treating NUs and high-grade COM, especially in cavitary defects, with high osseous integration rates and acceptable functional results. However, reinfection remains a concern, particularly with difficult-to-treat pathogens and extensive surgical histories. Early, comprehensive surgical intervention and tailored antibiotic strategies are essential. Patient selection, defect characteristics, and comorbidities significantly influence success. Further research is needed to optimize treatment protocols.

Maintaining a Cement Spacer for the Treatment of Bony Voids in Complicated Fracture Nonunions

Background Fracture nonunion is a rare but devastating outcome that can result in significantly increased morbidity and a lengthy recovery for the patient. In the cases of septic nonunion, treatment options include IV antibiotics and debridement of all nonviable bone. While this approach is often successful at clearing infection, it can result in a substantial bony void. To combat these defects, many surgeons have implemented multi-stage procedures such as the Masquelet technique (MT). MT is a well-studied concept that consists of debridement and the placement of an antibiotic cement spacer. After the infection has cleared, the second procedure removes the spacer and fills the void with bone graft. While successful, this multi-stage procedure can be associated with significant patient burden, a long, non-weight-bearing period, and an overall lengthy recovery. This case series highlights a variation of the standard MT technique, utilizing concepts of cement augmentation for fracture treatment while reducing the need for the second stage of the procedure. Case Series In this retrospective series, four consecutive patients with complicated fracture nonunions were subjected to a first-stage MT procedure with placement of an antibiotic polymethylmethacrylate cement spacer and definitive hardware placement. These nonunions included two distal femur fractures, a spiral humeral shaft fracture and a clavicle fracture. These four patients demonstrated good bone healing and quickly returned to their baseline activity levels. In each case, elective permanent retention of the cement spacer was discussed, and exchange for bone graft was only performed on an as-needed basis. All patients went on to develop bridging bone around the spacer with full healing of the adjacent cortices. Conclusions Maintaining the cement spacer allowed these patients to regain function quickly and return to their daily living activities while eliminating the risks associated with a second procedure.

Optimizing management strategies for malunion and nonunion of Hoffa fractures: a detailed case series with a proposed treatment algorithm.

This study aims to refine management strategies for malunion and nonunion of Hoffa fractures, as these rare complications present significant clinical challenges. We conducted a case series involving seven patients with Hoffa fracture complications, including four cases of malunion and three cases of nonunion. Each patient underwent individualized surgical treatment, depending on the nature of their complication. Treatment strategies varied from intra-articular osteotomies for malunions to revision surgery or total knee arthroplasty for nonunions. Postoperative outcomes were monitored, with follow-up ranging from 1 to 15years (mean follow-up time was 6.7years). In all malunion cases, intra-articular osteotomies restored the articular surface, leading to improved function and bone healing. In nonunion cases, two patients with non-reconstructible nonunions underwent total knee arthroplasty, while one patient achieved union with surgical revision. Overall, six out of seven patients showed significant functional improvements post-surgery, although some experienced mild residual pain or deformities. The management of malunion and nonunion in Hoffa fractures remains challenging, but the individualized strategy based on fracture type and patient-specific factors leads to favourable outcomes. The proposed treatment algorithm provides a useful framework for orthopaedic trauma surgeons in addressing these complications, with emphasis on stable fixation, early intervention, and personalized surgical planning.

Timing of Surgery for Elbow Fractures (OTA 13 A-C and 21 A-C) and Patient Outcomes.

