Significant Risk Factor For Nonunion Research Articles

Plating versus Intramedullary Nailing of OTA/AO 43C1 and C2 Intra-articular Distal Tibia Fractures: A Propensity Score and Multivariate Analysis.

To compare rates of loss of reduction, nonunion, and infection in intra-articular distal tibia fractures (IADTF) treated with limited open reduction internal fixation and intramedullary nailing (IMN) as compared to open reduction internal fixation with plate and screws (PF). Retrospective Review. Level-I academic trauma center. 110 patients, age ≥ 18 with operatively treated OTA/AO 43C1 and C2 IADTF between 2013-2021. Loss of reduction, surgical site infection (SSI), nonunion, and patient-reported outcomes (PROs). 110 patients met the inclusion criteria (IMN 33, PF 77). There was no loss of reduction reported. 17 nonunions (15% overall; IMN 4/33, PF 13/77) and 13 SSIs (12% overall; IMN 2/33, PF11/77) were identified. Despite several risk factors being identified for nonunion and SSI in bivariate analysis, only open fracture remained significant as a risk factor for both nonunion (OR 0.09 for closed fracture, 95% CI 0.02-0.56, p=0.009) and SSI (OR 0.07 for closed fracture, 95% CI 0.06-0.26, p=0.012) in the multivariate model. Propensity scoring based on presurgical variables was significantly different between patients that received IMN vs PF (p=0.03); however, logistic regression incorporating the propensity score revealed no significant association with nonunion and SSI. Adjusting for the propensity score, there remained no association comparing IMN versus PF with nonunion and SSI (p=0.54 and p=0.17, respectively). There was also no difference in PROs between IMN and PF (Physical function: p=0.25, Pain interference: p=0.21). Overall nonunion and SSI prevalence in our cohort was 15% and 12%, respectively, in operatively treated OTA/AO 43C1 and C2 IADTF. An open fracture is a significant risk factor for nonunion and SSI. Metaphyseal fixation via IMN or PF in IADTF did not affect the loss of reduction, nonunion, SSI, and PROs. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Early Definitive Fixation of Talus Fractures Is Safe: A Retrospective Review

Background Talus fractures are often result of high energy mechanisms and can lead to devastating complications. Treatment is often operative; however, the appropriate timing of this has been debated. The purpose of this study is to determine the efficacy and safety of the early treatment of talus fractures. Methods Patients aged 18 years or older who underwent definitive operative stabilization of their talus fracture at a single urban level 1 trauma center were retrospectively reviewed. Patients were split into 2 groups based on their time to definitive fixation: ≤ or >24 hours. Pertinent demographic, surgical, and follow-up data were collected and analyzed. Results A total of 108 fractures were treated with 65 in the ≤24 hours fixation group and 43 in the >24 hours fixation group. Fractures involving the talar neck were the most commonly treated fracture pattern followed by the body and the head. There was no difference between the 2 groups in length to full weight bearing, union, or time to union. Open fracture was found to be the only significant risk factor for nonunion in both groups. There was no significant difference in infection or arthrodesis rates between the 2 groups. Conclusion Definitive treatment of talus fractures within 24 hours from presentation is both safe and effective with equal outcomes and without increased complications when compared with those injuries that undergo delayed or staged definitive fixation. Level of Evidence: Level 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.

L5-S1 nonunion occurrence even after anterior column support combined with iliac screw fixation in long fusion for adult spinal deformity: CT-based analysis at 2-year follow-up.

Iliac screw fixation and anterior column support are highly recommended to prevent lumbosacral pseudarthrosis after long-level adult spinal deformity (ASD) surgery. Despite modern instrumentation techniques, a considerable number of patients still experience nonunion at the lumbosacral junction. However, most previous studies evaluating nonunion relied only on plain radiographs and only assessed when the implant failures occurred. Therefore, using CT, it is important to know the prevalence after iliac fixation and to evaluate risk factors for nonunion at L5-S1. Seventy-seven patients who underwent ≥ 4-level fusion to the sacrum using iliac screws for ASD and completed a 2-year postoperative CT scan were included in the present study. All L5-S1 segments were treated by interbody fusion. Lumbosacral fusion status was evaluated on 2-year postoperative CT scans using Brantigan, Steffee, and Fraser criteria. Risk factors for nonunion were analyzed using patient, surgical, and radiographic factors. The metal failure and its association with fusion status at L5-S1 were evaluated. Of the 77 patients, 12 (15.6%) showed nonunion at the lumbosacral junction on the 2-year CT scans. Multivariate analysis using logistic regression revealed that only higher American Society of Anesthesiologists (ASA) grade was a risk factor for nonunion (OR 25.6, 95% CI 3.196-205.048, p = 0.002). There were no radiographic parameters associated with fusion status at L5-S1. Lumbosacral junction rod fracture occurred more frequently in patients with nonunion than in patients with fusion (33.3% vs 6.2%, p = 0.038). Although iliac screw fixation and anterior column support have been performed to prevent lumbosacral nonunion during ASD surgery, 15.6% of patients still showed nonunion on 2-year postoperative CT scans. High ASA grade was a significant risk factor for nonunion. Rod fracture between L5 and S1 occurred more frequently in the nonunion group.

