Nonunion In Patients Research Articles

Effect of Ketorolac Administration on the Rate of Nonunion of Operatively Treated Pediatric Long-Bone Fractures

Background: Nonunion is a rare yet serious complication in pediatric fracture healing that can lead to patient morbidity and economic burden. The administration of nonsteroidal anti-inflammatory drugs (NSAIDs) has been associated with an increased risk of fracture nonunion in adults, but data are lacking in the pediatric population. This study examines the relationship between postoperative ketorolac administration and nonunion in operatively managed pediatric long-bone fractures. Methods: A retrospective cohort study was conducted with use of TriNetX, a research network that encompasses data from the United States, Canada, and Western Europe. A total of 462,260 patients from 52 health-care organizations met the inclusion criteria. Patients <18 years old with operatively managed upper or lower-extremity long-bone fractures were included. The exposure of interest was ketorolac administration within 30 days postoperatively between 2003 and 2023. Nonunion was identified and verified with use of the pertinent medical codes. Absolute risks and hazard ratios (HRs) were calculated for both study groups. Significance was set at p < 0.05. Results: After propensity score matching, 48,778 patients were identified per group. The incidence of nonunion was 2.19% in the ketorolac group and 0.93% in the non-ketorolac group (HR, 2.71; 95% confidence interval [CI]: 2.46, 3.21; p < 0.0001). Subgroup analyses demonstrated a higher risk of nonunion in patients with lower-extremity fractures (HR, 3.45; 95% CI: 3.14, 3.75; p < 0.0001) than in those with upper-extremity fractures (HR, 2.11; 95% CI: 1.84, 2.32; p < 0.0001). Among the fracture location subgroups, the greatest HR for nonunion was observed in patients with femoral fractures, followed sequentially by those with tibial and/or fibular fractures, humeral fractures, and radial and/or ulnar fractures. Conclusions: To our knowledge, this is the largest study to date to explore postoperative ketorolac use and nonunion in the setting of operatively managed pediatric long-bone fractures. Nonunion in children was rare, occurring in <1% of all included patients. Ketorolac administration was associated with a 2 to 3-fold increase in nonunion risks, with pronounced implications for patients with lower-extremity fractures, particularly those with femoral fractures. Clinicians should weigh the therapeutic advantages of non-opiate analgesia with ketorolac against the risk of nonunion in order to optimize postoperative pain management and recovery. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Tibial Malalignment is an Independent Predictor of Nonunion After Intramedullary Nailing of Tibial Shaft Fractures.

This study aimed to assess the relationship between postoperative alignment and nonunion in patients with tibial shaft fractures treated with intramedullary nailing. Design: Retrospective case-control study. Single academic trauma center. Adult patients with closed or open tibial shaft fractures (42A-C) treated with intramedullary nailing from 2007 to 2018. Case patients with nonunion were compared to control patients with radiographic evidence of healing in terms of the postoperative tibial alignment measured in the coronal and sagittal planes. Of the 192 included patients (median age, 38 years; 76% male), 51 patients had a nonunion, and 141 patients had united fractures and served as the control group. A strong association between postoperative tibial malalignment in one plane and nonunion (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.1 to 8.3; P = 0.03) was demonstrated. This association was even greater for malalignment in both coronal and sagittal planes (OR, 5.7; 95% CI, 2.1 to 16.1; P < 0.001) after controlling for confounders. After controlling for confounding factors, postoperative malalignment in the coronal or sagittal plane was associated with significantly increased odds of tibial shaft nonunion after intramedullary nailing. Therapeutic, Level III. See Instructions for Authors for a complete description of levels of evidence.

Enoxaparin and Early Postoperative Tibial Nailing: Increased Nonunion Revision Rates.

