May smokers and overweight patients be treated with a medial open-wedge HTO? Risk factors for non-union

Meidinger, Gebhart; Imhoff, Andreas B.; Paul, Jochen; Kirchhoff, Chlodwig; Sauerschnig, Martin; Hinterwimmer, Stefan

doi:10.1007/s00167-010-1335-6

Cited by 160 publications

(168 citation statements)

References 36 publications

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“…Surprisingly, the combination of a BMI [ 30 kg/m 2 and disruption of the lateral cortical hinge [ 2 mm was not a risk factor for delayed or nonunion. Previously, others have suggested using additional iliac crest bone grafting in these patients, whom they considered high risk [10]. Based on our results, we do not believe this is necessary.…”

Section: Discussionsupporting

confidence: 46%

“…In terms of clinical risk factors for nonunion, we found that smoking tobacco was the only significant predictor, a finding that others also have identified [10,12]. Some authors therefore do not advocate this surgical procedure in patients who use tobacco [8,17].…”

Section: Discussionmentioning

confidence: 79%

“…The results of the present study support this and suggest a 13.6% lower risk (19% for smokers, 5.4% for nonsmokers) for developing delayed/ nonunion when a patient stops smoking. Meidinger et al [10] found a strong correlation between use of tobacco and fracture of the lateral cortical hinge and the occurrence of nonunion. By contrast, we found that the presence of a lateral cortical hinge fracture was not a risk factor for developing nonunion.…”

Section: Discussionmentioning

confidence: 99%

“…Earlier studies pointed to a concern about the risk of nonunion with this approach [20,23], whereas some more recent work has suggested that the risk of nonunion for opening wedge HTO is not higher than that for the closed wedge technique [3,6,10].…”

Section: Introductionmentioning

confidence: 99%

“…Besides mechanical factors, patient-related factors are of influence. Patient-related factors that could lead to nonunion are smoking, obesity, infection, advanced age, diabetes mellitus, and use of NSAIDs and/or corticosteroids [5,10,15]. Because nonunions evolve over months, it would be important to identify patients who are at risk for nonunion after HTO and perhaps even to identify patients before surgery whose risk is so severe that they should not undergo HTO.…”

Section: Introductionmentioning

confidence: 99%

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Medial Open Wedge High Tibial Osteotomy: Can Delayed or Nonunion Be Predicted?

Houten

Heesterbeek

Heerwaarden

et al. 2014

Clinical Orthopaedics &Amp; Related Research

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Background The opening wedge approach to high tibial osteotomy (HTO) is perceived to have some advantages relative to the closing wedge approach but it may be associated with delayed and nonunions. Because nonunions evolve over months, it would be advantageous to be able to identify risk factors for and early predictors of nonunion after medial opening wedge HTO. Questions/purposes We sought to determine whether (1) preoperatively identifiable patient factors, including tobacco use, body mass index [ 30 kg/m 2 , and degree of correction, are associated with nonunion, and (2) a modified Radiographic Union Score for Tibial Fractures (RUST) score, taken at 6 weeks and 3 months, would be predictive for delayed or nonunion after medial opening wedge HTO. Methods The medical records and radiographs of 185 patients, 21 bilateral cases, treated with a medial open wedge HTO using the TomoFix 1 device were retrospectively evaluated. For all patients, demographic data regarding risk factors were collected from their records. Diagnosis for delayed or nonunion was already done earlier for standard medical care by the orthopaedic surgeon based on clinical and radiographic grounds. For the retrospective radiographic evaluation, a modified RUST score was used in which each tibial cortex is scored by one observer. Logistic regression analysis was used to identify preoperative and postoperative predictive factors for developing delayed or nonunion. In the series, a total of 19 patients (9.2%) developed clinically delayed/nonunion of whom 10 patients (4.9%) developed a nonunion. Results Smoking was identified as a risk factor for developing delayed/nonunion (19% for smokers versus 5.4% for nonsmokers; p = 0.005; odds ratio, 4

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Section: Discussionsupporting

confidence: 46%

Section: Discussionmentioning

confidence: 79%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Medial Open Wedge High Tibial Osteotomy: Can Delayed or Nonunion Be Predicted?

Houten

Heesterbeek

Heerwaarden

et al. 2014

Clinical Orthopaedics &Amp; Related Research

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Epidemiology of Fracture Nonunion in 18 Human Bones