Subtalar Arthrodesis Union Rates With and Without Adjacent Ankle Arthrodesis.

Subtalar arthrodesis is the surgical procedure commonly performed to treat subtalar arthritis. Subtalar arthrodesis may have a higher nonunion rate if there is a preexisting adjacent joint arthrodesis. The aim of this retrospective cohort study was to compare the subtalar arthrodesis union rate of patients with native tibiotalar joints to that of patients with prior tibiotalar arthrodesis. The secondary aim was to assess risk factors for nonunion. A retrospective cohort study of consecutive patients that underwent a subtalar arthrodesis in a single center between 2010 and 2020. The primary outcome of union was determined based on bridging callus on radiographs and clinical symptoms. If there was uncertainty, then a nonweightbearing CT was acquired. Chi-squared test and Mann-Whitney tests compared differences in demographics and risk factors for nonunion between groups. A logistical regression model was performed to determine risk factors for nonunion. Eighteen patients had an adjacent ankle arthrodesis and 53 patients did not. The successful subtalar arthrodesis union rate in those with a preexisting ankle joint arthrodesis (44.4%) was approximately half that in those without an ankle joint arthrodesis (86.8%) (P < .001). On multivariate logistic regression, an adjacent ankle arthrodesis was the only significant risk factor for nonunion. The odds ratio of nonunion of the subtalar joint with an adjacent ankle arthrodesis present was 4.90 (95% CI 1.02-23.56) compared to a subtalar arthrodesis with a native ankle joint. In addition, 9.4% of patients without an ankle arthrodesis underwent a revision subtalar arthrodesis compared with 44.4% of those with an adjacent ankle arthrodesis (P = .001). In our study, we found that patients undergoing a subtalar arthrodesis with an adjacent ankle arthrodesis have a significantly increased risk of nonunion compared with those undergoing a subtalar arthrodesis with a native ankle. Patients with a previously fused ankle need counseling about the high risk of nonunion and potential additional surgery.

Risk factors for nonunion following open reduction and internal fixation for proximal humerus fractures.

The incidence of proximal humerus fractures (PHF) is rising and surgical intervention carries risk for fracture nonunion. The purpose was (1) to compare patient demographics of those that developed nonunion and (2) identify patient risk factors that predispose to nonunion following open reduction and internal fixation (ORIF) for PHF. A retrospective review of the Medicare Claims Database from 2005 to 2014 for patients who underwent primary ORIF for PHFs. Patients who developed nonunion were identified as the study group (n = 1020) and compared to a control group (n = 51,209). Primary endpoints were to compare demographics of the study group and the comparison cohorts and to identify patient-related risk factors associated with nonunion within 6-months following the index procedure. A logistic regression model was constructed to determine the association of comorbid conditions on developing a nonunion. A p value of 0.001 was the significance threshold. Patients who developed nonunion were younger, more likely to be male, and had higher Elixhauser-Comorbidity Index scores (7 vs. 5; p < 0.0001) when compared with controls. Iron deficiency anemia (OR: 1.32; p = 0.0001), tobacco use (OR: 1.32; p = 0.0004), rheumatoid arthritis (OR: 1.29; p = 0.0001), depression (OR: 1.28; p = 0.0002), and BMI range from 30-39kg/m2 (OR: 1.21; p = 0.001) were significant risk factors for nonunion. Certain patient risk factors including tobacco use, iron deficiency anemia, rheumatoid arthritis, depression, and a BMI in the range of 30-39 were associated with nonunion within 6months of ORIF for PHF. This study may help in the risk stratification of these patients.