To determine the association between postoperative enoxaparin use and the risk of requiring surgery for nonunion in patients treated with intramedullary nailing for midshaft fractures of the tibia. Retrospective cohort analysis. Data were sourced from the PearlDiver national database. Patients were identified through the PearlDiver database by using Current Procedural Terminology and International Classification of Diseases (ICD-10) codes. Included patients had undergone intramedullary nailing for midshaft fractures of the tibia between 2015 and 2020 and subsequently underwent revision surgery due to nonunion. The primary outcome measured in this study was the rate of nonunion following intramedullary nailing for the different types of tibial shaft fractures (closed, Type I/II open, Type III open). For each fracture subtype, the study compared nonunion rates between those who received enoxaparin in the postoperative period and those who did not receive enoxaparin at any time during the first 6 weeks postoperatively. Factors such as the timing and duration of enoxaparin therapy and demographic variables were also considered. The study included 16,986 patients, average age was 49.2 years (SD 17.3); 43.1% were female. Five hundred four patients required revision surgery for nonunion (3.4%). Among patients who did not receive enoxaparin, the nonunion rates were 1.6%, 3.9%, and 6.9% for closed, Type I/II open, and Type III open fractures, respectively. For patients who received enoxaparin within the first 2 weeks, the nonunion rates were 2.6%, 4.7%, and 7.9% for closed (RR = 1.67, P < 0.0001), Type I/II open (RR = 1.21, P < 0.0001), and Type III open (RR = 1.17, P = 0.355) fractures, respectively. Logistic regression confirmed enoxaparin was independently associated with nonunion (odds ratios [OR] = 1.75, P = 0.0013 for closed fractures; OR = 1.51, P = 0.034 for Type I/II open fractures). Tobacco use was also a contributing factor (OR = 2.43, P < 0.0001 for closed fractures; OR = 2.00, P < 0.0001 for Type I/II open fractures; OR = 2.04, P = 0.0008 for Type III open fractures). The postoperative use of enoxaparin was associated with an elevated risk of nonunion in patients treated with intramedullary nailing for fractures of the tibial shaft. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Painful Nonunion in Patients With Clinically Plantigrade Diabetes-Associated Charcot Foot Arthropathy.

It has been assumed that diabetic patients with peripheral neuropathy should not have pain associated with Charcot foot arthropathy. During a 19-year period, 14 diabetic patients (15 feet) presented for treatment with pain following resolution of the acute phases of midfoot Charcot foot arthropathy. All were clinically plantigrade with plain radiographic evidence of bony union without deformity. Pain did not resolve with the use of appropriate therapeutic footwear. When used, CT scans uniformly demonstrated nonunion. All 14 patients had resolution of their presenting pain following successful arthrodesis. Nonunion was confirmed at surgery in all of the patients. One patient developed a fatal pulmonary embolus following removal of the external fixator. Two required late exostectomy for bony overgrowth at the surgical site of fusion for nonunion. This small series of patients would suggest that nonunion of the Charcot neuroarthropathy process was responsible for complaints of pain not able to be managed with therapeutic footwear. Successful arthrodesis resolved the pain. CT imaging may help identify a treatable source of pain in this population.

Evaluating the Effect of Diabetic Medications on Rates of Nonunion in Patients Undergoing Foot and Ankle Arthrodesis Treatments

Introduction/Purpose: Diabetes mellitus (DM) is known to negatively impact outcomes following surgical operations and increase the susceptibility of affected individuals to higher rates of nonunion, surgical site infection, ulceration, increased risk of amputation of the extremities, and various other perioperative complications. A number of in vitro studies suggest that the increase in undesired outcomes is largely secondary to the effects of diabetes-induced prolonged inflammation and advanced glycation end products (AGEs) on these patients' vascular systems and skeletal microarchitecture. However, there is a paucity of literature investigating the effects of blood glucose-regulating medications on the clinical outcomes of diabetic patients following fusion procedures. This study aims to determine the impact of commonly prescribed diabetic medications on bone health and bone healing following foot and ankle operations. Methods: A retrospective review was conducted of 114 diabetic patients undergoing ankle, hindfoot, or midfoot arthrodesis by one of two fellowship-trained foot and ankle orthopaedic surgeons from 2015-2022. Patients were identified by having undergone surgery via 27870, 27815, 27825, or 27835 CPT codes, as well as having been diagnosed with diabetes mellitus prior to or at time of surgery. Joints fused included the tibiotalar joint (n=45; 39.5%), subtalar joint (n=62; 54.4%), talonavicular joint (n=31; 27.2%), and calcaneocuboid (n=14; 12.3%). Data collected included demographics, medical history, diabetic medication, postoperative complications, readmission rates, and reoperation rates. 36 patient cases were noted to not have concurrent medications prescribed to control their diabetes, while the other 78 patient cases were concurrently prescribed either metformin (33 cases; 28.9%), insulin (19 cases; 16.7%), both metformin and insulin (18 cases; 15.8%), glipizides (11 cases; 9.6%), dulaglutides (7 cases; 6.1%), semaglutides (9 cases; 7.9%), and sitagliptins (8 cases; 7.0%). Results: The overall cohort was majority male (62.3%) with mean age 60.38 (range 31-76) years, mean BMI 34.00 (range 21.47- 61.38) kg/m2 and mean follow-up 1.90 (range .50-6.25) years. The cohort had a 27.2% superficial infection rate, 28.9% deep infection rate, 41.2% non-union rate, 47.4% reoperation rate, and a 14% 90-day readmission rate. Except for insulin-treated patients, who had significantly higher infection (insulin=45.9%, non-insulin=18.2%; p=.003) and deep infection rates (insulin=45.9%, non-insulin=18.2%; p=.003), there was no statistically significant difference in any outcomes by specific medication or any diabetic medication use. Patients with Charcot arthropathy (n=42) had significantly higher superficial infection (charcot=42.9%, non- Charcot=18.1%; p=.005), deep infection (Charcot=52.4%, non-Charcot=15.3%; p&lt;.001), and 90-day readmission rates (Charcot=26.2%, non-Charcot=6.9%; p=.006). Conclusion: Our results indicate that patients on insulin or patients with Charcot arthropathy may be at increased risk of infection following foot and ankle fusion procedures. Other common medications to control diabetes mellitus were not found to increase risk of adverse outcomes. This finding is useful for surgeons and physicians attempting to optimize the clinical outcomes of diabetic patients undergoing the described procedures. However, further study with a greater sample size is necessary to confirm these findings.

