Symptomatic Nonunion Research Articles

The use of a dorsal capsular-based flap graft for scaphoid pseudarthrosis – long-term functional results

Introduction The scaphoid has a very tenuous blood supply that limits its capacity to recover from injury. A fracture of the scaphoid therefore presents an important risk of delayed union, pseudarthrosis and avascular necrosis. The fact that this type of fracture is many times missed on the first observation further increases the risk of pseudarthrosis. The use of pedicle grafts has the ability to fill the nonunion defect with new bone, bringing new osteoblasts and blood supply to the injury site. In 2006, Sotereanos described a capsular-based vascularized distal radius graft for the treatment of scaphoid pseudarthrosis that was readily available, close to the pseudarthrosis, required minimal rotation and did not need the dissection of a pedicle. The goal of our study was to evaluate the long-term results of the treatment of pseudarthrosis of the scaphoid using a capsular-based vascularized distal radius graft (as described by Sotereanos et al., 2006). Materials and methods Ten patients who underwent this procedure were identified, and the average follow-up time was 4,5 years (range 2–6 years). All but one patient were male, with an average age of 30 years (range 18–45). In 8 patients the non-dominant limb was the one affected. A dorsal approach was used, and the technique was according to Sotereanos et al., 2006. Results There were no postoperative complications such as infection or hardware migration. Of the 10 patients, 8 evolved to union, as determined by x ray and clinical examination. None of the patients was forced to abandon their professional activity after surgery, even though 25% required some type of adaptation necessary at their workplace. The average functional capacity was, according to the Mayo Wrist Score, of 82 points (range 65–90), corresponding to a “Good” function. The average disability according to the QuickDASH was 12.6 (range 0–45.5). The two patients with persistent symptomatic nonunions declined further surgical treatment and presented with the worst outcomes. All patients had decreased ROM after surgery. Discussion The union rate after surgery in this series is in line with previously published studies about this technique. No other published studies present long-term functional studies with this technique. Conclusion This technique is safe, easy and reliable for the treatment of scaphoid nonunions. Patients presented a good functional result at a mean follow-up of 4.5 years.

Reoperation Rates for Symptomatic Nonunions in Anterior Cervical Fusions From a National Spine Registry.

A retrospective cohort study with chart review. To determine the reoperation rates for symptomatic nonunions for 1-level, 2-level, and 3-level anterior cervical discectomies and fusions (ACDFs) from a national spine registry. There is very little data reported in the literature on reoperation rates for symptomatic nonunions after ACDFs. The reported nonunion rates are primarily based on radiographical evidence, although some of these may be asymptomatic. Similarly, there may be symptomatic patients with nonunions who elect not to have a reoperation. We think, however, data from a national spine registry provide a realistic and unbiased assessment of routine cervical spine fusion care and represent a heterogeneous population with varied indications and surgical techniques and are best suited to determine reoperations for symptomatic nonunions. Using data from a Spine Implant Registry developed at a large integrated health care system (Kaiser Permanente), patients with ACDFs between January 2009 and December 2012 with 2-year follow-up were identified. Patient characteristics, admitting diagnosis, and number of levels fused were extracted from the registry. Reoperations for symptomatic nonunions from the index spinal procedure were identified by chart review. A cohort of 1054 patients with more than 2 years of follow-up were found to have reoperations for nonunions of 0.2%, 2.9%, and 6.5% for 1-level, 2-level, and 3-level ACDFs, respectively. A large cohort of ACDF patients with more than 2 years of follow-up had reoperations for nonunion rates significantly lower than reported in the literature for radiographical nonunions. We think our data add to the literature an important parameter (reoperations for nonunion rates) and provide useful information for patients, spine surgeons, and health care payers.

Low-Intensity Pulsed Ultrasound Bone Stimulator Treatment for Symptomatic Distal Phalangeal Shaft Fracture Nonunion.

Two cases of symptomatic distal phalangeal fracture nonunion that were treated with a course of digital splinting and daily external low-intensity pulsed ultrasound (LIPUS) treatment are presented. Osseous union, symptom resolution, and full range of motion were successfully achieved in both cases without surgery. Digital splinting and daily LIPUS should be considered as a treatment option for symptomatic nonunion of the distal phalanx in cases that do not require correction of bone deformity.

Comparison of Osteochondral Autografts and Allografts for Treatment of Recurrent or Large Talar Osteochondral Lesions.

