Fracture healing is a critically important clinical event for fracture patients and for clinicians who take care of them. The clinical evaluation of fracture healing is based on both radiographic findings and clinical findings. Risk factors for delayed union and nonunion include patient dependent factors such as advanced age, medical comorbidities, smoking, non-steroidal anti-inflammatory use, various genetic disorders, metabolic disease and nutritional deficiency. Patient independent factors include fracture pattern, location, and displacement, severity of soft tissue injury, degree of bone loss, quality of surgical treatment and presence of infection. Established nonunions can be characterised in terms of biologic capacity, deformity, presence or absence of infection, and host status. Hypertrophic, oligotrophic and atrophic radiographic appearances allow the clinician to make inferences about the degree of fracture stability and the biologic viability of the fracture fragments while developing a treatment plan. Non-unions are difficult to treat and have a high financial impact. Indirect costs, such as productivity losses, are the key driver for the overall costs in fracture and non-union patients. Therefore, all strategies that help to reduce healing time with faster resumption of work and activities not only improve medical outcome for the patient, they also help reduce the financial burden in fracture and non-union patients.

Delayed union and nonunions: epidemiology, clinical issues, and financial aspects.

No standard criteria exist for diagnosing fracture nonunion, and studies suggest that assessment of fracture healing varies among orthopaedic surgeons. This variability can be problematic in both clinical and orthopaedic trauma research settings. An understanding of risk factors for nonunion and of diagnostic tests used to assess fracture healing can facilitate a systematic approach to evaluation and management. Risk factors for nonunion include medical comorbidities, age, and the characteristics of the injury. The method of fracture management also influences healing. Comprehensive evaluation includes an assessment of the patient's symptoms, signs, and immune and endocrine status as well as the biologic capacity of the fracture, presence of infection, and quality of reduction and fixation. Diagnostic tests include plain radiography, CT, ultrasonography, fluoroscopy, bone scan, MRI, and several laboratory tests, including assays for bone turnover markers in the peripheral circulation. A systematic approach to evaluating fracture union can help surgeons determine the timing and nature of interventions.

Assessment of compromised fracture healing.

Intramedullary nailing is the preferred method for treating fractures of the femoral shaft. The piriformis fossa and greater trochanter are viable starting points for antegrade nailing. Alternatively, retrograde nailing may be performed. Each option has relative advantages, disadvantages, and indications. Patient positioning can affect the relative ease of intramedullary nailing and the incidence of malalignment. The timing of femoral intramedullary nailing as well as the use of reaming must be tailored to each patient to avoid systemic complications. Associated comorbidities, the body habitus, and associated injuries should be considered when determining the starting point, optimal patient positioning for nailing, whether to use reduction aids as well as which to use, and any modifications of standard technique. Intramedullary nailing of diaphyseal femur fractures provides a stable fixation construct that can be applied using indirect reduction techniques. This method yields high union rates and low complication rates when vigilance is maintained during preoperative planning, the surgical procedure, and the postoperative period.

Intramedullary nailing of femoral shaft fractures: current concepts

Segmental bone defects cause significant disability in patients. Modern orthopaedic surgical techniques have proved to be reliable for reconstruction of these defects. Autogenous bone graft remains the standard of care for reconstruction of small defects (<5 cm). Induced membrane technique and distraction osteogenesis are contemporary strategies of choice for reconstruction of larger bony defects. The use of vascularized fibular grafts has waned in popularity because of donor site morbidity and the success of alternative methods. Complications are ubiquitous with all methods of reconstruction for segmental bone defects but can be limited with careful surgical judgment and technique. In most cases, the rehabilitation period is prolonged, although some treatment options are shorter and enable a more active recovery than do others.

Management of segmental bone defects.