Should we always perform scaphoid nonunion surgery in patients with minor preoperative symptoms?

The objective of this study was to assess the downsides of surgical treatment of scaphoid fracture nonunion in patients with minor preoperative symptoms. Patients were classified with minor symptoms based on the Patient-Rated Hand/Wrist Evaluation questionnaire. Of the 35 included patients, most patients encountered problems with patient-specific activities; 9% reported worse postoperative functional outcomes, 34% were not satisfied with the treatment and 9% were reoperated. The risk of a worse functional outcome after surgery with the need for further operations and the chance of developing wrist osteoarthritis, along with the possibility of poor patient satisfaction and ongoing daily functional impairment, should be considered during preoperative counselling.Level of evidence: III.

Risk factors for nonunion in patients with transcondylar fracture of the distal humerus after open reduction and internal fixation

Transcondylar fractures have been reported to rarely occur in the distal humerus, and stable fixation is difficult because of the unique fracture pattern. However, few studies have reported the risk factors for nonunion after open reduction and internal fixation (ORIF). This study aimed to evaluate the demographic and surgical risk factors for nonunion in patients who had undergone ORIF for transcondylar fractures. We retrospectively reviewed 68 patients who underwent ORIF for transcondylar fractures. Preoperative demographic factors, including diabetes mellitus (DM) and smoking, and operative factors, including fixation methods (e.g., dual plate/single plate/tension bend wiring [TBW]) were assessed as risk factors for nonunion. Nonunion occurred in eight out of 68 patients (11.8%). Univariate analysis revealed that among the demographic factors, DM (4/8 [50%] vs. 8/60 [13.3%], p=0.028) and smoking (3/8 [37.5%] vs. 4/60 [6.7%], p=0.031) were significantly different between nonunion and union patients. Regarding operative factors, the fixation method (dual plate/single plate/TBW; 2[25.0%]/2[25.0%]/4[50%] vs. 29 [48.3%]/25[41.7%]/6[10.0%], p=0.033) showed significant differences between nonunion and union patients. Multivariate regression analysis showed that DM (odds ratio [OR], 10.560; 95% CI, 1.308-85.247; p = 0.027), smoking (OR 22.371; 95% CI, 2.111-237.081; p=0.010), and TBW (OR 15.390; 95% CI, 1.348-175.666; p = 0.028) were independent risk factors for nonunion. Nonunion occurred in approximately 12% of the patients who underwent ORIF in the transcondylar region of the distal humerus. The risk of nonunion was higher in patients with DM and those who smoked. In addition, among the fixation methods, the TBW technique was a significant risk factor for nonunion.

Dual-Energy CT-based Opportunistic Volumetric Bone Mineral Density Assessment of the Distal Radius.

