Delayed union and nonunions: Epidemiology, clinical issues, and financial aspects

Hak, David J.; Fitzpatrick, Daniel; Bishop, Julius A.; Marsh, J. Lawrence; Tilp, Susanne; Schnettler, Reinhard; Simpson, A. H. R. W.; Alt, Volker

doi:10.1016/j.injury.2014.04.002

Cited by 471 publications

(365 citation statements)

References 31 publications

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“…Although these materials meet the requirements of clinical application in terms of biocompatibility and mechanical properties, the incidence of fracture-related complications such as infection, delayed union, and nonunion remain a major clinical problem that further increases the suffering and financial burden of fracture patients. [7][8][9][10] Therefore, imparting antibacterial and/ or osteogenic properties to the existing metal implants is crucial for improving the prognosis of fracture and reducing postoperative complications.…”

Section: Introductionmentioning

confidence: 99%

Nano-copper-bearing stainless steel promotes fracture healing by accelerating the callus evolution process

Wang¹,

Li²,

Ren³

et al. 2017

IJN

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Treatment for fractures requires internal fixation devices, which are mainly produced from stainless steel or titanium alloy without biological functions. Therefore, we developed a novel nano-copper-bearing stainless steel with nano-sized copper-precipitation (317L-Cu SS). Based on previous studies, this work explores the effect of 317L-Cu SS on fracture healing; that is, proliferation, osteogenic differentiation, osteogenesis-related gene expression, and lysyl oxidase activity of human bone mesenchymal stem cells were detected in vitro. Sprague–Dawley rats were used to build an animal fracture model, and fracture healing and callus evolution were investigated by radiology (X-ray and micro-CT), histology (H&E, Masson, and safranin O/fast green staining), and histomorphometry. Further, the Cu 2+ content and Runx2 level in the callus were determined, and local mechanical test of the fracture was performed to assess the healing quality. Our results revealed that 317L-Cu SS did not affect the proliferation of human bone mesenchymal stem cells, but promoted osteogenic differentiation and the expression of osteogenesis-related genes. In addition, 317L-Cu SS upregulated the lysyl oxidase activity. The X-ray and micro-CT results showed that the callus evolution efficiency and fracture healing speed were superior for 317L-Cu SS. Histological staining displayed large amounts of fibrous tissues at 3 weeks, and cartilage and new bone at 6 weeks. Further, histomorphometric analysis indicated that the callus possessed higher osteogenic efficiency at 6 weeks, and a high Cu 2+ content and increased Runx2 expression were observed in the callus for 317L-Cu SS. Besides, the mechanical strength of the fracture site was much better than that of the control group. Overall, we conclude that 317L-Cu SS possesses the ability to increase Cu 2+ content and promote osteogenesis in the callus, which could accelerate the callus evolution process and bone formation to provide faster and better fracture healing.

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Section: Introductionmentioning

confidence: 99%

Nano-copper-bearing stainless steel promotes fracture healing by accelerating the callus evolution process

Wang¹,

Li²,

Ren³

et al. 2017

IJN

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“…The rate of tibial nonunions ranges between 5% and 15% [2,22]. Hak et al [23] estimate direct medical costs of USD 11,000 for a long bone nonunion, and Antonova et al [1] estimate that a tibial shaft nonunion costs USD 14,000 more than a tibial shaft fracture that heals.…”

Section: Introductionmentioning

confidence: 99%

Will My Tibial Fracture Heal? Predicting Nonunion at the Time of Definitive Fixation Based on Commonly Available Variables

O’Halloran

Coale

Costales

et al. 2016

Clinical Orthopaedics &Amp; Related Research

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Background Accurate prediction of tibial nonunions has eluded researchers. Reliably predicting tibial nonunions at the time of fixation could change management strategies and stimulate further research. Questions/purposes We asked (1) whether data from medical records, fracture characteristics, and radiographs obtained at the time of fixation would identify features predictive of tibial fracture nonunion; and (2) whether this information could be used to create a model to assess the chance of nonunion at the time of intramedullary (IM) nail fixation of the tibia. Methods We retrospectively reviewed all tibial shaft fractures treated at our center from 2007 to 2014. We conducted a literature review and collected data on 35 factors theorized to contribute to delayed bone healing. Patients were followed to fracture healing or surgery for nonunion. Patients with planned prophylactic nonunion surgery were excluded because their nonunions were anticipated and our focus was on unanticipated nonunions. Our cohort consisted of 382 patients treated with IM nails for tibial shaft fractures (nonunion, 56; healed, 326). Bivariate and multivariate regression techniques and stepwise modeling approaches examined the relationship between variables available at definitive fixation. Factors were included in our model if they were identified as having a modest to large effect size (odds ratio [ 2) at the p \ 0.05 level. Results A multiple variable logistic regression model was developed, including seven factors (p \ 0.05; odds ratio [ 2.0). With these factors, we created the Nonunion Risk Determination (NURD) score. The NURD score assigns 5 points for flaps, 4 points for compartment syndrome, 3 points for chronic condition(s), 2 points for open fractures, 1 point for male gender, and 1 point per grade of American Society of Anesthesiologists Physical Status and percent cortical contact. One point each is subtracted for spiral fractures and for low-energy injuries, which were found to be predictive of union. A NURD score of 0 to 5 had a 2% chance of nonunion; 6 to 8, 22%; 9 to 11, 42%; and[12, 61%. Conclusions The proposed nonunion prediction model (NURDS) seems to have potential to allow clinicians to better determine which patients have a higher risk of nonunion. Future work should be directed at prospectively validating and enhancing this model. Level of Evidence Level III, diagnostic study.

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“…It has been estimated that 100,000 fractures go on to non-union each year in the USA; 4 however, prior to epidemiological studies reported in 2013, there is a paucity of population-based data, and non-union rates have traditionally been fracture-or treatment-specific.…”

Section: Incidencementioning

confidence: 99%

Fracture non-union epidemiology and treatment

Nandra

Grover

Porter

2015

Trauma

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Fracture non-union remains a clinical problem despite advances in the understanding of basic science and technology. Each fracture has a unique personality as does the patient suffering the injury. Thus, each case must be treated on an individual basis. This article defines the problem of fracture non-union and reports recent epidemiological studies. We discuss relevant risk factors and methods for assessing patients who have a tendency toward fracture non-union. There are many treatment options for patients with non-union, where a number of these modalities are still under review. We discuss current evidence with the use of bone morphogenic protein, platelet-rich plasma and low-intensity pulsed ultrasound to augment the treatment of fracture non-union.

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Delayed union and nonunions: Epidemiology, clinical issues, and financial aspects

Cited by 471 publications

References 31 publications

Nano-copper-bearing stainless steel promotes fracture healing by accelerating the callus evolution process

Nano-copper-bearing stainless steel promotes fracture healing by accelerating the callus evolution process

Will My Tibial Fracture Heal? Predicting Nonunion at the Time of Definitive Fixation Based on Commonly Available Variables

Fracture non-union epidemiology and treatment

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