Background. Femoral neck nonunion is a challenging problem. If it is not treated properly, it will be ended with a catastrophe because the victims are younger and active patients and missing hip joint will result in a handicapped like person. If the head is viable, the best treatment is valgus osteotomy. In the original technique, site of nonunion was not explored but in our technique, there is exploration and cleaning of nonunion site and after reduction of fragments, fixation and subtrochanteric osteotomy were done. Materials and methods. Patients with established nonunion of femoral neck fracture entered in study. Inclusion criteria's were age under 60 years old, spherical head of femur without changing the density of it and femoral neck nonunion at least 6 months after fracture. Nonunion site was freshed and any hard ware was removed and head was reduced as possible and subtrochanteric valgus osteotomy to 150 degree was done and fixed with angle blade plate. Bone graft was not used. Patients were studied one year monthly for signs of union of fracture site and signs of avascular necrosis of femoral head. Results. 29 patients were entered in study. 21 male and 8 female with the mean age of 33 years(18 to 55). 19 had Garden type 4 and 7 garden type 3 and the rest 3 had garden type2 at first. Fracture of fixation device were seen in 15 patients. After average 4 months (3 to 5.5) 27 of them showed union of fracture site but in 7 cases, because of some collapse in fracture site, tip of hard ware entered the joint and in 2 cases avascular necrosis of head appeared. Discussion. Exploration of nonunion has some advantages. At first, in some cases removing of broken implants would be necessary for proper insertion of new device. Second, better reduction of fracture site may improve fixation and biomechanics. Third, it seems that in these cases there were through union but in the original method, there were metaplasia of fibrous tissue in the fracture site nonunion

Aim. Treatment algorithms for fracture-related nonunion depend on the presence or absence of bacterial infection. However, the manifestation of septic nonunion varies. Low-grade infections, unlike manifest infections, lack clinical signs of infection and present similarly to aseptic nonunion. The clinical importance of low-grade infection in nonunion is not entirely clear. Therefore, the aim of this study was to evaluate the clinical relevance of low-grade infection in the development and management of femoral or tibial nonunion. Method. A prospective, multicenter clinical study enrolled patients with nonunion and regular healed fractures. Preoperatively, complete blood count without differential, C-reactive protein (CRP), and procalcitonin were obtained, clinical signs of infection were recorded, and a suspected septic or aseptic diagnosis was made based on history and clinical examination. During surgical nonunion revision or routine implant removal, tissue samples were collected for microbiology and histopathology, and osteosynthesis material for sonication. Nonunion patients were followed for 12 months. Definitive diagnosis of “septic” or “aseptic” nonunion was made according to diagnostic criteria for fracture-related infection, considering the results of any further revision surgery during follow-up. Results. 34 patients with regular healed fractures were included. 62 nonunion patients were diagnosed as aseptic, 22 with manifest, and 23 with low-grade infection. The positive predictive value was 88% and the negative predictive value 72% for the suspected diagnosis. The nonunion groups had significantly higher CRP levels than the regular healer group. Differentiation between septic and aseptic nonunion based on blood values was not possible. Low-grade infection demonstrated less frequently histopathologic signs of infection than manifest infection (22% vs. 50%, p=0.048), with 15% of regular healers having histopathologic signs of infection. Cutibacterium acnes was less present in manifest compared to low-grade infection (p=0.042). Healing rates for septic nonunion involving C. acnes were significantly lower for manifest infection (20%) than for low-grade infection (100%, p=0.002). Patients with low-grade infection were treated with systemic antibiotics less frequently than patients with manifest infection (p=0.026), with no significant difference in healing rate (83% vs. 64%), which was slightly lower for low-grade infection than for aseptic nonunion (90%). Conclusions. Low-grade infections play a significant role in nonunion development and are difficult to diagnose preoperatively due to the lack of clinical signs of infection and unremarkable blood counts. However, our results imply that for low-grade infections, antibiotic therapy may not always be mandatory to heal the nonunion. This study was supported by the German Social Accident Insurance (FF-FR0276)

To develop a reliable and effective radiological score to assess the healing of isolated ulnar shaft fractures (IUSF), the Radiographic Union Score for Ulna fractures (RUSU). Initially, 20 patients with radiographs six weeks following a non-operatively managed ulnar shaft fracture were selected and scored by three blinded observers. After intraclass correlation (ICC) analysis, a second group of 54 patients with radiographs six weeks after injury (18 who developed a nonunion and 36 who united) were scored by the same observers. In the initial study, interobserver and intraobserver ICC were 0.89 and 0.93, respectively. In the validation study the interobserver ICC was 0.85. The median score for patients who united was significantly higher than those who developed a nonunion (11 vs 7, p<0.001). A ROC curve demonstrated that a RUSU ≤8 had a sensitivity of 88.9% and specificity of 86.1% in identifying patients at risk of nonunion. Patients with a RUSU ≤8 (n = 21) were more likely to develop a nonunion (n = 16/21) than those with a RUSU ≥9 (n = 2/33; OR 49.6, 95% CI 8.6–284.7). Based on a PPV of 76%, if all patients with a RUSU ≤8 underwent fixation at 6-weeks, the number of procedures needed to avoid one nonunion would be 1.3. The RUSU shows good interobserver and intraobserver reliability and is effective in identifying patients at risk of nonunion six weeks after fracture. This tool requires external validation but may enhance the management of patients with isolated ulnar shaft fractures