The purpose of this study was to prospectively evaluate and compare the long-term clinical and radiographic outcomes of using osteochondral autograft and allograft to manage either recurrent or large osteochondral lesions of the talar dome (OLT) in a single surgeon's practice. Between January 2008 and January 2014, a total of 40 patients presented with either a recurrent OLT that failed initial arthroscopic treatment (ie, excision, curettage, debridement, and micro-fracture) or a primary OLT greater than 1.5 cm2 that had undergone no prior surgery. Before surgery, 20 patients were randomized to receive osteochondral autograft plugs (Arthrex, Naples, FL) from the ipsilateral superolateral distal femoral condyle whereas the remaining 20 were randomized to receive osteochondral allograft plugs from a fresh size-matched donor talus (Joint Restoration Foundation, Centennial, CO, and Arthrex, Naples, FL), but 4 of these were excluded that received a hemi-talus allograft with internal fixation. Preoperative and postoperative function and pain was graded using the Foot and Ankle Ability Measures (FAAM) scoring system and a Visual Analog Scale (VAS) of pain, respectively. Radiographs were assessed for osteochondral graft healing, joint congruency, and degenerative changes. Data regarding postoperative complications and revision surgeries were also recorded. Of the 20 patients who received osteochondral autograft, the mean FAAM score increased from 54.4 preoperatively to 85.5 at the time of final follow-up. The mean VAS pain score decreased from 7.9 of 10 preoperatively to 2.2 of 10 at final follow-up. Two patients (10%) that received osteochondral autograft, 1 for a recurrent OLT of 1.3 cm2 and 1 for a primary OLT of 2.0 cm2, developed a symptomatic nonunion at the entire graft site. Both of these patients had their autograft converted to talar allograft plugs and achieved full osteochondral healing. At the time of final follow-up, no patients who received osteochondral autograft developed ankle degenerative changes or knee complications. The mean FAAM score of the 16 patients who received osteochondral allograft plugs increased from 55.2 preoperatively to 80.7 at the time of final follow-up. This postoperative score was lower than that of the osteochondral autograft group, but not to a statistically significant degree (P = .25). The mean VAS pain score decreased from 7.8 of 10 preoperatively to 2.7 of 10 at final follow-up. This postoperative score was higher than that of the osteochondral autograft group but not to a statistically significant degree (P = .15). Three patients (18.8%) that received osteochondral talar allograft, 2 for recurrent OLTs less than 1.5 cm2 and 1 for a primary OLT of 2.2 cm2, developed a symptomatic nonunion at the entire graft site. Two of these 3 patients had their allograft converted to osteochondral autograft plugs harvested from the ipsilateral superolateral distal femoral condyle and achieved full osteochondral healing. At the time of final follow-up, 1 of these 16 (6.3%) patients who received talar allograft as OLT treatment had developed asymptomatic anterior ankle arthritis upon radiographs. Using fresh talar osteochondral allograft provided results that were comparable to the use of distal femoral osteochondral autograft for treating recurrent or large OLTs. Although the use of allograft avoided the risk of knee complications when harvesting autograft from the distal femur, fresh talar allograft may have lower healing rates than osteochondral autograft. Level II, comparative case series.

The operative outcomes of displaced medial-end clavicle fractures

Nonoperative treatment of displaced medial clavicle fractures often leads to poor functional outcomes and painful nonunions. This study investigates the functional outcomes of patients undergoing operative fixation of these fractures. We investigated 27 patients undergoing operative fixation of a medial clavicle fracture; 24 had an acute, displaced fracture and 3 had fixation for nonunions. Preoperative radiographs or computed tomography scans were obtained, and data collected included age, sex, mechanism of injury, and fixation method. Follow-up included physical examination and radiographs for assessment of union; Disabilities of the Arm, Shoulder, and Hand scores at 12 months; and the recording of complications. The median age was 37 years (interquartile range, 17-47 years). There were 26 male patients and one female patient included, with 7 physeal injuries and 20 adult injuries. The most common mechanism of fracture was vehicular accident (n = 15). Three patients had operations for nonunions and 2 for a periprosthetic fracture medial to an existing plate. The fracture was fixed with plate and screws in 19 cases and with transosseous sutures in 8 cases. The median Disabilities of the Arm, Shoulder, and Hand score at 12 months was 0.4 (interquartile range, 0-5.0), with a union rate of 100% at 12 months. All patients had full shoulder range of motion at final follow-up and were able to return to preinjury occupational activities. There were no significant complications. Operative fixation of displaced medial clavicle fractures results in anatomic reconstruction and excellent functional outcomes, even in the setting of fixation performed for symptomatic nonunion. Early intervention can minimize the risk of painful nonunion.