Background In patients with distal radius fractures (DRFs), low bone mineral density (BMD) is associated with bone substitute use during surgery and bone nonunion, but BMD information is not regularly available. Purpose To evaluate the feasibility of dual-energy CT (DECT)-based BMD assessment from routine examinations in the distal radius and the relationship between the obtained BMD values, the occurrence of DRFs, bone nonunion, and use of surgical bone substitute. Materials and Methods Scans in patients who underwent routine dual-source DECT in the distal radius between January 2016 and December 2021 were retrospectively acquired. Phantomless BMD assessment was performed using the delineated trabecular bone of a nonfractured segment of the distal radius and both DECT image series. CT images and health records were examined to determine fracture severity, surgical management, and the occurrence of bone nonunion. Associations of BMD with the occurrence of DRFs, bone nonunion, and bone substitute use at surgical treatment were examined with generalized additive models and receiver operating characteristic analysis. Results This study included 263 patients (median age, 52 years; IQR, 36-64 years; 132 female patients), of whom 192 were diagnosed with fractures. Mean volumetric BMD was lower in patients who sustained a DRF (93.9 mg/cm3 vs 135.4 mg/cm3; P < .001), required bone substitutes (79.6 mg/cm3 vs 95.5 mg/cm3; P < .001), and developed bone nonunion (71.1 mg/cm3 vs 96.5 mg/cm3; P < .001). Receiver operating characteristic curve analysis identified these patients with an area under the curve of 0.71-0.91 (P < .001). Lower BMD increased the risk to sustain DRFs, develop bone nonunion, and receive bone substitutes at surgery (P < .001). Conclusion DECT-based BMD assessment at routine examinations is feasible and could help predict surgical bone substitute use and the occurrence of bone nonunion in patients with DRFs. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Carrino in this issue.

Implementing an orthoplastic treatment protocol for open tibia fractures reduces complication rates in tertiary trauma unit

IntroductionOpen tibia fracture (OTF) causes a considerable increase in morbidity and risk for complications compared to closed fractures. The most significant OTF complication leading to morbidity is commonly considered to be fracture-related infection (FRI). In September 2016, Tampere University Hospital (TAUH) introduced a treatment protocol for OTFs based on the BOAST 4 guideline. The aim of this study is to investigate the outcomes before and after implementation of the OTF treatment protocol. Materials and methodsA retrospective cohort study was conducted using handpicked data from the patient record databases of TAUH from May 1, 2007, to May 10, 2021. For patients with OTF, we collected descriptive information, known risk factors for FRI and nonunion, bony fixation method, possible soft tissue reconstruction method, information about the timing of internal fixation and soft tissue coverage, and timing of primary operation. As outcome measures, we collected information on FRI, reoperation due to non-union, flap failure, and secondary amputation. We then compared the incidence of complications before and after the implementation of the OTF treatment protocol at TAUH. ResultsAfter predefined exclusions, a total of 203 patients with OTF were included. Of these, 141 were treated before and 62 after the implementation of the OTF treatment protocol. The FRI rate in the pre-protocol group was significantly higher compared to the protocol group (20.6% vs 1.6%, p = 0.0015). The incidence of reoperation due to nonunion was also significantly higher in the pre-protocol group (27.7% vs 9.7%, p = 0.0054). According to multivariable analysis, definitive fixation and soft tissue coverage performed in separate operations was an independent risk factor for both FRI and reoperation due to nonunion. ConclusionsAfter implementation, the BOAST 4 based OTF treatment protocol reduced the rate of FRI and reoperation due to nonunion in patients with OTF treated at TAUH during the study period. We, therefore, recommend the implementation of such a treatment protocol in all major trauma centers treating patients with OTF. Furthermore, we also recommend the immediate referral of patients with complex OTF from hospitals lacking the preconditions to provide BOAST 4 based treatment to specialized centers.

EE22 Risk Factors and Healthcare Costs Associated with Long Bone Fracture Non-Union – A US Claims Database Analysis

Non-union is a common complication following long bone fractures, often requiring significant incremental healthcare resources. The payer cost of long bone non-union in patients with or without concurrent infection is not well documented. Our study evaluated 2-year incremental healthcare costs of non-union in patients with fractures.

Association of Talar Neck Fractures With Body Extension and Risk of Avascular Necrosis.

The objective of this study was to determine whether talar neck fractures with proximal extension (TNPE) into the talar body are associated with higher rates of avascular necrosis (AVN) compared to isolated talar neck (TN) fractures. A retrospective review of patients sustaining talar neck fractures at a level I trauma center from 2008 to 2016 was performed. Demographic and clinical data were collected from the electronic medical record. Fractures were characterized as TN or TNPE based on initial radiographs. TNPE was defined as a fracture that originates on the talar neck and extends proximal to a line subtended from the junction of the neck and the articular cartilage dorsal to the anterior portion of the lateral process of the talus. Fractures were classified according to the modified Hawkins classification for analysis. The primary outcome was the development of AVN. Secondary outcomes included nonunion and collapse. These were measured on postoperative radiographs. There were 137 fractures in 130 patients, with 80 (58%) fractures in the TN group and 57 (42%) in the TNPE group. Median follow-up was 10 months (interquartile range, 6-18 months). The TNPE group was more likely to develop AVN as compared to the TN group (49% vs 19%, P < .001). Similarly, the TNPE group had a higher rate of collapse (14% vs 4%, P = .03) and nonunion (26% vs 9%, P = .01). Even after adjusting for open fracture, Hawkins fracture type, smoking, and diabetes, AVN still remained significant for the TNPE group as compared to the TN group with an odds ratio of 3.47 (95% CI, 1.51-7.99). We found a higher rate of AVN, subsequent collapse, and nonunion in patients with TNPE compared to isolated TN fractures. Level III, retrospective cohort study.