Risk Factors for Nonunion Following Tibiotalocalcaneal Arthrodesis: A Systematic Review and Meta-Analysis

Category:Ankle; Ankle Arthritis; TraumaIntroduction/Purpose:Tibiotalocalcaneal (TTC) arthrodesis is a routinely utilized salvage procedure that treats patients with severe talar and subtalar joint disease. Unfortunately, nonunion is a relatively common complication postoperatively which can increase risks and costs for patients. The goal of this study is to review the literature to identify risk factors for nonunion post TTC arthrodesis and stratify them based on strength of evidence. A meta-analysis will be performed on risk factors when appropriate to establish values based on pre-existing studies.Methods:Five databases (CINAHL, Cochrane Library, EMBASE, MEDLINE, and Web of Science) were searched from inception to May 17th, 2020. Two independent reviewers screened abstracts and full-text articles for those that included risk factors predictive of nonunion for TTC arthrodesis. Any disagreements were discussed between the two reviewers and a third reviewer served as the ultimate decision maker if a consensus could not be reached. Relevant data regarding participants’ characteristics, study design, follow-up time, statistical tests and identified risk factors were extracted from the included studies. The two reviewers independently appraised the methodological quality of the studies using the Quality In Prognosis Studies tool. Those risk factors described in multiple studies were included in the meta-analysis. Random effects meta-analyses were summarized as forest plots of individual study and pooled random effect results. Results were reported as odds ratios (OR) with 95% confidence intervals (CI).Results:Database search identified 428 articles, of which 113 were screened for full text. Eight studies involving 607 patients were included and 33 potential risk factors for nonunion were identified. Risk factors were stratified into demographic, preoperative, intraoperative and postoperative. Results of the meta-analysis established two significant risk factors for nonunion following TTC arthrodesis. Strong evidence supports that prior neurological deficits, such as Charcot neuroarthropathy and diabetes neuropathy, are associated with nonunion following surgery (OR: 2.86, 95% CI: 1.56 - 5.23). There was moderate evidence to suggest that preoperative infection was predictive for nonunion (OR: 3.99, 95% CI: 1.26 - 12.68). Although our meta- analysis did not find smoking (OR: 1.75, 95% CI: 0.90 - 3.38) or diabetes (OR: 2.28, 95% CI: 0.98 - 5.34) to be significant risk factors, multiple high quality studies support these as comorbidities that increase the likelihood of nonunion.Conclusion:TTC arthrodesis can be an effective salvage procedure but is associated with high nonunion rates. The results of our meta-analysis suggest that prior neurological deficits, such as Charcot neuroarthropathy or diabetes neuropathy, have strong evidence for failure to achieve union. Although our meta-analysis did not find other statistically significant risk factors, the findings of individual studies in our review suggest that diabetes mellitus and smoking are both factors which can lead to failure of fusion. Surgeons should be cognizant of these risks when performing TTC arthrodesis and carefully monitor patients with the aforementioned comorbidities to achieve successful results.