Surgical interventions for treating acute fractures or non-union of the middle third of the clavicle.

This review covers two conditions: acute clavicle fractures and non-union resulting from failed fracture healing. Clavicle (collarbone) fractures account for around 4% of all fractures. While treatment for these fractures is usually non-surgical, some types of clavicular fractures, as well as non-union of the middle third of the clavicle, are often treated surgically. This is an update of a Cochrane review first published in 2009. To evaluate the effects (benefits and harms) of different methods of surgical treatment for acute fracture or non-union of the middle third of the clavicle. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (27 June 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 5), MEDLINE (1966 to June week 3 2014), EMBASE (1988 to 2014 week 25), LILACS (1982 to 27 June 2014), trial registries and reference lists of articles. We applied no language or publication restrictions. We considered randomised and quasi-randomised controlled trials evaluating any surgical intervention for treating people with fractures or non-union of the middle third of the clavicle. The primary outcomes were shoulder function or disability, pain and treatment failure (measured by the number of participants who had undergone or were being considered for a non-routine secondary surgical intervention for symptomatic non-union, malunion or other complications). Two review authors selected eligible trials, independently assessed risk of bias and cross-checked data. Where appropriate, we pooled results of comparable trials. We included seven trials in this review with 398 participants. Four trials were new in this update.The four new trials (160 participants) compared intramedullary fixation with open reduction and internal fixation with plate for treating acute middle third clavicle fractures in adults. Low quality evidence from the four trials indicated that intramedullary fixation did not result in a clinically important improvement in upper arm function (despite a statistically significant difference in its favour: standardised mean difference 0.45, 95% confidence interval (CI) 0.08 to 0.81; 120 participants, three trials) at long term follow-up of six months or more. Very low quality evidence indicated little difference between intramedullary fixation and plate fixation in pain (one trial), treatment failure resulting in non-routine surgery (2/68 with intramedullary fixation vs. 3/65 with plate fixation; risk ratio 0.69, 95% CI 0.16 to 2.97, four trials) or time to clinical fracture consolidation (three trials). There was very low quality evidence of a lower incidence of participants with adverse events (mainly infection, poor cosmetic result and symptomatic hardware) in the intramedullary fixation group (18/68 with intramedullary fixation vs. 27/65 with plate fixation; RR 0.64, 95% CI 0.39 to 1.03) but the CI of the pooled results also included the small possibility of a lower incidence in the plate fixation group. None of the four trials reported on quality of life or return to previous activities. Evidence is pending from two ongoing trials, with planned recruitment of 245 participants, testing this comparison.There was low or very low quality evidence from three small trials, each testing a different comparison. The three trials had design features that carried a high risk of bias, potentially limiting the reliability of their findings. Low-contact dynamic compression plates appeared to be associated with significantly better upper-limb function throughout the year following surgery, earlier fracture union and return to work, and a reduced incidence of implant-associated symptoms when compared with a standard dynamic compression plate in 36 adults with symptomatic non-union of the middle third of the clavicle. One quasi-randomised trial (69 participants) compared Knowles pin versus a plate for treating middle third clavicle fractures or non-union. Knowles pins appeared to be associated with lower pain levels and use of postoperative analgesics and a reduced incidence of implant-associated symptoms. One study (133 participants) found that a three-dimensional technique for fixation with a reconstruction plate was associated with a significantly lower incidence of symptomatic delayed union than a standard superior position surgical approach. Evidence is pending from two ongoing trials, with planned recruitment of 130 participants, comparing anterior versus superior plates for acute fractures. There is very limited and low quality evidence available from randomised controlled trials regarding the effectiveness of different methods of surgical fixation of fractures and non-union of the middle third of the clavicle. The evidence from four ongoing trials is likely to inform practice for the comparisons of intramedullary versus plate fixation and anterior versus superior plates for acute fractures in a future update. Further randomised trials are warranted, but in order to optimise research effort, these should be preceded by research that aims to identify priority questions.

