Management Of Nonunion Research Articles

Round table discussion. The management of proximal scaphoid nonunion.

The management of scaphoid nonunion, although relatively common, continues to pose challenges, especially if complicated by avascular necrosis of the proximal pole, humpback or dorsal intercalated segment instability deformities, and early scaphoid nonunion advanced collapse. In this round table article, four surgeons were asked to answer key questions on a clinical example of a proximal scaphoid nonunion to outline their approach and rationale in their preferred treatment choices. The current panel of experts leans towards arthroscopic methods of treatment and most agree that arthroscopic bone grafting has become an important and revolutionary treatment option, which has yielded excellent results. However, both open and arthroscopic grafting are validated methods of treatment and which is to be performed is largely based on the surgeon's preference.

Update on Management of Scaphoid Fractures.

After studying this article, the participant should be able to: 1. Accurately diagnose scaphoid fractures through examination and appropriate imaging selection. 2. Recognize those fractures that can be treated with nonoperative management. 3. Outline the different surgical approaches for scaphoid fractures. 4. Appreciate the surgical options for management of scaphoid nonunion. This article includes the most up-to-date information on the diagnosis, work-up, and treatment of scaphoid fractures.

Marginal bone resection and immediate internal fixation in multidrug resistant chronic septic nonunions of lower limb long bones: a case series.

This study aimed to evaluate the efficacy of a combined treatment approach integrating extensive debridement, immediate internal fixation, and the Masquelet technique for the management of infected nonunion of long bones in the lower limbs caused by multidrug-resistant (MDR) and extensively drug-resistant (XDR) bacteria. This retrospective case series was conducted at the Imam Khomeini Hospital Complex, Tehran, Iran, a tertiary-level academic referral centre. The study documented consecutive cases of patients presenting with infected nonunion of the tibia or femur, with a positive culture for MDR or XDR bacteria, treated between January 2019 and December 2022. Inclusion criteria were adults with a confirmed diagnosis of infected nonunion due to MDR or XDR bacteria, with exclusion criteria including patients with unrelated infections or allergies to the components of the treatment regimen. The primary outcomes measured were infection resolution and bone healing. The study cohort comprised 16 patients, predominantly male (87.5%) with an average age of 38.5 years. Methicillin-resistant Staphylococcus aureus (MRSA) was identified as the causative agent in 31.25% of the infections. Patients were followed for a period ranging from 12 to 26 months. The treatment protocol was uniformly applied across all cases. Successful bone union was observed in the majority of patients within 140 to 240 days following grafting. However, there were two instances where amputation was necessitated due to the failure to eradicate the infection. Complications arose in three cases during the follow-up period: two required re-debridement due to a recurrence of the infection, and one was subjected to bone transport owing to persistent nonunion. Notably, all cases that either failed or encountered complications were smokers. In this integrated approach, high rates of infection resolution and bone healing were achieved, suggesting this method as a viable option for these complex cases.

Management of chronic septic nonunion of the femur associated with an extended drug resistant nosocomial germ: a case report

Introduction and Importance: Septic nonunion of long bones poses significant treatment challenges, often necessitating extended hospital stays and multiple surgical interventions. This report details a chronic septic nonunion of the femur, complicated by drug-resistant pathogens, managed through an integrated surgical approach. Case Presentation: A 32-year-old male with a history of infected nonunion and multiple failed surgeries presented with a vast bone defect and osteomyelitis. Treatment involved single-session debridement, bone resection, intramedullary fixation, and trifocal segment bone transport using the Limb Reconstruction System (LRS) and Masquelet technique. After eight months, the patient achieved radiologic and clinical bone healing, regained full ambulation, and resumed work without re-infection over an 18-months follow-up. Clinical Discussion: The management of septic nonunion, particularly with drug-resistant infections, requires a multifaceted approach. This case exemplifies the efficacy of combining radical bone resection, targeted debridement, and advanced reconstructive techniques. The use of antibiotic-impregnated cement beads and bone transport procedures played pivotal roles in the successful outcome. While such procedures can be complex and necessitate vigilant monitoring, they are crucial for improving treatment success and functional recovery. Conclusion: Septic nonunion caused by extended drug-resistant germs of the lower extremity long bones can be managed in a single-session bone resection and debridement, local antibiotic administration, and later bone defect reconstruction.