Fracture-related infection (FRI) remains a challenging complication that creates a heavy burden for orthopaedic trauma patients, their families and treating physicians, as well as for healthcare systems. Standardization of the diagnosis of FRI has been poor, which made the undertaking and comparison of studies difficult. Recently, a consensus definition based on diagnostic criteria for FRI was published. As a well-established diagnosis is the first step in the treatment process of FRI, such a definition should not only improve the quality of published reports but also daily clinical practice. The FRI consensus group recently developed guidelines to standardize treatment pathways and outcome measures. At the center of these recommendations was the implementation of a multidisciplinary team (MDT) approach. If such a team is not available, it is recommended to refer complex cases to specialized centers where a MDT is available and physicians are experienced with the treatment of FRI. This should lead to appropriate use of antimicrobials and standardization of surgical strategies. Furthermore, an MDT could play an important role in host optimization. Overall two main surgical concepts are considered, based on the fact that fracture fixation devices primarily target fracture consolidation and can be removed after healing, in contrast to periprosthetic joint infection were the implant is permanent. The first concept consists of implant retention and the second consists of implant removal (healed fracture) or implant exchange (unhealed fracture). In both cases, deep tissue sampling for microbiological examination is mandatory. Key aspects of the surgical management of FRI are a thorough debridement, irrigation with normal saline, fracture stability, dead space management and adequate soft tissue coverage. The use of local antimicrobials needs to be strongly considered. In case of FRI, empiric broad-spectrum antibiotic therapy should be started after tissue sampling. Thereafter, this needs to be adapted according to culture results as soon as possible. Finally, a minimum follow-up of 12 months after cessation of therapy is recommended. Standardized patient outcome measures purely focusing on FRI are currently not available but the patient-reported outcomes measurement information system (PROMIS) seems to be the preferred tool to assess the patients’ short and long-term outcome. This review summarizes the current general principles which should be considered during the whole treatment process of patients with FRI based on recommendations from the FRI Consensus Group. Level of evidence: Level V.

/pdf/general-treatment-principles-for-fracture-related-infection-wq7mkah02a.pdf

General treatment principles for fracture-related infection: recommendations from an international expert group.

ObjectivesTo determine whether patients with unexplained nonunions, patients with a history of multiple low-energy fractures with at least one progressing to a nonunion, and patients with a nonunion of a nondisplaced pubic rami or sacral ala fracture would have an underlying metabolic or end

Metabolic and endocrine abnormalities in patients with nonunions

Objectives:The purpose of this study was to evaluate the effectiveness of a systematic approach to exchange nailing for the treatment of aseptic tibial nonunion.Design:Retrospective cohort.Setting:Tertiary referral center.Patients:Forty-six aseptic tibial nonunion sites in 40 patients (2 bilateral a

Results of a systematic approach to exchange nailing for the treatment of aseptic femoral nonunions.

Objective To evaluate the healing rate of aseptic nonunions of the distal third of the tibia treated with Ilizarov slow gradual compression and deformity correction. Design Retrospective cohort study. Setting Tertiary referral center. Patients/participants Ninety-four consecutive adult patients with 94 distal third tibial aseptic nonunions. Intervention Ilizarov external fixation and slow gradual compression; most patients also underwent bone grafting, deformity correction, or both before the initiation of compression. Main outcome measurements Rate of bony union. Results Eighty-seven of 94 cases (92.6%) healed after slow gradual compression across the nonunion site with a circular external fixator. Four of the 7 patients who failed treatment healed after additional operative treatment, and the remaining 3 refused further care. Conclusions Circular external fixation with slow gradual compression was successful in treating aseptic nonunions of the distal third of the tibia in 92.6% of cases. Careful selection of patients for this treatment method can lead to a high success rate with a relatively low rate of major complications. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

High Rate of Union for Aseptic Distal Tibial Nonunions in Adults Treated With Slow Gradual Compression via Circular External Fixation.