Trends in Epidemiology and Management of Traumatic Type II Odontoid Fracture: Experience in Latin America

Introduction Odontoid fractures (OF) are frequent in the trauma population, and there is no universally accepted single method of management. The objective of this study was to evaluate the epidemiology and management of type II OF in Latin America treated either with rigid cervical orthosis or surgery. Patients and Methods A total of 83 patients treated conservatively or by surgery were enrolled in this retrospective study. Medical charts, imaging studies, and outcomes of patients were analyzed in the pretreatment period and at the last medical evaluation. The fractures were assessed using conventional radiographs, three-dimensional computed tomographic (3D-CT) scans, and magnetic resonance images. Fracture gaps, the direction and the degree of displacement of the odontoid process, the fracture line anatomy, the degrees of atlantoaxial instability, the comminuted fracture, and the surface contact area were analyzed. The decision for operative or nonoperative treatment was based on anesthesia risk, and patient's choice of the nonoperative treatment. The nonoperative management generally consisted of a rigid cervical orthosis for 3 months. The type of surgery to be performed was chosen by the surgeon. The solid bony union was defined as the presence of bony bridges and the definite continuity of cortical bone. Fibrous union was considered present when no degree of motion was evident in dynamic radiographs despite persistent cortical bone discontinuity within a fracture gap on 3D CT scans. Nonunion was defined as a definite fracture gap with abnormal motion of the fractured dens on dynamic radiographs and on a 3D CT scan. Results A total of 83 patients were included in this study. The patients were 78.3% men, the mean age = 44.98 ( ± 23.20 years) years. Traffic accidents (66.3%) were the most common cause of trauma. The main symptom was pain (85.5%) in the posterior cervical region. The median time elapsed from accident to surgery was 7 days (P25: 2/P75: 27.5). Median follow-up was 23.66 ( ± 25.43 months) months. Conservative treatment with cervical orthosis, for example, Miami J collar or halo-vest was used in 20.5% of the cases. Odontoid screw technics (57.6%) were the most common surgical treatment adopted as primary surgical treatment. Symptomatic nonunion was observed in two cases with conservative treatment and three cases after odontoid screw fixation. All the patients were referred to posterior C1–C2 fixation. The posterior fixation tended to be used after conservative failed therapy, after nonunion anterior screw surgery, and in fractures with greater displacement. The most common radiological feature was no displacement of the odontoid process in relation to the body of C2, horizontal fracture line, gap fracture < 2 mm, no subluxation across each C1–C2 facet joint and no comminuted fracture. Conclusion The patients treated nonoperatively with a rigid collar may have an overall favorable outcome compared with surgical treatment. A well-designed prospective study is needed to better elucidate optimal treatment algorithms from both an outcomes and cost-effectiveness perspective.

What Is the Outcome of Allograft and Intramedullary Free Fibula (Capanna Technique) in Pediatric and Adolescent Patients With Bone Tumors?

After bone tumor resection, reconstruction for limb salvage surgery can be challenging because of the resultant large segmental bony defects. Structural allografts have been used to fill these voids; however, this technique is associated with high complication rates. To circumvent the complications associated with this procedure, massive bony allografts have been supplemented with an intramedullary vascularized free fibula. However, few studies have examined the outcomes using this technique in the pediatric and adolescent populations. The purpose of this study was to examine the revision-free survival using he Capanna technique for limb salvage for pediatric lower limb salvage. We attempted to answer the following questions: (1) What was the overall limb salvage rate along with incidence of reoperation and complications? (2) How did pediatric and adolescent patients functionally perform after this technique? (3) What was the incidence of late complications including infection and fracture? (4) What was the incidence of limb length discrepancy? Eighteen pediatric patients who underwent lower extremity limb salvage with the use of cadaveric allograft and intramedullary free fibular transfer (Capanna technique) were identified. There were nine boys males and nine girls with a mean age of 11years (range, 5-18years) and mean followup of 8years (range, 2-15years), respectively. All patients had at least 2years followup. Three patients have not been seen in followup during the past 5-years; however, all had made it to their 5-year clinical followup. The patients' medical records were reviewed for clinical and functional outcomes as well as postoperative complications. Time to union was recorded through an evaluation of radiographs. Mankin functional outcome and Musculoskeletal Tumor Society (MSTS) rating scale were recorded for each patient. The overall limb salvage rate was 94%. Fourteen patients underwent an additional surgical procedure. Six patients underwent additional procedure(s) to treat a symptomatic nonunion. Seventeen of the patients had a good or excellent Mankin score with a mean MSTS rating of 93% at last followup. Six of the patients underwent a limb length modification procedure. Use of large allografts in conjunction with intramedullary vascularized free fibulas appears to be a reliable method for the reconstruction of large bony tumors of the lower extremity in this population, although we did not directly compare this with allografts alone in our study. The use of locked plates may improve union times. The proportion of patients achieving limb preservation was high and complication rates are acceptable. Level IV, therapeutic study.