Free Vascularized Scapula tip Flap to L5—S1 Vertebral Defect After Chronic Infection Related to Interbody Fusion Cage: A Case Report

ABSTRACTSeptic nonunion after vertebral fusion can lead to significant patient disability. The management of septic nonunions usually involves surgical debridement, bone fixation, and antibiotic therapy. Particularly challenging is lumbosacral vertebral nonunions, which necessitate a difficult surgical approach. We present a novel approach using a scapula tip free flap through an intra‐abdominal approach to reconstruct a L5–S1 vertebral defect after a septic nonunion. Our patient, 31‐year‐old man, with no medical conditions, had a fusion of L5–S1 due to severe lower back pain secondary to isthmic spondylolysis and spondylolisthesis. Despite multiple attempts of surgical fusion, postoperatively the patient developed a septic nonunion. Following a modified DAIR, the nonunion was reconstructed with a scapula tip bone flap 4 × 3 × 2 cm. The subscapular vessels were anastomosed to the deep inferior epigastric vessels after an intra‐abdominal inset. The patient was discharged at 15 days postoperatively without any complications. At 1‐year follow‐up the patient is pain‐free, off opiate analgesia with radiological evidence of fusion between the scapula tip, L5 and the S1 vertebral body. This case report describes the use, for the first time, of a free scapula tip, to a lumbosacral spinal defect. The use of the free scapula tip flap may be considered for reconstruction of osseous spinal defects due to its long pedicle and the unique bone shape.

Assessment, Diagnosis and Management Strategies for Forearm Shaft Non-union: A Contemporary Perspective.

Forearm non-union poses a challenge in orthopaedic surgery due to its intricate anatomy and functional significance. This review provides a comprehensive overview of the assessment, diagnosis and management of forearm non-union. Initial evaluation involves a meticulous history, physical examination and imaging studies to identify factors contributing to non-union, including infection. Surgical approaches are discussed, with emphasis on restoring biomechanical stability and promoting bone healing. Treatment options range from autografts to allografts, with considerations for vascularised bone transfers in complex cases. Decision-making strategies are outlined, considering patient-specific factors and individualised treatment plans. Special considerations for specific types of forearm non-unions are addressed, along with postoperative care protocols to optimise healing and functional outcomes. Overall, this review aims to provide clinicians with a comprehensive understanding of forearm non-union management based on current evidence and clinical practice. Level of Evidence: Level V (Therapeutic).

Endocrine Abnormalities and Optimization in Patients with a Fracture Nonunion

Significant advancements have been made in the management and understanding of fracture nonunions. Recently, there has been an interest in identifying modifiable risk factors in patients with nonunions. Endocrine and metabolic abnormalities have been studied for their association with the development of nonunion. Identifying these abnormalities and correcting them requires a multidisciplinary approach involving the orthopaedic surgeon, primary care provider, and endocrinologist. This article discusses the various endocrine abnormalities and their association with fracture nonunion, and highlights studies that have focused on methods of endocrine optimization of patients with a nonunion.

Treatment of infected humeral shaft nonunion and presumed aseptic nonunion with positive intraoperative cultures: a retrospective single-center study.

The management of infected humeral shaft nonunion (HSN) remains challenging due to the lack of consensus and the potential for occult infection. The aim of this study was to evaluate a surgical strategy based on a two-stage treatment for suspected infection or a one-stage treatment for infection diagnosed retrospectively based on systematic bacteriological sampling. We retrospectively reviewed 16 patients with a median age of 36 years who were treated for septic HSN: 9 patients underwent a two-stage procedure using the induced membrane technique, and 7 patients were treated in a single stage. Revision parameters included achieving bone union, its time frame, and a functional assessment based on joint motion and the Quick-DASH score. At a median follow-up of 47.5 months, 12 out of 16 patients were cured with acquired bone union and no septic recurrence. The median time to bone union was 5.5 months. Smoking and previous surgeries were adverse factors for bone healing. Radiological and functional outcomes were comparable between patients treated in a single stage and those treated in two stages. This study confirms the relevance of one-stage surgery for HSN with occult infection and the value of systematic bacteriological sampling during the revision of humeral diaphyseal osteosynthesis.