et al. 2016

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IMPORTANCE Failure of bone fracture healing occurs in 5% to 10% of all patients. Nonunion risk is associated with the severity of injury and with the surgical treatment technique, yet progression to nonunion is not fully explained by these risk factors.OBJECTIVE To test a hypothesis that fracture characteristics and patient-related risk factors assessable by the clinician at patient presentation can indicate the probability of fracture nonunion.DESIGN, SETTING, AND PARTICIPANTS An inception cohort study in a large payer database of patients with fracture in the United States was conducted using patient-level health claims for medical and drug expenses compiled for approximately 90.1 million patients in calendar year 2011. The final database collated demographic descriptors, treatment procedures as per Current Procedural Terminology codes; comorbidities as per International Classification of Diseases, Ninth Revision codes; and drug prescriptions as per National Drug Code Directory codes. Logistic regression was used to calculate odds ratios (ORs) for variables associated with nonunion. Data analysis was performed from January 1, 2011, to December 31, 2012, EXPOSURES Continuous enrollment in the database was required for 12 months after fracture to allow sufficient time to capture a nonunion diagnosis. RESULTSThe final analysis of 309 330 fractures in 18 bones included 178 952 women (57.9%); mean (SD) age was 44.48 (13.68) years. The nonunion rate was 4.9%. Elevated nonunion risk was associated with severe fracture (eg, open fracture, multiple fractures), high body mass index, smoking, and alcoholism. Women experienced more fractures, but men were more prone to nonunion. The nonunion rate also varied with fracture location: scaphoid, tibia plus fibula, and femur were most likely to be nonunion. The ORs for nonunion fractures were significantly increased for risk factors, including number of fractures (OR, 2.65; 95% CI, 2.34-2.99), use of nonsteroidal anti-inflammatory drugs plus opioids (OR, 1.84; 95% CI, 1.73-1.95), operative treatment (OR, 1.78; 95% CI, 1.69-1.86), open fracture (OR, 1.66; 95% CI, 1.55-1.77), anticoagulant use (OR, 1.58; 95% CI, 1.51-1.66), osteoarthritis with rheumatoid arthritis (OR, 1.58; 95% CI, 1.38-1.82), anticonvulsant use with benzodiazepines (OR, 1.49; 95% CI, 1.36-1.62), opioid use (OR, 1.43; 95% CI, 1.34-1.52), diabetes (OR, 1.40; 95% CI, 1.21-1.61), high-energy injury (OR, 1.38; 95% CI, 1.27-1.49), anticonvulsant use (OR, 1.37; 95% CI, 1.31-1.43), osteoporosis (OR, 1.24; 95% CI, 1.14-1.34), male gender (OR, 1.21; 95% CI, 1.16-1.25), insulin use (OR, 1.21; 95% CI, 1.10-1.31), smoking (OR, 1.20; 95% CI, 1.14-1.26), benzodiazepine use (OR, 1.20; 95% CI, 1.10-1.31), obesity (OR, 1.19; 95% CI, 1.12-1.25), antibiotic use (OR, 1.17; 95% CI, 1.13-1.21), osteoporosis medication use (OR, 1.17; 95% CI, 1.08-1.26), vitamin D deficiency (OR, 1.14; 95% CI, 1.05-1.22), diuretic use (OR, 1.13; 95% CI, 1.07-1.18), and renal insufficiency (OR, 1.11; 95% CI, 1.04-1.17) (multivariate P < .001 for all).C...

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Assessment of contrast‐enhanced computed tomography for imaging of cartilage during fracture healing

Hayward

Bakker

Gerstenfeld

et al. 2012

Journal Orthopaedic Research

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Assessment of the early stages of fracture healing via X-rays and computed tomography is limited by the low radio-opacity of cartilage. We validated a method of contrast-enhanced computed tomography (CECT) for non-destructive identification of cartilage within a healing fracture callus. Closed, stabilized fractures in femora of C57BL/6 mice were harvested on post-operative day 9.5 and imaged ex vivo with micro-computed tomography (μCT) before and after incubation in a cationic contrast agent that preferentially accumulates in cartilage due to the high concentration of sulfated glycosaminoglycans in the tissue. Co-registration of the pre- and post-incubation images, followed by image subtraction, enabled two- and three-dimensional delineation of mineralized tissue, soft callus, and cartilage. The areas of cartilage and callus identified with CECT were compared to those identified with the gold-standard method of histomorphometry. No difference was found between the areas of cartilage measured by the two methods (p = 0.999). Callus area measured by CECT was smaller than, but strongly predictive of (R2 = 0.80, p < 0.001), the corresponding histomorphometric measurements. CECT also enabled qualitative identification of mineralized cartilage. These findings indicate that the CECT method provides accurate, quantitative, and non-destructive visualization of the shape and composition of the fracture callus, even during the early stages of repair when little mineralized tissue is present. The non-destructive nature of this method would allow subsequent analyses, such as mechanical testing, to be performed on the callus, thus enabling higher-throughput, comprehensive investigations of bone healing.

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May smokers and overweight patients be treated with a medial open-wedge HTO? Risk factors for non-union

Cited by 160 publications

References 36 publications

Medial Open Wedge High Tibial Osteotomy: Can Delayed or Nonunion Be Predicted?

Medial Open Wedge High Tibial Osteotomy: Can Delayed or Nonunion Be Predicted?

Epidemiology of Fracture Nonunion in 18 Human Bones

Assessment of contrast‐enhanced computed tomography for imaging of cartilage during fracture healing

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