Medial epicondyle fractures in children.

The present review discusses the relevant anatomy, clinical presentation, and management of medial epicondyle fractures, including diagnostic controversies, the indications for operative and nonoperative management, and outcomes. Recent studies have highlighted the underestimation of fracture displacement seen on typical radiographic views and have attempted to define the location of the medial epicondyle on radiographs to improve the accuracy of measuring displacement. They have demonstrated variable outcomes following open reduction and internal fixation of medial epicondyle fractures that are associated with intra-articular incarceration. Newer evidence supports the fixation of medial epicondyle fractures in adolescent athletes, to allow return to competitive sports. Medial epicondyle fractures of the distal humerus account for 12% of pediatric elbow fractures and are frequently associated with intra-articular incarceration of the fracture fragment, elbow dislocation, ulnar nerve injury, and other upper extremity fractures. Recent literature calls into question the accuracy of measuring fracture displacement, and controversy exists regarding optimal management of these fractures. Good outcomes have been achieved with nonoperative treatment for minimally displaced fractures, despite a high rate of nonunion. In patients with displaced fractures, fixation yields stability, functional range of motion, and the ability to return to previous activity levels, including sports. Complications include stiffness, instability, deformity, superficial wound infections, and symptomatic nonunion. Further study is required to standardize the measurement of displacement and to clarify indications for operative treatment in both sedentary and active children.

Functional computed tomography scanning for evaluating fusion status after anterior cervical decompression fusion.

Nonunion is a major complication of anterior cervical fusion that causes poor outcomes and occasionally requires additional operative intervention. The purpose of this study is to evaluate the accuracy of functional computed tomography (CT) scanning for determining fusion status after anterior cervical fusion by comparing with functional radiographs. The fusion status in 59 patients treated by anterior cervical fusion was assessed by functional radiography and functional CT scanning at 6 and 12 months after surgery. Fusion rates and clinical symptoms were evaluated. Fusion on functional radiography was defined as less than 2 mm of motion between adjacent spinous processes and a particular bony trabeculation on functional CT; fusion was defined as nonexistence of a clear zone or a gas pattern and a particular bone connection on reconstructed sagittal-view images. Functional radiographs demonstrated solid fusion in 83.9% at 6 months and 91.1% at 12 months postoperatively; functional CT showed solid fusion in 55.3 and 78.6%, respectively. The fusion rate detected on functional CT images was significantly lower than that on functional radiographs at each period. At 6 months postoperatively, patients with incomplete union on functional CT were more likely to have neck pain than those who had complete union on functional CT. (46.2 vs 13.3%, P < 0.05) CONCLUSION: Functional CT can detect nonunion more clearly than functional radiography. At 6 months postoperatively, patients with incomplete union on functional CT images were likely to have more neck pain. Functional CT may allow accurate detection of symptomatic nonunion after anterior cervical fusion.

Surgical Management of Isolated Acromion Fractures

Acromion fractures of the scapula are rare and most often occur with concomitant fractures of the ipsilateral glenoid, neck and body of the scapula as sequelae of high-energy injuries. Indications for operative management include symptomatic nonunion, displaced fractures, or acromion fractures associated with other lesions of the superior shoulder suspensory complex. Less displaced acromion fractures resulting in decreased subacromial space may also warrant surgery. Although surgical indications have been reported, the literature regarding surgical approaches and fixation techniques for management of these factures is limited. Acromion fractures can generally be addressed with a direct posterior approach using either tension band or low-profile plating in combination with cortical lag screws to obtain a stable construct. This technique is both effective in achieving fracture union and safe to the patient. When associated with a more complex fracture of the glenoid and/or scapula body, the surgical approach and fixation strategy should be dictated by the optimal approach to other displaced elements of a scapula fracture. The purpose of this study was to describe a step-wise approach to the surgical management of isolated acromion fractures, describe surgical tips and techniques, and to present the early clinical outcomes in 13 patients after surgical treatment with this approach.