Treatment of Diaphyseal Tibial Non-unions After Open Fracture: A Retrospective Observational Study on Characteristics and Outcomes

Abstract Purpose Non-union is a significant complication following open diaphyseal tibia fractures. Management can be complex and unpredictable. Several principles must be addressed often in combination to achieve union. The aim of this study is to report on the characteristics, management and eventual outcome of non-united open tibial fractures over a 12-year period from a level I trauma centre. Methods This is a retrospective observational study of all adults (age 18 years and older) presenting to a level 1 trauma centre with a diaphyseal tibia fracture. Non-union was diagnosed using the standard FDA definition of incomplete union by 9 months or no progress to union in the preceding 3 months. Injury and patient demographics in addition to all interventions and complications were recorded for each patient. Results Forty three cases of diaphyseal non-union were identified from 2008 to 2019. Only the presence of peripheral vascular disease demonstrated a statistically significant association with the development of non-union. In 44% of cases, more than one additional operation was required to achieve union. Successful union was achieved in 90% of cases with 74% of patients returning to full pre-injury function without complication. Conclusion Management of non-union is a complex problem which requires a multifaceted and bespoke approach. We have included an algorithm to help guide decision making based on our institutional experience. A satisfactory result is achievable in the majority of patients.

Graft choice for managing scaphoid non-union: umbrella review

IntroductionSince the introduction of the non-vascularized bone graft by Matti and Russe, followed by vascularized grafts and more recently by free vascularized bone grafts, the choice of technique in scaphoid non-union has been controversial. The purpose of the present study was to address the following questions in an umbrella review: Do union rates differ between techniques? Is there any evidence that one technique is superior to another? MethodsAn umbrella review conducted during September 2023 month included systematic reviews and meta-analyses. The primary criterion was mean union rate according to technique. The secondary criterion was indication according to type of non-union. The PubMed, Cochrane, and MEDLINE databases were searched using a predefined methodology according to the criteria of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA version 2020). The quality of the systematic reviews included was evaluated by the “Assessing the Methodological Quality of Systematic Reviews” instrument (AMSTAR 2). ResultsNine studies (systematic reviews or meta-analyses) were included. Quality ranged between low and high. A Table was constructed to summarize the qualitative findings of each article. There was no significant difference in union rates between vascularized and non-vascularized bone grafts in 8 of the 9 studies: vascularized bone graft, 84–92%; non-vascularized bone graft, 80–88%. One study found higher union rates with vascularized bone graft (RR 1.1; 95% CI 1.0–1.2; P = 0.02), but no significant difference in functional results. However, vascularized bone graft was more effective in case of avascular necrosis of the proximal pole (74–88% union for vascularized bone graft vs. 47–62% for non-vascularized bone graft) and in revision cases, while non-vascularized bone graft showed fewer failures in case of humpback deformity and/or dorsal intercalated segment instability (IRR 0.7 ± 0.09; P = 0.01). ConclusionsThis umbrella review provides an overview for management of scaphoid non-union. There were no significant global differences between techniques. Thus, various factors need to be considered when selecting the appropriate technique.