The Impact of Injury of the Tibial Nutrient Artery Canal on Type of Nonunion of Tibial Shaft Fractures: A Retrospective Computed Tomography Study

Blood supply is vital for sound callus formation. The tibial nutrient artery (TNA) is the main diaphyseal artery nurturing the tibial shaft. The objective is to investigate the impact of TNA canal (TNAC) injury on the development of atrophic, oligotrophic, and hypertrophic nonunion in patients with tibial shaft fractures. Between January 2010 and December 2020, patients with a nonunion of a tibial shaft fracture were retrospectively included. Two readers independently evaluated the integrity of the TNAC and classified nonunion type. A multinomial regression model was utilized to evaluate if a TNAC injury has an impact on the type of nonunion. From an initial set of 385 patients with the diagnosis of a nonunion of the lower leg, a total of 60 patients could be finally included in the study. Most patients were males (78%), diabetic (95%), smokers (73%), and had an American Society of Anesthesiologists (ASA) score of 2 (72%). TNAC injury was noted in 24 patients (40%): an iatrogenic TNAC injury was observed in 13 (22%) patients, a traumatic TNAC injury in 11 (18%) patients. Most patients had a hypertrophic nonunion (29 patients (48%)), followed by an oligotrophic nonunion (24 patients (40%)) and lastly an atrophic nonunion (seven patients (11%)). The multinomial regression model showed that there was no impact of TNAC injury on the development of a specific type of non-union (p=0.798 for oligotrophic vs. atrophic nonunion; p=0.943 for hypertrophic vs. atrophic nonunion). Furthermore, patients were about four times more likely to develop an oligotrophic/hypertrophic nonunion rather than atrophic one (odds ratio 3.75 and 4.25, respectively), regardless of the presence of a TNAC injury. In the evaluated patient cohort with tibial shaft fractures, we could not find a statistically significant association between TNAC injury and type of nonunion. However, patients were almost four times more likely to develop oligotrophic or hypertrophic nonunion rather than an atrophic one although common risk factors for impaired (micro)vascular blood supply were highly prevalent in the study group. Multicenter studies with a larger number of atrophic nonunions are warranted to further evaluate this result.

Factors associated with nonunion of the posttraumatic subtalar arthrodesis after displaced intra-articular calcaneal fractures

BackgroundThis study investigated the incidence of and risk factors for nonunion in patients with posttraumatic subtalar arthrodesis (SA). MethodsWe retrospectively reviewed 165 posttraumatic SA cases. Nonunion was diagnosed at 6 months after surgery based on the findings of clinical evaluations, plain radiographs, and CT scans. Patient-specific factors and surgeon-specific factors were evaluated as potential risk factors. ResultsThe overall nonunion rate was 13.3 % (22 of 165 cases). In the final multivariate logistic regression analysis, smoking (odds ratio [OR] = 3.64; 95 % confidence interval [CI] = 1.23–10.75), parallel screw configuration (OR = 5.70; 95 % CI = 1.62–20.06), and freeze dried iliac crest (OR = 9.16; 95 % CI = 2.28–36.79) were demonstrated as risk factors for nonunion of posttraumatic SA. ConclusionPatients with a history of smoking, parallel screw configuration fixation, and those who received freeze dried iliac crest as an interpositional graft, had a significantly higher rate of nonunion.

Combination of albumin-to-globulin ratio and plasma fibrinogen is a sensitive tool for preoperative screening of infected nonunion in patients undergoing reoperation after open reduction and internal fixation: a retrospective study