Nonoperative Management of Displaced Olecranon Fractures in Low-Demand Elderly Patients

The aim of this study was to document both the short and the long-term outcomes following primary nonoperative management of isolated displaced fractures of the olecranon. We identified, from our prospective trauma database, all patients who had been managed nonoperatively for a displaced olecranon fracture over a thirteen-year period. Inclusion criteria included all isolated fractures of the olecranon with >2-mm displacement of the articular surface. The primary short-term outcome measure was the Broberg and Morrey Elbow Score. The primary long-term outcome measure was the Disabilities of the Arm, Shoulder and Hand (DASH) score. There were forty-three patients with a mean age of seventy-six years (range, forty to ninety-eight years) in the study cohort. A low-energy fall from a standing height accounted for 84% of all injuries, and one or more comorbidities were documented in thirty-eight patients (88%). At a mean of four months (range, 1.5 to ten months) following injury, the mean Broberg and Morrey score was 83 points (range, 48 to 100 points), with 72% of the patients having an excellent or good short-term outcome. No patient underwent surgery for a symptomatic nonunion. At a mean of six years (range, two to fifteen years) postinjury, the mean DASH score was 2.9 points (range, 0 to 33.9 points) and the mean Oxford Elbow Score was 47 points (range, 42 to 48 points); 91% (twenty-one) of twenty-three patients available for follow-up expressed satisfaction with the result of the procedure. We found satisfactory short-term and long-term outcomes following the nonoperative management of isolated displaced olecranon fractures in older, lower-demand patients.

Treatment of scaphoid nonunion: Pedicled vascularized bone graft vs. traditional bone graft

The clinical results of the application of pedicled vascularized bone graft (VBG) from Lister's tubercle vs. traditional bone graft (TBG) were evaluated and compared. Thirteen cases of symptomatic scaphoid nonunion were treated between January 2011 and December 2012, including 7 cases subject to VBG and the rest 6 cases to TBG, respectively. Outcomes were assessed by modified Mayo wrist score system. All cases were followed up for an average period of 3.5 months after operation. The results showed that total scores in VBG group were 86.4±9.4 after operation with excellent result in 4 cases, good in 2 and acceptable in one, and those in TBG group were 71.7±9.3 after operation with good result in 2 cases, acceptable in 3 and disappointing in one. Total score of wrist function was significantly improved in VBG group as compared with TBG group (P<0.05). Our study suggests that VBG method is more effective for treating scaphoid nonunion than TBG method.

Revision MTP Arthrodesis for Failed MTP Arthroplasty

Although the gold standard to address hallux rigidus that fails conservative treatment is an arthrodesis, some surgeons have attempted to use arthroplasty to improve range of motion and to simulate a normal joint. When these implants do fail, a salvage MTP arthrodesis is the only surgical option for these patients. This research aims to outline various methods to arthrodese the MTP joint in salvage situations. We retrospectively looked at patients who underwent a first-MTP fusion after failure of an implant arthroplasty. All fusions involved either bone allograft or autograft and internal fixation. The patients were assessed clinically, radiographically, and with the Ankle Society Hallux Metatarsophalangeal-Interphalangeal (AOFAS MTP-IP) clinical questionnaire preoperatively and postoperatively. In all, 11 patients met the inclusion criteria. The average age of patients at the time of the salvage MTP arthrodesis was 57 years. The interval time between primary surgery and revision arthrodesis was on average 84.2 months. There was a high reoperation rate, with 7 operative procedures occurring per 12 arthrodeses (58%). The average time to radiographic fusion was 6.9 ± 4.8 months; 41.7% of patients had a delayed union (>6 months to fusion). Two patients had symptomatic nonunions (16.7%). All the patients had an improvement in their AOFAS MTP-IP score. Although salvage arthrodeses for failed arthroplasties generally have favorable satisfaction rates and are a powerful tool in treating this painful condition, they are fraught with complications. They unite slower, have a significantly higher reoperation rate, and have lower AOFAS scores than primary fusions.