A REVIEW OF ANIMAL MODELS FOR BONE FRACTURE NONUNION AND THEIR ROLE IN STUDYING BIOLOGICAL THERAPY EFFICACY

The bone healing impairment, such as non-union fractures after injuries of long bones, lead to loss of working capacity and result in significant financial costs, which emphasizes the socioeconomic significance of the problem. However, it is not known which method of modeling the non-union bone fractures is more optimal for further research into the effectiveness of biological therapy aimed at treating bone healing impairment. For a detailed study of methods of non-union fracture treatment of, it is necessary to determine the developed animal models. The objective was to analyze the existing animal models of fracture nonunion in long bones in vivo and to consider the possibility of their further use to evaluate the effectiveness of the use of modern biotechnologies for the in the management of fracture nonunion. It was found that the majority of developed animal models of atrophic long bone non-union were created using small animals, namely rats, mice, and rabbits. A more common method of modeling bone non-union is performing an osteotomy with the formation of a defect of different widths between the bone fragments and subsequent removal of the periosteum proximal and distal to the osteotomy site; damage to the endosteum or removal of bone marrow. Also, in such animal models, researchers use a silicone spacer, a polysulfone plate, or a latex-silicone foil to physically prevent fracture union. In these animal models, studies using mesenchymal stromal cells, platelet-rich plasma or bone morphogenetic protein-2 (BMP-2) have already been conducted for the management of non-union bone fractures. At the same time, the clinical results of the application of various biological therapies are ambiguous, which determines the conduct of further experimental studies, in particular, in vivo. However, there are disagreements about which in vivo modeling methods give a reproducible result and prevent bone union, which determines the need for further analysis of existing modeling tools for conducting research in this direction.

Arthroscopic Scaphoid Bone Graft Combined with Percutaneous Fixation versus Open Scaphoid Fixation with Non Vascularized Graft in Scaphoid Non-Union

Abstract Background Consensus about Management of scaphoid nonunion is controversial, many procedures have been described. This study compares between 2 modalities for management of scaphoid nonunion either arthroscopic scaphoid bone grafting from iliac bone combined with percutaneous fixation versus open scaphoid fixation and non-vascularized bone graft from iliac bone in management of scaphoid nonunion to identify if one technique is better as regards union rate, time to union and functional outcome. Patients and Methods A prospective randomized control trial held to recruit the patients between September 2019 and December 2020 between open grafting group (group O) for scaphoid non union (15 patient) and arthroscopic group (group A) ( 15 patients), randomization was done by using computerized random allocation. The mean follow up was 17.2 months(12- 24 months). We evaluated the results as regards union rate, time to union, complications, grip strength functional outcome according to disability of arm, shoulder and hand questionnaire (DASH) score and modified mayo wrist score (MMWS). We analyzed the results by using Statistical Package for the Social Sciences software (SPSS) version 25. Results union rate for group A was 100 % with time to union mean of 9.73 weeks (±2.4 weeks), union rate for group O was 93.33% with time to union mean of11.64 weeks(±1.82 weeks) which was significantly faster to union for group A(p value<0.05) . The open group showed significantly less operative time, the mean operative time was59.2 min±11.01, 90.6min±11.77 for group O and group A respectively. Grip strength, range of motion, VAS, MMWS and DASH score improved post operative for both groups with no statistical difference between them with comparable complication rate. Conclusion arthroscopic grafting technique for scaphoid non unions showed comparable results as regard union rate, complications, range of motion and functional outcomes with significantly faster time to union however, significantly longer operative time.

Efficacy and safety of autologous or allogeneic mesenchymal stromal cells from adult adipose tissue expanded and combined with tricalcium phosphate biomaterial for the surgical treatment of atrophic nonunion of long bones: a phase II clinical trial