To determine if there is a correlation between time to surgery (TTS) and outcomes following repair of elbow fractures. Design: Retrospective comparative study. A single, urban hospital system. Patients from March 2011 to September 2022 who sustained an isolated fracture about the elbow joint (AO/OTA 13-A, B, and C and 21-A, B, and C), underwent surgical repair, and had at least 6 months of post-operative follow up identified from an Institutional Review Board-approved database. Time to surgery, in days, was recorded. Radiographic and clinical follow up was obtained at all visits and a Mayo Elbow Performance Index (MEPI) was calculated based on the latest follow up. Complications recorded: elbow contracture, infection, early hardware failure, reoperation, and fracture nonunion. Multivariable regression and Spearman correlation analysis were used to determine any significant outcome differences based on time to surgery. 351 patients included with a mean age of 54.8 (range: 18 - 86) years with 217 females (61.8%) and 134 males (38.2%). Eighty-two patients (23.4%) developed at least one complication while 269 patients (76.6%) did not. As a continuous variable, TTS was not correlated with arc of motion at any follow up visit nor with the latest recorded MEPI score (p > 0.05). Mean TTS for patients who did and did not experience a complication was 6 (range: 0-24) and 10 (range: 0-38) days, respectively, and this was not significantly different (p = 0.217). Complication rate and any of the individual complications were not associated with TTS following a multivariable analysis controlling for age, sex, injury mechanism, open fracture, Charlson Comorbidity Index, and AO/OTA classification (p > 0.05 for all). Timing of surgery following OTA 13 A-C and 21 A-C elbow fractures was not associated with differences in post-operative complications or range of elbow motion. Level III.

Research Progress on the Application of Nanomaterials in Bone Defect Repair

Bone defects refer to the loss or damage of bone tissue, commonly occurring due to trauma, tumor resection, infection, and non-union fractures. Clinically, bone defects not only affect the patient's function and quality of life but may also lead to chronic pain, mobility impairment, and psychological issues. Repairing large bone defects remains challenging, and traditional treatment methods such as autologous and allogeneic bone grafting face difficulties related to donor site morbidity, postoperative complications, and poor bone healing. Therefore, the development of novel bone repair materials has become a research focus. Nanomaterials, due to their unique physicochemical properties, such as high specific surface area, excellent biocompatibility, and tunable mechanical properties, are increasingly being applied in the field of bone repair. Nanoparticles can enhance the mechanical properties of matrix materials, improving the strength and toughness of bone repair constructs and promoting the proliferation and differentiation of bone cells. Furthermore, nanomaterials can facilitate bone regeneration by releasing bioactive factors or modulating the microenvironment. Consequently, the application of nanomaterials in bone repair holds significant promise. This review aims to summarize the recent research on the application of nanomaterials in the field of bone defect repair.

Is Artificial Intelligence the Future of Radiology? Accuracy of ChatGPT in Radiologic Diagnosis of Upper Extremity Bony Pathology.

Artificial intelligence (AI) is a promising tool to aid in diagnostic accuracy and patient communication. Prior literature has shown that ChatGPT answers medical questions and can accurately diagnose surgical conditions. The purpose of this study was to determine the accuracy of ChatGPT 4.0 in evaluating radiologic imaging of common orthopedic upper extremity bony pathologies, including identifying the imaging modality and diagnostic accuracy. Diagnostic imaging was sourced from an open-source radiology database for 6 common upper extremity bony pathologies: distal radius fracture (DRF), metacarpal fracture (MFX), carpometacarpal osteoarthritis (CMC), humerus fracture (HFX), scaphoid fracture (SFX), and scaphoid nonunion (SN). X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) modalities were included. Fifty images were randomly selected from each pathology where possible. Images were uploaded to ChatGPT 4.0 and queried for imaging modality, laterality, and diagnosis. Each image query was completed in a new ChatGPT search tab. Multinomial linear regression was used to identify variations in ChatGPT's diagnostic accuracy across imaging modalities and medical conditions. Overall, ChatGPT provided a diagnosis for 52% of images, with accuracy ranging from 0% to 55%. Diagnostic accuracy was significantly lower for SFX and MFX relative to HFX. ChatGPT was significantly less likely to provide a diagnosis for MRI relative to CT. Diagnostic accuracy ranged from 0% to 40% with regard to imaging modality (x-ray, CT, MRI) though this difference was not statistically significant. ChatGPT's accuracy varied significantly between conditions and imaging modalities, though its iterative learning capabilities suggest potential for future diagnostic utility within hand surgery.