T.A.C.’ Pin Fixation for Basal Ulnar Styloid Fractures Associated With Distal Radius Fractures

Distal radius fractures often accompany ulnar styloid fractures. As basal ulnar styloid fractures sometimes result in symptomatic nonunion causing distal radioulnar joint instability, surgical intervention should be considered as a method of treatment. However, conventional methods of internal fixation for ulnar styloid involving tension band wiring and pinning often causes irritation of hardware, and required further surgery. We performed T.A.C.' pin fixation for basal ulnar styloid fractures associated with distal radius fractures in 24 patients. X-rays showed union at an average of 6.8 weeks postoperatively in all but 1 case, which resulted in asymptomatic fibrous nonunion. Irritation from the hardware was recognized in 3 cases, but soon disappeared after recutting or removal of the pin. At the final follow-up, no symptoms involving ulnar wrist pain or distal radioulnar instability were noted. T.A.C.' pin fixation for basal ulnar styloid is a useful method and rarely requires further surgery compared with conventional methods.

Complications of rhBMP-2 utilization for posterolateral lumbar fusions requiring reoperation: a single practice, retrospective case series report

Background contextRecombinant human bone morphogenetic protein-2 (rhBMP-2) (INFUSE, Medtronic, Memphis, TN, USA) has been used off-label for posterolateral lumbar fusions for many years. PurposeThe goal of this study was to evaluate the complications requiring reoperation associated with rhBMP-2 application for posterolateral lumbar fusions. Study design/settingDuring a 7-year period of time (2002–2009), all patients undergoing lumbar posterolateral fusion using rhBMP-2 (INFUSE) were retrospectively evaluated within a large orthopedic surgery private practice. Patient sampleA total of 1,158 consecutive patients were evaluated with 468 (40.4%) males and 690 (59.6%) females. Outcome measuresComplications related to rhBMP were defined as reoperation secondary to symptomatic failed fusion (nonunion), symptomatic seroma formation, symptomatic reformation of foraminal bone, and infection. MethodsInclusion criteria were posterolateral fusion with rhBMP-2 implant and age equal to or older than 18 years. Surgical indications and treatment were performed in accordance with the surgeon's best knowledge, discretion, and experience. Patients consented to lumbar decompression and arthrodesis using rhBMP-2. All patients were educated and informed of the off-label utilization of rhBMP-2. Patient follow-up was performed at regular intervals of 2 weeks, 6 weeks, 12 weeks, 6 months, 1 year, and later if required or indicated. ResultsAverage age was 59.2 years, and body mass index was 30.7 kg/m². Numbers of levels fused were 1 (414, 35.8%), 2 (469, 40.5%), 3 (162, 14.0%), 4 (70, 6.0%), 5 (19, 1.6%), 6 (11, 0.9%), 7 (7, 0.6%), 8 (4, 0.3%), and 9 (2, 0.2%). Patients having complications requiring reoperation were 117 of 1,158 (10.1%): symptomatic nonunion requiring redo fusion and instrumentation 41 (3.5%), seroma with acute neural compression 32 (2.8%), excess bone formation with delayed neural compression 4 (0.3%), and infection requiring debridement 26 (2.2%). Nonunion was related to male sex and previous BMP exposure. Seroma formation was significantly higher in patients with higher doses of rhBMP-2 (p=.050) and with more than 12 mg of rhBMP-2 (χ2=0.025). Bone reformation and neural compression at the laminectomy and foraminotomy sites occurred in a delayed fashion. Infection was associated with obesity and respiratory disease. Infections were noted with a greater BMP dose (p<.001), more than 12 mg (χ2<0.001), fusion more than three levels (χ2<0.001), and reexposed to BMP (χ2=0.023). ConclusionsrhBMP-2 utilization for posterolateral lumbar fusions has a low symptomatic nonunion rate. Prior rhBMP-2 exposure and male sex were related to symptomatic nonunion formation. rhBMP-2–associated neural compression acutely with seroma formation and delayed with foraminal bone formation is concerning and associated with higher rhBMP-2 concentrations.

Nonunion of an Isolated Cuboid Fracture

Nonunion of an isolated undisplaced cuboid fracture is unusual. We report a case of symptomatic nonunion of an isolated cuboid fracture after nonoperative treatment. Fracture union was achieved with surgery, and the patient returned to full activities.