BackgroundAutologous bone grafting is the standard treatment for the surgical management of atrophic nonunion of long bones. Other solutions, such as bone marrow mesenchymal stem cells (BM-MSC) combined with phospho-calcium material, have also been used. Here we evaluate the safety and early efficacy of a novel procedure using autologous or allogenic adipose tissue mesenchymal stromal cells (AT-MSC) seeded in a patented tricalcium phosphate-based biomaterial for the treatment of bone regeneration in cases of atrophic nonunion.MethodsThis was a prospective, multicentric, open-label, phase 2 clinical trial of patients with atrophic nonunion of long bones. Biografts of autologous or allogenic AT-MSC combined with a phosphate substrate were manufactured prior to the surgical procedures. The primary efficacy was measured 6 months after surgery, but patients were followed for 12 months after surgery and a further year out of the scope of the study. All adverse events were recorded. This cohort was compared with a historical cohort of 14 cases treated by the same research team with autologous BM-MSC.ResultsA total of 12 patients with atrophic nonunion of long bones were included. The mean (SD) age was 41.2 (12.1) years and 66.7% were men. Bone healing was achieved in 10 of the 12 cases (83%) treated with the AT-MSC biografts, a percentage of healing similar (11 of the 14 cases, 79%) to that achieved in patients treated with autologous BM-MSC. Overall, two adverse events, in the same patient, were considered related to the procedure.ConclusionsThe results of this study suggest that AT-MSC biografts are safe for the treatment of bone regeneration in cases of atrophic nonunion and reach high healing rates.Trial registrationStudy registered with EUDRA-CT (2013-000930-37) and ClinicalTrials.gov (NCT02483364).

Reconstruction of gap non-union tibia with composite use of extramedullary fixation and bone transport by monorail fixator: a prospective case series.

Non-union is a complex, multifactorial orthopaedic problem that requires multiple treatment modalities for its management. It can result from infection, segmental bone loss, soft-tissue loss, and associated host factors. External fixators as management of gap non-union are bulky and give rise to a number of complications In our study, we have described a technique where we have used extramedullary fixation in the form of a tibial locking plate and transportation of part of the tibial bone after corticotomy by a monorail fixator. The procedure was done in two stages where internal and external fixation was done after creating a gap at the non-union site. The bone was transported after corticotomy and fixed to the internal fixation device in the second stage. The external fixator was removed in the second stage and the patient was then followed up till the bony union. The evaluation was done by functional and radiological assessment along with the complications noted with the described procedure. Ten patients were enrolled in the study with a mean age of 33 years. The mean age of the patients was 33.7 ± 11.32 years with a mean size of the defect was 4.8 ± 1.7 cm. At 30 weeks out of nine patients, three patients had excellent and six had good functional results on the Association of Surgeons for Application and Methodology of Ilizarov (ASAMI) scale. The composite Musculoskeletal Tumor Society (MSTS) score was 76.66 % at the end of 30 weeks of follow-up. The mean time of consolidation was 134.4 days, whereas the mean union time was 145 days from index surgery. Ankle stiffness was the most common complication affecting 50% of the patients. Following closely was pin tract infection, which was present in 40% of the patients. According to Paley's classification, there were 11 obstacles, two problems and none were true complications. The integrated fixation is both safe and effective and has the advantage of early removal of the external fixator and a low complication rate as compared to use of a bulky conventional fixator alone. Moreover, it gives protection to the regenerated bone for a long period. So, this technique can be recommended for the management of segmental tibial defects.

Radiographic and functional results of Ilizarov fixation in the management of nonunion of tibia and femur fractures: a retrospective case series.

Femoral and tibial fractures may result in delayed union and nonunion, posing significant challenges in orthopedic practice. The Ilizarov technique has emerged as a promising solution for managing these complex cases. Evaluate the radiographic and functional results of Ilizarov fixation in the treatment of nonunion of tibia and femur fractures. Retrospective. Hospitals affiliated with a university hospital. Patient demographics, fracture characteristics, and treatment details were analyzed for the period from October 2015 to September 2022 in patients who were treated for nonunion of the tibia and femur using the Ilizarov fixator. Clinical and radiological assessments were performed using the Association for the Study and Application of Methods of Ilizarov (ASAMI) criteria. The study focused on assessing the average duration for union and frame removal, bone results, successful union rates, and functional results using the ASAMI criteria, obtaining data from the existing medical records, spanning various medical facilities treating nonunion fractures. 126 patients. The average duration for union and frame removal was 8 months, with excellent bone results observed in 60.32% of cases. Out of 126 patients, 118 achieved successful union, while there were 2 failure cases necessitating amputation (1.52%). Functional results revealed excellent outcomes in 39.68% of cases. Complications included pin tract infections, ankle and knee stiffness, and limb shortening. External fixation duration and infection eradication were consistent with previous research, emphasizing the technique's effectiveness. The Ilizarov technique proved highly effective in managing nonunion tibia and femur fractures, offering favorable outcomes in terms of union, infection control, pain relief, and functional recovery. While excellent bone outcomes do not guarantee optimal function, this method remains a reliable approach for complex cases. Potential biases inherent in retrospective analyses and the need for further randomized controlled trials to comprehensively compare treatment modalities.