Risk Factors for Nonunion in Arthroscopic and Open Ankle Arthrodesis

Category:Ankle; Ankle Arthritis; ArthroscopyIntroduction/Purpose:Ankle arthrodesis remains the most popular surgical treatment option for end-stage ankle arthritis (ESAA) among surgeons in the United States. The primary objective endpoint for judging failure versus success of any arthrodesis is radiographic union versus nonunion. Overall, reported union rates in the last two decades have been excellent; however, there does remain significant variation in results with conflicting evidence regarding both treatment and patient factors that are associated with nonunion. We present a relatively large case series of ankle arthrodeses from a single institution with a high-risk patient population with the goal of further clarifying the patient and treatment factors that lead to nonunion.Methods:We conducted a retrospective chart review of 118 patients who underwent primary open or arthroscopic ankle arthrodesis at our institution between November 2014 and April 2019. Revision arthrodesis and patients with a history of complex open fracture were excluded. A minimum 6-month postoperative followup was required. The patients were divided into arthroscopic and open arthrodesis cohorts. The primary outcome measure was radiographic union at 6 months. Patient factors including demographics, BMI, medical comorbidities, and smoking status were analyzed as predictors of nonunion. Likewise, treatment factors such as surgical approach, method of fixation, and tourniquet time were analyzed as predictors of nonunion.Results:Of the 43 individuals that underwent arthroscopic ankle arthrodesis seven progressed to nonunion (16.27%). Among those undergoing open ankle arthrodesis 6 patients out of 46 progressed to nonunion (13.04%). In the arthroscopic cohort, individuals with preoperative lower extremity infection had a significantly higher rate of nonunion compared to those without infection (50.00%, p=0.0447). The open group had two significant predictors of nonunion: use of external fixation and low tourniquet time. Individuals who underwent arthrodesis with the use of an external fixator had a 100% nonunion rate compared to 11.11% for those treated with screws and 0% for those treated with plate fixation (p=0.020). Individuals that had a total tourniquet time under 90 minutes had a non-union rate of 66.67% (p=0.0082).Conclusion:While it was unsurprising that preoperative infection was a significant risk factor for nonunion, it is interesting that this effect was only shown in the arthroscopic group and not the open group. This could have practice implications and warrants further study. Our findings also add to the body of evidence that external fixation is inferior to modern internal fixation techniques for achieving bony fusion. This result may also reflect the poor preoperative prognosis of those requiring external fixation. There remains little evidence that diabetes, smoking, or BMI are significant risk factors for nonunion in primary ankle arthrodesis.

The Impact of Age and Graft Type on Foot and Ankle Arthrodesis Fusion Success

Category:Ankle; Ankle Arthritis; Basic Sciences/Biologics; HindfootIntroduction/Purpose:A recent survey of 100 international foot and ankle orthopaedic surgeons revealed that patient age greater than 60 years is not considered to be a significant risk factor for nonunion following foot and ankle arthrodesis. This finding was surprising as published basic science research shows that autologous bone graft used during fusion surgery may be less effective when harvested from older patients due to both diminished osteogenic potential and migration capacity of mesenchymal stem cells. The purpose of this study was to evaluate the impact of patient age and graft type on fusion rates following hindfoot and ankle arthrodesis.Methods:A Level 1 clinical trial was performed comparing fusion success in 397 hindfoot or ankle arthrodesis subjects (597 joints) supplemented with either autograft or an osteoinductive recombinant human protein derived growth factor (rhPDGF- BB/β-TCP) bone graft substitute. Fusion status was determined using computed tomography, with fusion defined as evidence of at least 50% osseous bridging. In this secondary analysis of that dataset, the odds of fusion success were compared for joints in autograft subjects older or younger than the following age thresholds: 55, 60, 65, 70 and 75 years. This analysis was then repeated for joints in rhPDGF-BB/β-TCP subjects. Finally, odds of fusion success were also compared for the autograft and rhPDGF-BB/β- TCP groups for subjects older than each threshold age.Results:Joints in autograft subjects younger than 60 and 65 years exhibited over two times the odds of fusion as those in older subjects (60 years: OR 2.24, p=0.003; 65 years: OR 2.74, p<0.001). There was no significant difference for other intervals (55 years: OR 1.45, p=0.106; 70 years: 1.64, p=0.096; 75 years: OR 1.28, p=0.335). Interestingly, there was no significant difference for the rhPDGF-BB/β-TCP group at any threshold (55 years: OR 0.86, p=747; 60 years: OR 0.86, p=0.739; 65 years: 1.08, p=0.367; 70 years: 0.94, p=0.588; 75 years: OR 0.70, p=0.809). When odds of fusion were compared for the two groups in subjects older than each age threshold, rhPDGF-BB/β-TCP had approximately two times the odds of fusion success for all except 55 years (Figure 1).Conclusion:This study indicates that age is an identifiable and potentially concerning risk for nonunion following hindfoot or ankle arthrodesis. These findings are in contrast to the wider perception of the surgeon community, as documented in the published survey. Notably, patients over the age of 60 years who are supplemented with autograft have statistically lower odds of fusion compared to those younger, a difference not seen with the use of recombinant technology. This analysis suggests that use of rhPDGF-BB/β-TCP as an alternative bone healing adjunct may help mitigate the risk of nonunion when these procedures are performed in the elderly population.

Association of Lunate Morphology With Progression to Scaphoid Fracture Nonunion.