Endomedullary Screw Fixation for First Metatarsophalangeal Arthrodesis

The purpose of this study was to evaluate the clinical and radiological results in a group of patients who underwent first metatarsophalangeal joint arthrodesis with an endomedullary screw fixation technique (MPA-E). Between 2003 and 2009, 101 metatarsophalangeal arthrodesis were performed in 76 patients. There were 64 women and 12 men with an average age of 68 years. The indication for surgery was osteoarthritis with severe pain and functional limitation. Patients were evaluated radiologically and with the American Orthopaedic Foot & Ankle Society scoring system (AOFAS) at an average follow-up of 32 months (range, 24-92 months). The success rate was 93%, with an increase of the average preoperative AOFAS from 38.5 points to 85.5 points postoperatively (P < .0001). The consolidation rate after radiological evaluation was 90.1%; there were 5 cases (5.0%) with asymptomatic nonunion and 5 cases (5.0%) with poor results because of symptomatic nonunion. Screw removal was needed in 4 feet (4.0%), and 2 feet (2.0%) had acute postoperative superficial infection. No implant cutout was observed. The MPA-E technique provided consistent and high functional outcomes. This valid and effective alternative should be considered as an option for hallux metatarsophalangeal arthrodesis. Level IV, retrospective case series.

Symptomatic Extra-Articular Scaphoid Tuberosity Nonunion: Surgical Excision of the Ununited Fragment after Failed Nonoperative Management

Scaphoid fractures are the commonest fractures of the carpus [2], accounting for 60–70 % of carpal fractures; they most commonly affect young men following a fall on the outstretched hand [8], with forced dorsiflexion of the wrist, particularly during sports [5]. The management of scaphoid fractures falls into two general categories: nonoperative or surgical management. Nonoperative management with immobilisation in a cast or splint is commonly used for stable, undisplaced waist or tubercle fractures (Herbert type A). Surgical treatment by means of percutaneous or open fixation, with or without bone grafting, is used for unstable, displaced or ununited fractures (Herbert types B, C and D) [5]. Fractures of the scaphoid tuberosity account for between 8 and 20 % of scaphoid fractures [9, 11]. In a series of 222 scaphoid fractures, 38 (17 %) were of the scaphoid tubercle, and all of these were confirmed as united on imaging at 39 days, following an average of 30 days of immobilisation in a cast [8]. Other authors reported a 4 % incidence of tuberosity fractures in a series of 81 scaphoid fractures and advocated conservative management for the extra-articular type [7]. Management of symptomatic nonunion of the scaphoid tuberosity is a rare clinical dilemma which does not appear to fall into the algorithm based on the Herbert classification. Two male patients presented to our unit with long-standing symptoms from ununited extra-articular scaphoid tuberosity fractures following failed nonoperative management. Mean age at presentation was 23 (range 22–24 years). Surgical excision was offered as a management option to both of these patients. To our knowledge, only one case of surgical excision for failed nonoperative management has been previously reported in the international literature [10].

Infra-isthmal fracture is a risk factor for nonunion after femoral nailing: a case–control study

BackgroundThe rates of nonunion after femoral nailing are currently reported to be 4.1–12.5%. The purpose of this study was to identify the risk factors of noninfected nonunion after femoral nailing, focusing in particular on the effects of the length of the distal main fragment. MethodsA case–control study was conducted with 105 patients, with a case (nonunion group)–control (control group) ratio of 1:2. The nonunion group (n=35) comprised patients with consecutive symptomatic nonunions after femoral nailing who were treated in our institute; the control group (n=70) were matched by age to the nonunion group. Type of fracture, soft tissue injury, length of femur and nail length, incidence of screw breakage, nail diameter, mean length of distal main fragment, and any episode of dynamization were retrospectively examined. Univariate and multivariate analyses were performed to elucidate the risk factors of nonunion after femoral nailing. ResultsIncreased risk of nonunion after femoral nailing was associated with (1) open fracture, (2) screw breakage, (3) shorter length of a distal fragment, and (4) any episodes of dynamization. Receiver operating characteristic analysis showed that a distal fragment length of <43% of the total femur length was the cutoff level for nonunion after nailing. The odds ratio for nonunion was 6.40 (95% CI 2.70–15.2) when the length of the distal main fragment was <43% of the femur length. Multivariate logistic analysis revealed that the risk of nonunion after femoral nailing increased (1) with breakage of locking screws (p=0.0021), (2) with dynamization (p=0.0029), (3) with a shorter distal fragment length (p=0.0379), and (4) with an open fracture (p=0.0397). ConclusionThe elucidated risk factors of nonunion after femoral nailing were identified as open fracture, infra-isthmal femoral fracture, breakage of locking screw, and inappropriate dynamization. We believe that the surgeon should be consciously aware of the need for additional surgical fixation for the distal fragment when performing femoral nailing of infra-isthmal femoral fractures.