Effectiveness and safety of augmentative plating technique in managing nonunion following intramedullary nailing of long bones in the lower extremity: A systematic review and meta-analysis

PurposeTo methodically assess the effectiveness of augmentative plating (AP) and exchange nailing (EN) in managing nonunion following intramedullary nailing for long bone fractures of the lower extremity. MethodsPubMed, EMBASE, Web of Science, and the Cochrane Library were searched to gather clinical studies regarding the use of AP and EN techniques in the treatment of nonunion following intramedullary nailing of lower extremity long bones. The search was conducted up until May 2023. The original studies underwent an independent assessment of their quality, a process conducted utilizing the Newcastle-Ottawa scale. Data were retrieved from these studies, and meta-analysis was executed utilizing Review Manager 5.3. ResultsThis meta-analysis included 8 studies involving 661 participants, with 305 in the AP group and 356 in the EN group. The results of the meta-analysis demonstrated that the AP group exhibited a higher rate of union (odds ratio: 8.61, 95% confidence intervals (CI): 4.12 − 17.99, p < 0.001), shorter union time (standardized mean difference (SMD): −1.08, 95 % CI: -1.79 − -0.37, p = 0.003), reduced duration of the surgical procedure (SMD: -0.56, 95 % CI: -0.93 − -0.19, p = 0.003), less bleeding (SMD: -1.5, 95 % CI: -2.81 − -0.18), p = 0.03), and a lower incidence of complications (relative risk: -0.17, 95 % CI: -0.27 − -0.06, p = 0.001). In the subgroup analysis, the time for union in the AP group in nonisthmal and isthmal nonunion of lower extremity long bones was shorter compared to the EN group (nonisthmal SMD: -1.94, 95 % CI: -3.28 − -0.61, p < 0.001; isthmal SMD: -1.08, 95 % CI: -1.64 − -0.52, p = 0.002). ConclusionIn the treatment of nonunion in diaphyseal fractures of the long bones in the lower extremity, the AP approach is superior to EN, both intraoperatively (with reduced duration of the surgical procedure and diminished blood loss) and postoperatively (with an elevated union rate, shorter union time, and lower incidence of complications). Specifically, in the management of nonunion of lower extremity long bones with non-isthmal and isthmal intramedullary nails, AP demonstrated shorter union time in comparison to EN.

Nonvascularized Bone Grafting for Scaphoid Nonunion

Abstract Background Surgical management of scaphoid nonunions requires not only stable fixation but restoration of carpal alignment and reconstruction of bone defects. The latter can be done with either vascularized or non-vascularized bone grafts, depending largely on surgeon preference. Materials and Methods This article describes the use of non-vascularized bone grafts for scaphoid nonunions and examines reported outcomes. We also describe the senior author's preferred surgical treatment, the hybrid Russe procedure. Description of Technique The hybrid Russe procedure utilizes a corticocancellous strut from the volar aspect of the distal radius to restore anatomy in scaphoid nonunions with flexion deformities. Once the alignment of the scaphoid and associated lunate postural deformities are corrected, fixation then proceeds with a headless compression screw. This combination resulted in healing of 17 scaphoid fracture nonunions at an average time of 15 weeks. Conclusions The literature does not demonstrate a difference in union rates when comparing the use of vascularized and non-vascularized grafts for scaphoid nonunions. When the proximal pole of the scaphoid can be salvaged, the choice of fixation is left to the surgeon's discretion.

