Factors Associated With Development of Nonunion or Delayed Healing After an Open Long Bone Fracture

Westgeest, Joseph; Weber, Donald; Dulai, Sukhdeep; Bergman, Joseph; Buckley, Richard; Beaupré, Lauren A

doi:10.1097/bot.0000000000000488

Cited by 103 publications

(86 citation statements)

References 22 publications

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“…Yet fracture healing can go awry in 5–10% of cases in the form of delayed or nonunion fractures (referred to collectively as DNFs) . Recent data specific to open long bone fractures indicated that 17% developed nonunion and another 8% exhibited delayed union . With delayed union the initial periosteal response ceases before fracture bridging, while nonunion involves persistent lack of bridging after intramembranous and endochondral repair have ceased .…”

mentioning

confidence: 99%

“…Patient‐dependent risk factors include older age, diabetes, smoking, nutritional deficiencies, and the use of anti‐inflammatory agents . Local infection can be particularly deleterious to fracture healing, and some components of the adaptive immune system may inhibit fracture healing . Other local factors associated with DNF include the extent of soft tissue injury, and compartment syndrome .…”

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confidence: 99%

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Fracture healing physiology and the quest for therapies for delayed healing and nonunion

Kostenuik

Mirza

2016

Journal Orthopaedic Research

149

121

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Delayed healing and nonunion of fractures represent enormous burdens to patients and healthcare systems. There are currently no approved pharmacological agents for the treatment of established nonunions, or for the acceleration of fracture healing, and no pharmacological agents are approved for promoting the healing of closed fractures. Yet several pharmacologic agents have the potential to enhance some aspects of fracture healing. In preclinical studies, various agents working across a broad spectrum of molecular pathways can produce larger, denser and stronger fracture calluses. However, untreated control animals in most of these studies also demonstrate robust structural and biomechanical healing, leaving unclear how these interventions might alter the healing of recalcitrant fractures in humans. This review describes the physiology of fracture healing, with a focus on aspects of natural repair that may be pharmacologically augmented to prevent or treat delayed or nonunion fractures (collectively referred to as DNFs). The agents covered in this review include recombinant BMPs, PTH/PTHrP receptor agonists, activators of Wnt/β‐catenin signaling, and recombinant FGF‐2. Agents from these therapeutic classes have undergone extensive preclinical testing and progressed to clinical fracture healing trials. Each can promote bone formation, which is important for the stability of bridged calluses, and some but not all can also promote cartilage formation, which may be critical for the initial bridging and subsequent stabilization of fractures. Appropriately timed stimulation of chondrogenesis and osteogenesis in the fracture callus may be a more effective approach for preventing or treating DNFs compared with stimulation of osteogenesis alone. © 2016 The Authors. Journal of Orthopaedic Research published by Wiley Periodicals, Inc. on behalf of the Orthopaedic Research Society. J Orthop Res 35:213–223, 2017.

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confidence: 99%

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confidence: 99%

Fracture healing physiology and the quest for therapies for delayed healing and nonunion

Kostenuik

Mirza

2016

Journal Orthopaedic Research

149

121

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“…Although this typical trauma cohort consist mainly of young, psychically healthy adults, comorbidities such as psychiatric disorders and characteristics as smoking were abundant and may have contributed to impaired healing [30, 31]. …”