The purpose of this study was to report the extent of the effects of femoral nonunion on health-related quality of life.
Retrospective cohort.
Tertiary referral center.
One hundred eighty-seven consecutive patients (85 women, age 55.9 ± 16.9 years; 102 men, age 42.8 ± 16.1 years) with 188 nonunions of the femur, excluding those involving the hip or knee articular surfaces.
Average nonunion duration was 28.5 months. 5.7% of the nonunions were infected, and the distal third was the most frequently involved segment.
SF-12 Mental Component Summary (MCS) and Physical Component Summary (PCS) scores, Brief Pain Inventory (BPI), American Academy of Orthopaedic Surgeons Lower Limb Core Scale (LLCS), and Time Trade-Off (TTO) reported at the time of initial clinical evaluation at our center.
The MCS scores averaged 43 ± 6.5, and the PCS scores averaged 26.3 ± 6.5, indicating the large adverse impact of femoral nonunion on mental and physical health, respectively. The BPI average intensity score averaged 5.1 ± 2.5, indicating moderate to severe pain. The LLCS averaged 53.9 ± 20.0, indicating substantial lower extremity-specific disability. The TTO questionnaire responses indicated that these patients were willing to trade an average of 38.3% of their remaining years of life to regain health.
The impact of femoral shaft nonunion on physical health was comparable to end-stage hip arthrosis and tibial nonunion and worse than many other medical conditions. Femoral shaft nonunion is a debilitating chronic medical condition with substantial negative effects on health.
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Debilitating Effects of Femoral Nonunion on Health-Related Quality of Life.

Handle everyday research tasks with reliable, citation-backed results

Your personal Research Agent to handle research tasks with citation-backed results

Popular Tasks used by Researchers

How can I help with your research?

Meet SciSpace

Get more enhanced response by uploading the PDFs you want me to reference.

No relevant PDFs in your library

SciSpace is the AI research assistant for academics. Run systematic literature reviews on 280M+ papers, and write papers with cited sources. Trusted by 1M+ students, PhDs & researchers.

SciSpace | AI for Research

Analyze PDFs

Code & Manuscripts

Funding & Grants

Literature & Patents

Medical & Clinical Data

Systematic Review

Visualize & Present

Web & Data

Build a Google Scholar-like website for your research.

Build a website

Create charts and images for your research

Create a Chart

Write a paper for submission to a journal

Draft a manuscript

Patent Search

Design eye-catching scientific posters in minutes.

Scientific Poster Generation

Systematic Literature Review

One task is running at the moment. Your messages will be shown right after.

Drag and drop or click here to browse

Loved by <highlight>1 million+</highlight> researchers

Extract a list of specific topics and their sources from unstructured text

Topics

Compare and analyze relevant papers that matches with your search

Papers

Get insights from PDFs and bookmarked papers from your library

My library

Recent searches

Try searching for:

Catch AI-generated content in scholarly and non-scholarly content

{ai} Detector

Ai Writer

Get PDF Summaries, highlighted text explanations 

Chat with PDF

Effortlessly create in-text citations and bibliographies in APA and 2,500 other formats

Citation generator

Get explanations, summaries, and answers on academic papers

Ease up your research workflow with {scispace}'s cohort of exciting AI tools

Elevate your academic writing skills and convey your ideas the way you want

Paraphraser

Explore our range of reading and writing tools

Your file is being prepared and should be ready in a few minutes. If it's a large file, it might take a bit longer. You can close this window, and we'll email you the file when it's done.

You have reached a maximum limit of <strong>{limit}</strong> columns in the table. Remove at least <strong>1</strong> column to add or create another one.

Daniel P OʼConnor

Author Tools

Chat about Author

Papers

Metabolic and endocrine abnormalities in patients with nonunions

Results of a systematic approach to exchange nailing for the treatment of aseptic femoral nonunions.

High Rate of Union for Aseptic Distal Tibial Nonunions in Adults Treated With Slow Gradual Compression via Circular External Fixation.

Debilitating Effects of Femoral Nonunion on Health-Related Quality of Life.