A Novel Homozygous Synonymous Variant in CCDC134 as a Cause of Osteogenesis Imperfecta Type XXII.

Osteogenesis imperfecta (OI) is a heterogeneous group of rare, inherited connective tissue disorders. It includes over 20 defined subtypes, each of which is associated with distinct causative genes that are listed in the Online Mendelian Inheritance in Man (OMIM) database. Type XXII OI (OI 22) is caused by a homozygous variant in the coiled-coil domain containing 134 (CCDC134) gene, which is located on chromosome 22q13. OI, which is associated with CCDC134, is extremely rare with only five cases reported worldwide. All known cases involve the c.2 T > C (p. Met1Thr) homozygous missense variant in the CCDC134 gene. We present the case of a 13-year-old Chinese girl with non-union fracture, short stature and specific radiographic findings, which include scoliosis, pelvic tilt, thin clavicles, ribs, and limbs. Whole exome sequencing revealed a novel, homozygous c.492G > C (p. Leu164=) variation in the CCDC134 gene. RNA sequencing (RNA-seq) analysis identified this variant as an abnormal splicing variant that causes the deletion of Exon 5, which result in the observed disease phenotype. This case demonstrates the clinical phenotype of OI 22 associated with the c.492G > C (p. Leu164=) novel synonymous variation in the coding region of the CCDC134 gene in a female patient. This is the first reported case of OI 22 in the Chinese population, the sixth reported worldwide and the fourth reported genotype for diseases associated with a CCDC134 variant. It also enriches the global clinical phenotype spectrum of OI 22 patients.

γ-Fe2O3/Polydopamine/TiO2 nano-porous array composite coating (FPTCC) to modulate antibacterial, osteogenesis, and osseointegration through photothermal-magnetic response

Delayed-union or non-union of fractures due to infection and localized low osteogenic activity is a great physical, psychological and financial burden for patients. Therefore, there is an urgent need to find an economical and effective solution. In this study, a γ-Fe2O3/polydopamine/TiO2 nano-porous arrays composite coating (FPTCC) with photothermal-magnetic responsiveness was fabricated. The characterization of FPTCC was analyzed by FT-IR, SEM, and EDS. The photothermal ability, photothermal stability and magnetic hysteresis curves were examined to evaluate photothermal-magnetic response properties of FPTCC. The results demonstrated that FPTCC has outstanding hydrophilicity, strong substrate bonding and stable remotely controlled photothermal-magnetic response properties. Furthermore, in vitro and in vivo biological experiments were performed to verify the capability of FPTCC to modulate antibacterial, osteogenesis and osseointegration under the intervention of NIR irradiation and static magnetic field. In conclusion, the FPTCC with biocompatibility, antibacterial, and osteogenic capabilities may provide a potential strategy for the prevention and treatment of delayed-union or non-union of fracture.

Construction and validation of a nomogram prediction model for internal fixation failure after proximal femoral anti-rotation intramedullary nailing in the treatment of intertrochanteric fractures of the femur.