Section: Discussionmentioning

confidence: 99%

Effect of a standardized treatment regime for infection after osteosynthesis

et al. 2017

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BackgroundInfection after osteosynthesis is an important complication with significant morbidity and even mortality. These infections are often caused by biofilm-producing bacteria. Treatment algorithms dictate an aggressive approach with surgical debridement and antibiotic treatment. The aim of this study is to analyze the effect of such an aggressive standardized treatment regime with implant retention for acute, existing <3 weeks, infection after osteosynthesis.MethodsWe conducted a retrospective 2-year cohort in a single, level 1 trauma center on infection occurring within 12 months following any osteosynthesis surgery. The standardized treatment regime consisted of implant retention, thorough surgical debridement, and immediate antibiotic combination therapy with rifampicin. The primary outcome was success. Success was defined as consolidation of the fracture and resolved symptoms of infection. Culture and susceptibility testing were performed to identify bacteria and resistance patterns. Univariate analysis was conducted on patient-related factors in association with primary success and antibiotic resistance.ResultsForty-nine patients were included for analysis. The primary success rate was 63% and overall success rate 88%. Factors negatively associated with primary success were the following: Gustilo classification (P = 0.023), higher number of debridements needed (P = 0.015), inability of primary closure (P = 0.017), and subsequent application of vacuum therapy (P = 0.030). Adherence to the treatment regime was positively related to primary success (P = 0.034).ConclusionsThe described treatment protocol results in high success rates, comparable with success rates achieved in staged exchange in prosthetic joint infection treatment.

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“…1 They are mostly high velocity injuries in the young and domestic injuries due to osteoporosis in the elderly population. 1 With prompt surgical care, these fractures heal well with excellent functional results. However due to the above mentioned native bone setters, a small group of such fractures often end with non-unions.…”

Section: Introductionmentioning

confidence: 99%

“…The treatment of such non-unions still involves open reduction with internal fixation and bone grafting after freshening the fractures ends and removal of interposing soft and fibrous tissues. 1 The AO principles must still be adhered to with a pinch of salt and soft tissues must be respected. Here we present our functional assessment of 21 patients with distal femur fracture non-unions treated by open reduction and internal fixation with supplemental bone grafting.…”

Section: Introductionmentioning

confidence: 99%

Functional and radiological outcome following operative skeletal stabilisation with bone grafting in distal femur non-unions: a study of 21 patients

Balasubramanian

Sindhuja

2017

Int J Res Orthop

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INTRODUCTIONIn India, the number of road accidents are amongst the highest in the world. With an estimated 1,50,000 losing their lives on Indian roads every year. The number of non-fatal accidents with resulting long bone fractures is estimated to be in excess of 5 million each year. Although the number of health care centres, both government run and private owned is high, there are still a small but significant subset of people who throng to the native bone setters for their treatment inspite of the government's crackdown on such spurious centres. The main reason for this is the high cost involved in managing such fractures and the taboo associated with surgical correction. This in the recent past has shown a declining trend and more patients are attending fracture clinics and hospitals because of better medical insurance coverage (both government and private) and better patient awareness towards the complications associated with such native splinting. However we still encounter sporadic cases of either fracture malunion and non-unions in our clinical practice.Distal femur fractures show a bimodal age distribution. 1 They are mostly high velocity injuries in the young and domestic injuries due to osteoporosis in the elderly ABSTRACT Background: The study was done to assess the functional and radiological outcome after operative skeletal stabilisation with bone grafting in 21 patients who presented to us with distal femur non-unions. Methods: Between August 2008 and October 2015, 21 patients (M:F-14:7) with established non-unions of the distal femur were included. All patients presented to us with established non-union following treatment with a native bone setter using splints. There were 16 patients with AO Type A, 4 with AO Type B and one patient with Type C. All patients underwent open reduction, internal fixation with plate and screws and bone grafting. Serial follow-ups were done at 4,8, 12, 16, 20, 24 weeks and 6 monthly thereafter. Results: All 21 patients had complete fracture healing at average of 19 weeks . Knee flexion (ROM) improved from an average 16® pre-op to 66® post-operatively. There were no implant failure, infection or nonunions in our study. The Knee Society score improved from 54 pre-operatively to 74 post-operatively at last followup. Conclusions: Even in established non-unions, good results can be expected if good surgical technique is followed and with bone grafting satisfactory union rated can be achieved. Knee ROM also improves with dedicated postoperative rehabilitation.

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Factors Associated With Development of Nonunion or Delayed Healing After an Open Long Bone Fracture

Abstract: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Cited by 103 publications

References 22 publications

Fracture healing physiology and the quest for therapies for delayed healing and nonunion

Fracture healing physiology and the quest for therapies for delayed healing and nonunion

Effect of a standardized treatment regime for infection after osteosynthesis

Functional and radiological outcome following operative skeletal stabilisation with bone grafting in distal femur non-unions: a study of 21 patients

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