Background: The purpose of our study was to review a series of patients with scaphoid fractures to determine whether there was an association between lunate morphology and progression to delayed union or nonunion when treated operatively or nonoperatively. Secondary aims included evaluation of the relationship between lunate morphology and scaphoid fracture location. Methods: A retrospective review of all patients with a diagnosis of scaphoid fracture was performed at our institution between 2014 and 2017. Medical records and radiographs were evaluated to determine lunate morphology, scaphoid fracture location, treatment, and time to union. Differences between groups were determined using χ2 analysis with significance set at P <.05. Multiple logistic regression analyses were used to evaluate scaphoid union in the setting of lunate morphology when controlling for confounders. Results: A total of 169 patients were included; 45.0% (n = 76) of patients had type I lunate morphology, and 55.0% (n = 93) had type II. In all, 64.5% (n = 49) of patients with type I lunate and 68.8% (n = 64) with type II lunate had a fracture at the scaphoid waist. Among all patients with a scaphoid fracture, type II lunates were more likely than type I lunates to progress to nonunion when treated both operatively and nonoperatively (18.3% vs 4.0%, P = .0042). Lunate facet size was not shown to be a significant risk factor for nonunion among patients with a type II lunate (P = .4221). Conclusions: Patients with a scaphoid fracture and type II lunate morphology were more likely to progress to nonunion than patients with a type I lunate.

Is Femoral Fracture Healing Really Compromised in Patients with Rheumatoid Arthritis? Comparison Study Between Rheumatoid and Non-rheumatoid Arthritis Patients.

In patients with rheumatoid arthritis (RA), some problems might occur in fracture healing; however, clinical evidence is limited. Therefore, we compared the time to union and complication rate of femoral fractures between RA and non-RA patients. This study included 42 RA patients who underwent osteosynthesis for femoral trochanter or shaft fracture. For comparison with the RA group, 126 non-RA patients were selected as a control group. The RA group was divided into the trochanteric (RA group I) and shaft fracture group (RA group II) for comparison with each control group (control groups I and II). We analyzed risk factors for nonunion or delayed union and divided patients according to whether atypical or ordinary fracture in shaft fracture. Time to union (p = 0.823) and complication rate (p = 0.440) did not differ significantly between RA group I and control group I. A significantly longer time to union (p = 0.001) and higher nonunion rate (p = 0.013) were observed in RA group II compared with control group II. The presence of RA (p = 0.040) and atypical femoral fracture (p = 0.006) were significant risk factors for nonunion or delayed union. The high prevalence of atypical femoral fracture among the femur shaft fractures in the RA patients was considered a significant risk factor for nonunion and delayed union.

Incidence, Risk Factors, and Definition for Nonunion in Pediatric Lateral Condyle Fractures.

Lateral condyle fractures are a common pediatric elbow injury. Nonunion is a known complication of this injury but its incidence and causative risk factors are unknown. Further, a clear and consistent definition of nonunion for pediatric lateral condyle fractures does not exist. The purpose of this study is to determine the rate of nonunion, the risk factors associated with it and to provide a clear definition. A retrospective chart review of all pediatric lateral condyle fractures treated at an urban, tertiary pediatric care center between 2001 and 2014. Data collected included demographics, Weiss classification, type of treatment, follow-up, time from injury to surgery and complications. For patients with nonunions, additional treatments and final range of motion were also recorded. A nonunion was defined as lack of callus with fragment migration by 8 weeks after initiation of treatment. A total of 530 patients were identified of which 500 were available for review. There were 7/500 (1.4%) nonunions in the cohort. Nonunion occurred in 1.4% (2/140) of type I fractures, 0% (0 /178) of type II fractures, and 3% (5/168) of type III fractures. The only significant risk factor for nonunion was the presence of a type III fracture (P=0.05). Five patients with nonunion underwent revision surgery with a partially threaded cannulated cancellous screw. All of these patients went on to union. Four of the 5 patients had their screws removed after union. Nonunion after pediatric lateral condyle fracture is rare and is defined by lack of any callus with fragment migration at 8 weeks. The only significant risk factor for nonunion development was the presence of a type III fracture. Revision surgery with a partially threaded screw achieved union in all cases. Level IV-retrospective case review.

The Influence of Capsulotomy for Intracapsular Hip Fractures.