The aim was to study the independent risk factors of internal fixation failure in proximal femoral anti-rotation intramedullary nailing for intertrochanteric femur fracture, and to build a nomogram prediction model accordingly. Clinical data of patients with intertrochanteric femoral rotor fractures admitted to the First People's Hospital of Longquanyi District from January 2018 to January 2023 were retrospectively collected. The occurrence of spiral blade cut out, internal fixation breakage, peri-internal fixation fracture, hip internal rotation deformity, and fracture nonunion within 1 year after surgery were included in the internal fixation failure group, and the rest were included in the internal fixation success group. Univariate and multivariate logistic regression analyses were used to determine the independent risk factors for postoperative internal fixation failure, and the corresponding nomogram was established. Subject operating characteristic curves and calibration curves were plotted to assess model performance, and to further improve the reliability of the validation results, internal validation was performed using Bootstrap combined with 10-fold cross-validation rows to assess the clinical utility of the model using decision curve analysis. Ultimately, 374 patients with intertrochanteric fractures were included in the study, and 57 patients were included in the internal fixation failure group, with an internal fixation failure rate of 15.24%. After univariate and multivariate logistic regression analyses, a total of 5 factors were identified as independent risk factors for internal fixation failure after intertrochanteric femur fracture surgery: unstable fracture, comorbid underlying disease, severe osteoporosis, a cusp distance of >30 mm, and poor quality of fracture reduction. Postoperative internal fixation failure of intertrochanteric fractures of femur is affected by multiple factors, and clinically orthopedic surgeons should formulate reasonable and effective solutions for high-risk patients in order to protect the surgical effect and improve the success rate of surgery.

Double plating and iliac crest bone graft can safely fix femoral shaft nonunion

Introduction Femoral shaft nonunion can be extremely vexing and result in significant morbidity. We aimed to evaluate the outcomes of patients with nonunion of the femoral shaft fracture undergoing double plating and bone grafts from the iliac crest and femoral canal. Methods This retrospective study included 44 patients with femoral shaft nonunion between March 2020 to March 2022. Patients underwent dual plating, bone grafting from the iliac crest, and the utilization of the femoral canal. Age, sex, body mass index (BMI), the two surgical interventions interval, union time after the second surgery, hip range of motion (ROM), limb length discrepancy (LLD), infections, and deep vein thrombosis (DVT) were evaluated. Results Patients comprised 21 males (47.7%) and 23 females (52.3%), with a mean age of 42.3 ± 15.2 years. The mean BMI was 26.7 ± 3.77 kg/m2. The mean duration between the two surgical interventions for the patients was 17.07 ± 6.6 months. The patients were followed for ≥ 12 months. All patients achieved successful union and fracture healing, with an average time of 5 months. The mean hip flexion and extension were 112.84 ± 7.7˚ and 14.8 ± 5.2˚ degrees, respectively. Thirteen patients showed LLD after the first surgery, with a mean LLD of 7.15 ± 5.04 millimeters. LLDs were successfully rectified in all patients following the surgical intervention. No patients experienced postoperative infections or DVT. Conclusion According to our findings, the utilization of double-plate fixation in combination with iliac crest and femoral canal bone graft has proven to be a secure, productive, and straightforward surgical alternative for the management of femoral nonunion.

Management of aseptic nonunions of bicondylar tibial plateau fractures.

Nonunion of bicondylar tibial plateau (BTP) fractures following open reduction internal fixation (ORIF) is rare but challenging. We report a case series of aseptic BTP nonunions, approaches to treatment, and long-term outcomes. Retrospective case series of aseptic nonunion in operatively treated BTP fractures. Cases with deep infection prior to a revision were excluded. Demographic, injury, and initial fixation characteristics were collected. Clinical course following diagnosis of nonunion was reviewed. Revision operation characteristics, timing, and outcomes were recorded. 13 patients with aseptic nonunion were identified from 508 BTP fractures. Mean (SD) follow-up was 5.2years (4.6) from the first revision operation for nonunion. Nine patients underwent revision ORIF, which led to union in 6/9 cases. Two patients had total knee arthroplasty (TKA) performed as the initial revision operation for nonunion. One patient was treated with bone grafting without revision of implants and one patient was lost to follow-up after diagnosis of nonunion. Three patients subsequently had TKA performed following failed revision ORIF. In total 5/13 patients underwent TKA. Revision ORIF of aseptic nonunion of a BTP fracture often leads to successful union. However, TKA may be utilized in select cases and at a higher rate than in primary tibial plateau fractures.

Comparison of Single-Stage and Dual-Stage Approaches for Nonunion Repair in the Absence of Evident Infections.