BackgroundAccurate preoperative diagnosis of infected nonunion remains a challenge. Here, we evaluated the diagnostic potential of novel biomarkers for infected nonunion.MethodsA cohort of 275 patients who underwent surgery for suspected septic nonunion after open reduction and internal fixation were enrolled. Preoperatively analyzed clinical parameters included white blood cell (WBC) count, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), albumin, globulin, albumin-to-globulin ratio (AGR), plasma D-dimer, plasma fibrinogen, platelet count (PC), monocyte-lymphocyte ratio (MLR), neutrophil–lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR). Receiver operating characteristic (ROC) curves, sensitivity, and specificity were utilized to compare the diagnostic potential of those biomarkers.ResultsThe WBC count and levels of CRP, ESR, NLR, MLR, PLR, PC, plasma D-dimer, plasma fibrinogen, and globulin in infected nonunion patients were significantly higher (p < 0.05) than those in aseptic patients. The albumin and AGR levels of the infected nonunion group were significantly lower (p < 0.05) than the aseptic group. The ROC curve analysis showed that the diagnostic accuracy of AGR and plasma fibrinogen was good. The combination of AGR with plasma fibrinogen had the highest area under the curve (AUC) (0.916). The sensitivity and specificity were 70.27% and 91.04% for AGR, and 67.57% and 84.08% for plasma fibrinogen, respectively. The combination of AGR with plasma fibrinogen showed a sensitivity of 86.49% and specificity of 92.54%. In patients with comorbidities, the diagnostic accuracy of the combination of AGR with plasma fibrinogen was also good.ConclusionsAGR and plasma fibrinogen are promising biomarkers to improve the diagnosis of infected nonunion. The combination of AGR with plasma fibrinogen is a sensitive tool for screening infected nonunion.

Incidence of Complications and Risk Factors for Nonunion After Ankle Fracture in Diabetes Mellitus.

To evaluate complications and risk factors for nonunion in patients with diabetes after ankle fracture. We conducted a retrospective study of 139 patients with diabetes and ankle fractures followed for 1 year. We evaluated the incidence of wounds, infections, nonunions, Charcot's arthropathy, and amputations. We determined Fracture severity (unimalleolar, bimalleolar, trimalleolar), nonunion, and Charcot's arthropathy from radiographs. Nonunion was defined as a fracture that did not heal within 6 months of fracture. Analysis of variance was used to compare continuous variables, and χ2 tests to compare dichotomous variables, with α = 0.05. Logistic regression was performed with a binary variable representing nonunions as the dependent variable. Complications were common: nonunion (24.5%), Charcot's arthropathy (7.9%), wounds (5.2%), wound site infection (17.3%), and leg amputation (2.2%). Patients with nonunions were more likely to be male (55.9% versus 29.5%; P = .005), have sensory neuropathy (76.5% versus 32.4%; P < .001), have end-stage renal disease (17.6% versus 2.9%; P < .001), and use insulin (73.5% versus 40.1%; P < .001), β-blockers (58.8% versus 39.0%; P = .049), and corticosteroids (26.5% versus 9.5%; P = .02). Among patients with nonunion, there was an increased risk of wounds (odds ratio [OR], 3.3; 95% confidence interval [CI], 1.46-7.73), infection (OR, 2.04; 95% CI, 0.72-5.61), amputation (OR, 7.74; 95% CI, 1.01-100.23), and long-term bracing (OR, 9.51; 95% CI, 3.8-23.8). In the logistic regression analysis, four factors were associated with fracture nonunion: dialysis (OR, 7.7; 95% CI, 1.7-35.2), insulin use (OR, 3.3; 95% CI, 1.5-7.4), corticosteroid use (OR, 4.9; 95% CI, 1.4-18.0), and ankle fracture severity (bimalleolar or trimalleolar fracture) (OR, 2.5; 95% CI, 1.1-5.4). These results demonstrate risk factors for nonunions: dialysis, insulin use, and fracture severity after ankle fracture in patients with diabetes.

What are the long-term patient-reported and clinical outcomes after lateral clavicle fractures? A cross-sectional study of 619 patients

BackgroundLateral clavicle fractures account for 17% of all clavicle fractures and large studies comparing nonoperative and operative treatment are lacking. Therefore, patients cannot be properly informed about different treatment options and prognosis. We assessed long-term patient-reported and clinical outcomes in patients with lateral clavicle fractures.MethodsA multicenter cross-sectional study was performed in patients treated for lateral clavicle fractures between 2007 and 2016. Primary outcome included patient-reported outcome measures (PROMs) (DASH, EQ-5D, return to work, sports, cosmetics and satisfaction). Questionnaires were sent to 619 eligible patients, of which 353 (57%) responded after a mean follow-up of 7.4 ± 2.8 years. Secondary outcome included adverse events and secondary interventions. Outcomes after nonoperative vs. operative treatment (stratified by nondisplaced vs. displaced fractures) were compared using Student t tests and linear regression analysis.ResultsNondisplaced lateral clavicle fractures were treated nonoperatively and resulted in excellent PROMs. Six patients (3%) developed a nonunion. For displaced lateral clavicle fractures, no differences were found between nonoperative and operative treatment with regard to DASH score (7.8 ± 12.5 vs 5.4 ± 8.6), EQ-5D (0.91 ± 0.13 vs 0.91 ± 0.09), pain (0.9 ± 1.7 vs. 0.8 ± 1.6), patient satisfaction (90.1 ± 25.5 vs. 86.3 ± 20.4), return to work (96.4% vs. 100%) and sports (61.4% vs. 62.3%). The absolute risk of nonunion in patients with a displaced fracture was higher after nonoperative than operative treatment (20.2% vs. 2.9%; p = 0.002), with six patients needing treatment to avoid one nonunion.ConclusionsNondisplaced lateral clavicle fractures should be treated nonoperatively and result in good functional outcomes and high union rates. For displaced fractures, neither nonoperative nor operative treatment seems superior. Patients opting for nonoperative treatment should be informed that nonunion occurs in 20% of patients, but only half of these need additional operative treatment. Patients who opt for surgery should be told that nonunion occurs in only 3%; however, most patients (56%) will require secondary intervention for elective implant removal. Regardless of the type of treatment, no differences in functional outcome and PROMs should be expected at long-term follow-up.