Young patients with femoral neck fractures undergo operative stabilization urgently to prevent complications of avascular necrosis (AVN) and nonunion. The necessity of capsulotomy to prevent these sequelae is disputed. A retrospective chart review performed on 113 patients who underwent fixation of a femoral neck fracture found 62 patients following exclusion criteria, who were analyzed for demographic and fracture characteristics, operative variables, and radiographic outcomes. Sixty-two patients (age 18-85), with a mean follow-up of 21.2 months, had a mean time to union of 5.3 months. Capsulotomies were performed in 32 patients. Seven patients demonstrated AVN (5 with capsulotomy) (p = 0.285). Age was not a risk factor for nonunion or AVN. Additionally, nine fractures (four with capsulotomy) went on to nonunion (p = 0.602). We did not find increased risk of AVN in patients with diabetes or smoking, although a pre-existing diagnosis of hypertension was associated with a significantly increased risk of AVN (p = 0.04). Overall, AVN rates after operative stabilization of femoral neck fractures was 11% and not statistically influenced by capsulotomy. Hypertension was the only significant risk factor for nonunion.

Bone Turnover Markers as a New Predicting Factor for Nonunion After Spinal Fusion Surgery.

Retrospective observational study. We investigated whether bone turnover markers could be a useful indicator for prediction of nonunion. Nonunion is a major complication of lumbar spinal fusion surgery. The involvement of bone turnover in the process of bony union in spinal fusion surgery is, however, poorly understood. Of the 74 patients analyzed, 13 were diagnosed with nonunion. We evaluated the significance of the following risk factors: age, sex, number of fused segments, serum levels of total alkaline phosphatase, procollagen type 1 amino-terminal propeptide (P1NP), tartrate-resistant acid phosphatase 5b (TRACP-5b), and albumin, and history of diabetes mellitus, cigarette smoking, or alcohol use. We also defined the bone turnover ratio (BTR) as a value that equals serum TRACP-5b concentration divided by serum P1NP concentration to evaluate patients' individual bone turnover balance and investigated the significance of BTR as a risk factor. Univariate analysis showed that older age, malnutrition, and lower P1NP are risk factors for nonunion. Stepwise logistic regression analysis revealed that in the presence of lower P1NP, higher TRACP-5b becomes a risk factor. Furthermore, we identified BTR as the most significant risk factor for nonunion. The optimum cut-off value of BTR by receiver-operating characteristic curve was 11.74. These findings show a relation between bone turnover and nonunion after spinal fusion surgery. The measurement of bone turnover markers could potentially be used to predict nonunion after spinal fusion surgery. 4.

Predictors of Nonunion in Humerus Shaft Fractures in Adults in Lom&amp;#233; (Togo)

Background: To identify predictors of humerus shaft fractures nonunion in adults whatever the type of treatment performed. Patients and Methods: We conducted a retrospective study among patients who had a fracture of the humeral shaft moving towards healing or nonunion. Patients were treated in the orthopedic trauma unit of Sylvanus Olympio Teaching Hospital and two other private clinics in Lome between January 2008 and June 2012. On the X-ray of each patient, we measured the angulation, the diastasis, and inter fragmentary contact. For each included patient, we looked for: age, sex, medical history, body mass index (BMI), according to the third location of the shaft fracture, the type of fracture according to AO classification and the type of opening according Tscherne classification. Results: During the study period, 184 patients with humeral shaft fracture were identified. Of these 108 were men. The mean age of patients was 37.3 years. The fractures were treated conservatively in 100 patients (54.3%), 78 treated surgically and six (3.3%) have discharged from hospital against medical advice for traditional treatment. The factors that were associated with nonunion of humerus shaft fractures in these patients were: the opening of the fracture (RR = 4.5; 95% CI = [2.9; 7.1]), the presence of immediately radial paralysis (RR = 5.6; 95% CI = [3.7; 8.5]), the existence of other associated lesions or fracture (RR = 1.8; 95% CI = [1.1; 3.1]), energy of the trauma (RR = 2.3; 95% CI = [1.3; 4.4]) and type III classification of Tscherne (RR = 0.3; 95% CI = [0.2; 0.6]). After multivariate analysis, factors that remained significantly associated with the failure of consolidation were: the existence of diastasis > 2 mm (OR = 7.6; 95% CI = [2.2; 25.6)), the Body Mass Index (BMI) > 25 (OR = 1.3; 95% CI = [1.1 - 1.6]) and the existence of other bone lesion (OR = 4.3; 95% CI = [1.4 - 18.9]). Conclusion: BMI greater than 25, the existence of an interfragmentary gap of more than 2 mm and existence of other bone lesions are significant risk factors for nonunion in humerus shaft fractures. The traditional treatment, common singular factor to the African environment, should not be ignored. Control of these predictors is necessary in carrying out the treatment of humerus shaft fractures.