This study aimed to determine if routine dual-stage nonunion repair (DSR) surgery lead to better outcomes than single-stage nonunion (SSR) repair surgery in fracture nonunions without evident clinical or laboratory signs of infection. Design: Retrospective comparison study. Level One Trauma Center affiliated with an academic teaching hospital. Skeletally mature patients diagnosed with fracture nonunion between June 2013 and January 2022 were included. Patients with previous non-operative treatment, definitive external fixation, previous or current diagnosis of FRI, or less than 12 months of follow-up were excluded. Patient characteristics and details of the primary and the revision surgery were recorded. Comparison of the primary outcome measures - FRI, recalcitrant nonunion, and implant failures were performed between SSR and DSR groups. A total of 113 patients met the eligibility criteria. Eighty-six patients (mean age 44.8 years, range - 17 - 80 years, 64 percent males) underwent SSR, while 27 patients (mean age 50.8 years, range 21-77 years, 52 percent males) underwent DSR. Seventy six percent underwent SSR and 24 percent underwent DSR. Baseline characteristics were similar between groups (open fractures, p=0.918; smoking, p=0.86; lower limb fractures, p=0.238; Diabetes, p=0.503; ESR, p=0.27; CRP, p=0.11; age, p=0.11; CCI, p=0.06) except for a higher rate of DSR in cases initially treated elsewhere (p = 0.015) and in obese patients (p=0.044). Bone grafting was more frequent in DSR using plates (p = 0.030). No significant differences were observed in subsequent infections (6.97 % vs 7.41 %, p=0.939), persistent nonunion (28.2 % vs 14.81 %, p=0.169), or implant failure (19.76 % vs 22.22 %, p=0.782) between SSR and DSR. No difference was found in infection, recalcitrant nonunion, and implant failure between single stage repair and dual stage repair for nonunions without overt signs of infection. The study challenges the routine use of DSR, questions the necessity of subjecting patients to two surgical procedures, and advocates for a more judicious approach in the absence of overt FRI in a fracture nonunion. Level III.

Pediatric Scaphoid Nonunions: Does Insurance Status Play a Role?

There are no studies that evaluate the effects that insurance or socioeconomic status may have on treatment and outcomes of scaphoid nonunions in children. We evaluated whether there is an association between insurance status and (1) time from injury to hand surgeon evaluation, (2) time from specialist evaluation to surgery, and (3) postoperative outcomes of scaphoid fracture nonunions in children. A chart review was performed for patients who underwent surgical treatment of scaphoid fracture nonunion from January 2015 and April 2021 at a large tertiary care pediatric hospital. Underinsured patients were defined as those with no medical insurance or Medicaid/state-funded insurance. There were 21 privately insured patients and 17 patients who were underinsured. There was no difference in age, race, or fracture characteristics between the two groups. The mean time between injury and hand surgeon evaluation was 192 SD 195 days for the privately insured group compared with 155 SD 205 days for the underinsured group (P = 0.57). The mean time between specialist evaluation and surgical treatment was 35 SD 54 days for the privately insured group and 31 SD 31 days for the underinsured group (P = 0.82). Union was achieved in 80% of patients with private insurance compared with 88% of underinsured patients after primary surgery (P = 0.67). There was no difference detected in the proportion of patients who had residual pain (15% vs 19%), range of motion deficits (38% vs 40%), strength deficit (6% vs 7%), and return to activity (94% vs 93%) between privately insured and underinsured patients, respectively (P = 1.00). There was no difference in time from injury to specialist evaluation, time from evaluation to surgery, or postoperative outcomes based on insurance status for pediatric patients with scaphoid fracture nonunions. Although insurance status was not associated with access to care for pediatric scaphoid fracture nonunions at our institution, this information may not be generalizable to other populations, including patients who sustain primary scaphoid fractures and who have not yet developed nonunions. Level III-retrospective cohort study.