Identification of Up-Regulated ANXA3 Resulting in Fracture Non-Union in Patients With T2DM

Diabetes mellitus is a metabolic disorder that increases fracture risk and interferes with bone formation and impairs fracture healing. Genomic studies on diabetes and fracture healing are lacking. We used a weighted co-expression network analysis (WGCNA) method to identify susceptibility modules and hub genes associated with T2DM and fracture healing. First, we downloaded the GSE95849, GSE93213, GSE93215, and GSE142786 data from the Gene Expression Omnibus (GEO) website, analyzed differential expression genes and constructed a WGCNA network. Second, we screened out 30 hub genes, which were found to be enriched in neutrophil activation, translational initiation, RAGE receptor binding, propanoate metabolism, and other pathways through Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG), and gene set enrichment analysis (GSEA) analyses. Third, we searched for genes related to bone metabolism and fracture healing in the published genome-wide single nucleotide polymorphism (SNP) data, built a protein-protein interaction (PPI) network with hub genes, and found that they were associated with metabolic process, blood vessel development, and extracellular matrix organization. ANXA3 was identified as the biomarker based on gene expression and correlation analysis. And the AUC value of it was 0.947. Fourth, we explored that ANXA3 was associated with neutrophils in fracture healing process by single-cell RNA sequencing analysis. Finally, we collected clinical patient samples and verified the expression of ANXA3 by qRT-PCR in patents with T2DM and fracture non-union. In conclusion, this is the first genomics study on the effect of T2DM on fracture healing. Our study identified some characteristic modules and hub genes in the etiology of T2DM-associated fracture non-union, which may help to further investigate the molecular mechanisms. Up-regulated ANXA3 potentially contributed to fracture non-union in T2DM by mediating neutrophils. It can be a prognostic biomarker and potential therapeutic target.

Anterior cervical discectomy and fusion in the era of motion preserving surgery

Background. Anterior cervical discectomy and fusion is accepted as the standard surgical treatment of cervical spondylotic myelopathy. Cervical disc arthroplasty has gained widespread acceptance as an alternate choice for ACDF. We intend to present the clinical and radiologic outcomes of patients who underwent ACDF in our department. Methods. Designed as a retrospective study, the primary objective was to assess the nonunion in patients undergoing ACDF and Anterior cervical Corpectomy and fusion. The article discusses the outcome for the discectomy group. All patients who underwent ACDF for CSM from January 2014 to December 2018 were included. Patients who underwent posterior fusion in addition to anterior approach, revision surgery and congenital anomalies of the spine were excluded. Of the 230 eligible patients,46 subjects were part of the study. They underwent neurologic and radiographic examination and their past records were examined. Neurologic outcome was assessed using Nurick grade and mJOA score. Dysphagia was assessed using the Bazaz score. Neck radiographs were analysed for fusion, Adjacent segment Disease, subsidence, cervical and segmental lordosis. Results. The overall response rate was 25.65%. The mean follows up duration was 4 years. The mean age of the population was 47.1 years. The most common operating level was C5/6. The neurologic status of patients improved from the baseline. There was mild transient dysphagia in 5(10.9%) patients. The overall rate of fusion was 91.3%. Subsidence was seen in 10.9%. Degenerative changes were noted in postop x rays of 67.4% of patients. There was no mortality. Conclusion. ACDF achieves thorough decompression thereby resulting in neurologic improvement. It produces effective and sustained neurologic improvement. Preoperative adjacent segment degenerative changes were significantly associated with the development of ASD during follow up. This is can due to the progression of the disease. Though the procedure improves the lordosis, it tends to decrease with follow up.