Middle third clavicular fractures: to fix or not to fix?

Clavicular fractures are common injuries with the incidence quoted between 29 and 198 per 10 000 population per year.1 They are classified into three types:- Type 1: Middle third Type 2: Lateral third (distal to coraco-clavicular ligament) Type 3: Medial third The majority of fractures (> 70%) are type 1. Traditionally these fractures have been treated conservatively with initial immobilisation in a broad arm sling, collar and cuff, or figure of eight strapping. The results of conservative treatment were generally felt to be satisfactory. Nordqvist et al2 in Malmo reviewed 225 mid clavicular fractures at an average of 17 years from injury. The great majority (185/82%) were symptom free. Thirty-nine (17%) had moderate pain and one patient was classified as poor. Fifty-three of the patients had a malunion and seven had nonunions. Forty of the patients with malunited fractures and three with nonunion were rated as good. Fagg1 reviewed the available literature and found an incidence of nonunion of 7% in displaced mid shaft fractures at that time. Thormodsgard et al3 looked at patient satisfaction after non-operative management of clavicular fractures using the Disabilities of the Arm, Shoulder and Hand (DASH) classification. They looked particularly at clavicular shortening and found that patients with shortening of over 2 cm had the highest DASH scores indicating disability and dissatisfaction with their outcome after the injury. They looked at all types of clavicular fracture but found that DASH scores were higher in type 1 fractures. They concluded, “patients with midshaft clavicle fractures with shortening of greater than 2 cm may be good candidates for operative repair.” Murray et al4 assessed the significant risk factors for nonunion in 941 conservatively treated mid shaft clavicular fractures in adults. One hundred and twenty-five (13.3%) had clinical and radiological evidence of nonunion. …

Characteristic Radiographic or Magnetic Resonance Images of Fresh Osteoporotic Vertebral Fractures Predicting Potential Risk for Nonunion

Prospective multicenter study. To identify radiographic or magnetic resonance (MR) images of fresh vertebral fractures that can predict a high risk for delayed union or nonunion of osteoporotic vertebral fractures (OVFs). Vertebral body fractures are the most common fractures in osteoporosis patients. Conservative treatments are typically chosen for OVFs, and associated back pain generally subsides within several weeks with residual persistent deformity of the vertebral body. In some patients, OVF healing is impaired and correlated with prolonged back pain. However, assessments such as plain radiograph or MR images taken during the early phase to predict high risks for nonunions of OVFs and/or poor prognoses have not been identified. A total of 350 OVF patients from 25 institutes were enrolled in this clinical study. Plain radiograph and MR images of the OVFs were routinely taken at enrollment at the respective institutes. The findings on the plain radiograph and MR images were classified after enrollment in the study. All the patients were treated conservatively without any surgical intervention. After a 6-month follow-up, the patients were classified into two groups, a union group and a nonunion group, depending on the presence of an intravertebral cleft on plain radiograph or MR images. The associations of the images from the first visit with those of the corresponding nonunions at the 6-month follow-up were analyzed by multivariate logistic regression to elucidate specific image characteristics that may predict a high risk for nonunion of OVFs. Forty-eight patients (49 vertebrae) among the 350 patients (363 vertebrae) were classified as nonunions, indicating a nonunion incidence of 13.5% for conventional conservative treatments for OVFs. The statistical analyses revealed that a vertebral fracture in the thoracolumbar spine, presence of a middle-column injury, and a confined high intensity or a diffuse low intensity area in the fractured vertebrae on T2-weighted MR images were significant risk factors for nonunion of OVFs. The results of this study revealed significant relationships between plain radiograph and MR images of acute phase OVFs and the incidence of nonunion. As these risk factors are defined more clearly and further validated, they may become essential assessment tools for determining subsequent OVF treatments. Patients with one or more of the earlier-described risk factors for nonunion should be observed carefully and provided with more intensive treatments.

109. What are the Statistically Significant Risk Factors for Nonunion when Performing Anterior Cervical Discectomy with Allograft and Cervical Plating?

109. What are the Statistically Significant Risk Factors for Nonunion when Performing Anterior Cervical Discectomy with Allograft and Cervical Plating?