Management of non-unions of the malleolar fractures- Current Evidence

Although malleolar non-union is uncommon, it is associated with significant morbidity. Managing this problem requires understanding ankle fracture biomechanics and bone healing. We present in this article the pertinent points to be considered in evaluating and managing patients with malleolar non-union. Our discussion will focus on the important risk factors contributing to this problem, and the need to carefully consider the biomechanical stability and the biological environment to ensure successful bony unions.

Nonunion scaphoid bone shape prediction using iterative kernel principal polynomial shape analysis.

The scaphoid is an important mechanical stabilizer for both the proximal and distal carpal columns. The precise estimation of the complete scaphoid bone based on partial bone geometric information is a crucial factor in the effective management of scaphoid nonunion. Statistical shape model (SSM) could be utilized to predict the complete scaphoid shape based on the defective scaphoid. However, traditional principal component analysis (PCA) based SSM is limited by its linearity and the inability to adjust the number of modes used for prediction. This study proposes an iterative kernel principal polynomial shape analysis (iKPPSA)-based SSM to predict the pre-morbid shape of the scaphoid, aiming at enhancing the accuracy as well as the robustness of the model. Sixty-five sets of scaphoid images were used to train SSM and nine sets of scaphoid images were used for validation. For each validation image set, three defect types (tubercle, proximal pole, and avascular necrosis) were virtually created. The predicted shapes of the scaphoid by PCA, PPSA, KPCA, and iKPPSA-based SSM were evaluated against the original shape in terms of mean error, Hausdorff distance error, and Dice coefficient. The proposed iKPPSA-based scaphoid SSM demonstrates significant robustness, with a generality of 0.264mm and a specificity of 0.260mm. It accounts for 99% of variability with the first seven principal modes of variation. Compared to the traditional PCA-based model, the iKPPSA-based scaphoid model prediction demonstrated superior performance for the proximal pole type fracture, with significant reductions of 25.2%, 24.7%, and 24.6% in mean error, Hausdorff distance, and root mean square error (RMSE), respectively, and a 0.35% improvement in Dice coefficient. This study showed that the iKPPSA-based SSM exploits the nonlinearity of data features and delivers high reconstruction accuracy. It can be effectively integrated into preoperative planning for scaphoid fracture management or morphology-based biomechanical modeling of the scaphoid.

Deap-seated infection and nonunion following internal fixation for Charcot foot deformity correction. A proportional meta-analysis of level 4 evidence

BackgroundGiven the paucity of literature on the management of infected metalwork and nonunion in neuropathic diabetic patients, a meta-analysis was designed to investigate the two major complications following Charcot reconstruction performed by means of internal fixation methods. MethodsWe searched PubMed, Scopus and CENTRAL until the 17th of May 2022 for completed studies investigating outcomes following midfoot and/or hindfoot and/or ankle diabetic Charcot reconstruction. For a paper to qualify for inclusion, an internal fixation element should have been considered. Random effects meta-analysis of proportion was performed to calculate the rate of post-operative deep-seated infections with the associated amputation rate and nonunions by using Open Meta-analyst software. Sub-analysis linked to anatomical location of reconstruction was performed and the quality of the included studies was appraised using the Moga tool. ResultsThirty studies with 492 eligible reconstructions were considered. Of those, deep-seated infections were diagnosed in 46 cases (Estimated proportion was 6.7%, 95% CI [4.2%–9.2%]). Debridement and antibiotic administration with or without metalwork removal were considered in the majority of the participants with successful clinical outcomes. Amputation was performed in 15 patients due to unmanageable post-operative infection and nonunion was reported in 17 studies (Estimated rates were 36.6%, 95% CI [18.4%–56.3%]; and 11.9%, 95%CI [6.6%–18.1%]; respectively). ConclusionsMeta-analysis showed that although the overall risk of infection development is less than 10%, just below one third of the infected cases undergo late amputation. Moreover, internal fixation reconstructions carry a nonunion risk of just above 10%.