Optimal blocking screw placement for retrograde IM nail fixation of distal femur fracture: a standardized biomechanical study of "osteoporotic" synthetic bone.

Intramedullary (IM) nail use for metaphyseal fracture management is problematic in long bones like the femur because the larger medullary cavity allows increased fracture motion and potentially increased implant failure and malunion/nonunion risk; Achieving effective distal femur fracture fixation is even more difficult in osteoporotic bone. Blocking screws to control IM nail movement are known to be effective for tibia fracture management. Few studies have evaluated IM nail and blocking screw use efficacy for distal femur fracture fixation in osteoporotic bone. This study used an osteoporosis simulation synthetic bone model to evaluate retrograde IM nail fixation of a standardized non-comminuted, extra-articular distal femur fracture with and without blocking screws. The hypothesis was that use of one or two blocking screws would increase IM nail fixation stability as evidenced by greater peak IM nail load and lesser movement. A servohydraulic device under displacement control collected loading force versus movement deflection data. Shapiro-Wilk tests confirmed data normality. One-way analysis of variance and Tukey post hoc tests were used to compare condition specific loading force and movement differences. In the coronal plane, blocking screw conditions displayed greater loading ranges (38.3 ± 2 vs. 19.1 ± 2N, 100.5% difference) (p < 0.0001) and lesser movement (2.0 ± 0.3 vs. 6.86 ± 0.4mm, 243% difference) (p < 0.0001). In the sagittal plane, the two blocking screw condition displayed a significantly greater loading magnitude (29.9 ± 6 vs. 20.8 ± 2.3N, 43.8% difference) than the identical control condition without blocking screws (p = 0.018); however, movements were comparable (p = 0.82). Long-axis rotational loading failed to reveal load magnitude differences (p = 0.28); however, two different blocking screw conditions displayed decreased movement (1.32 ± 0.2 vs. 2.05 ± 0.3mm, 53.8% difference) compared to other conditions (p ≤ 0.018). Use of one or two blocking screws on the medial and lateral sides of the IM nail decreased coronal plane movement in the intramedullary canal. Combining retrograde IM nail implantation with blocking screws reduced medial-lateral IM nail movement and increased fracture stability. These characteristics may help prevent fixation failure, malunion, and even nonunion in patients with a distal femur fracture in osteoporotic bone.

Radiographic Outcomes, Union Rates, and Complications Associated With Plantar Implant Positioning for Midfoot Arthrodesis.

Background:Midfoot arthrodesis has long been successfully included in the treatment paradigm for a variety of pathologic foot conditions. A concern with midfoot arthrodesis is the rate of nonunion, which historically has been reported between 5% and 10%. Plantar plating has also been noted to be more biomechanically stable when compared to traditional dorsal plating in previous studies. Practical advantages of plantar plating include less dorsal skin irritation and the ability to correct flatfoot deformity from the same medial incision. The purpose of this study is to report the arthrodesis rate, the success of deformity correction, and the complications associated with plantar-based implant placement for arthrodesis of the medial column.Methods:A retrospective review was undertaken of all consecutive patients between 2012 and 2019 that underwent midfoot arthrodesis with plantar-positioned implants. Radiographic outcomes and complications are reported on 62 patients who underwent midfoot arthrodesis as part of a correction for hallux valgus deformity, flatfoot deformity, degenerative arthritis, Lisfranc injury, or Charcot neuroarthropathy correction.Results:Statistically significant improvement was seen in the lateral talus–first metatarsal angle (Meary angle) and medial arch sag angle for patients treated for flatfoot deformity correction. In patients treated for hallux valgus deformity, there was a reduction in the intermetatarsal angle from 15.4 to 6.8 degrees. The overall nonunion rate was 6.45% in all patients. The rate of nonunion was higher at the NC joint compared to the TMT joint and with compression claw plates. One symptomatic nonunion required revision surgery (1.7%). There were no nonunions when excluding neuroarthropathy patients and smokers. The odds ratio (OR) for nonunion in patients with neuroarthropathy was 6.05 (P < .05), and in active smokers the OR was 2.33 (P < .05).Conclusion:Plates placed on the plantar bone surface for midfoot arthrodesis achieved and maintained deformity correction with rare instances of symptomatic hardware for a variety of orthopedic conditions. An overall clinical and radiographic union rate of 94% was achieved. The radiographic union rate improved to 100% when excluding both neuroarthropathy patients and smokers. The incidence of nonunion was higher in smokers, neuroarthropathy patients, naviculocuneiform joint fusions, use of compression claw plates, and when attempting to fuse multiple joints. Incisional healing complications were rarely seen other than in active smokers.Level of Evidence:Level IV, case series.