Aim. Differentiation of infected (INF) nonunion from aseptic (AS) nonunion is crucial for the choice of intra- and postoperative treatment. Preoperative diagnosis of infected nonunion is challenging, especially in case of low-grade infection lacking clinical signs of infection. Standard blood markers such as C-reactive protein or leucocyte count do not aid in preoperative diagnosis. Proteomic profiling has shown promising results for differentiation of numerous chronic disease states, and in this study was applied to preoperative blood samples of patients with nonunion in an attempt to identify potential biomarkers. Method. This prospective multicenter study enrolled patients undergoing revision surgery of femur or tibia nonunion. Patients with implant removal after regular fracture healing (HEAL) were included as a control-group. Preoperative blood samples, intraoperative tissue samples, sonication of osteosynthesis material and 1-year-follow-up questionnaire were taken. Nonunion patients were grouped into INF or AS after assessing bacterial culture and histopathology of retrieved samples. Diagnosis of infection followed the fracture related infection consensus group criteria, with additional consideration of healing one year after revision surgery. Targeted proteomics was used to investigate a predefined panel of 45 cytokines in preoperative blood samples. Statistical differences were calculated with Kruskal Wallis and Dunn's post hoc test. Cytokines with less than 80% of samples being above the lower limit of detection range (LLDR) were excluded for this study. Results. We recruited 62 AS, 43 INF and 32 HEAL patients. Patients in the two nonunion groups (INF and AS) did not differ concerning smoking, diabetes or initial open or closed fracture. Thirty-two cytokines were above LLDR in >80% of patients. INF patients showed a significant difference in expression of 8 cytokines compared to AS, with greatest differences observed for Macrophage Colony Stimulating Factor 1 (MCSF-1) and Hepatocyte Growth Factor (HGF) (p<0.01). In comparing AS with HEAL patients, 9 cytokines displayed significant differences, including interleukin (IL)-6, Vascular Endothelial Growth Factor A (VEGFA), Matrix Metalloproteinase 1 (MMP-1). Comparison of INF with HEAL patients revealed significantly different expression of 20 cytokines, including. IL-6, IL-18, VEGFA or MMP-1. Conclusions. Our study revealed differences in plasma cytokine profile of blood samples from INF and AS patients. Although no single biomarker is sufficient to differentiate these patients preoperatively in isolation, future multivariant analysis of this cytokine data in combination with clinical characteristics may provide valuable diagnostic insights. Funded by German Social Accident Insurance (FF-FR 0276) and AO Trauma (AR2021_04)

Aim. Failed consolidation (nonunion) after foot and ankle arthrodesis is a major complication, which can lead to additional revision arthrodesis with increased risk of morbidity. Multiple factors can contribute to developing a nonunion, including a low-grade infection. The aim of this study was to investigate the rate of unsuspected low-grade infection in revision arthrodesis for nonunions after foot and ankle arthrodesis. We also analyzed the outcome of unsuspected low-grade infections. Method. We conducted a retrospective study in The Sint Maartenskliniek, The Netherlands. All patients who underwent revision arthrodesis for assumed aseptic nonunion after foot and ankle arthrodesis between January 2020 and July 2021 were included. Patients were excluded if <5 tissue samples were obtained during revision arthrodesis or if they were treated for infection after the index arthrodesis. For the included patients, at least 5 tissue samples for culture were taken during the revision arthrodesis. The causative microorganisms, antibiotic susceptibility and treatment were assessed. An unsuspected infection was defined as ≥2 positive cultures with phenotypical identical microorganisms. Success was defined as union on imaging during clinical follow-up, without signs of persistent infection after finishing the antibiotic treatment. Results. In total 91 revision arthrodesis due to nonunion were performed. The mean duration between index and revision arthrodesis was 571 days. In 14 patients, an unexpected infection was diagnosed. The most frequent causative bacteria identified were Cutibacterium acnes (n=10) and Staphylococcus spps. (n=5). One infection was caused by a Gram-negative bacilli (Acinetobacter spps.). Two infections were polymicrobial. Of the 14 infections, 12 were treated with antibiotics for 12 weeks, 1 for 6 weeks and 1 was not treated. After one-year follow-up, the success rate was 86% and in one patient re-surgery was performed for a non-infectious reason. Conclusions. In 18% of the revisions for nonunion after foot and ankle arthrodesis, an unexpected low- grade infection was the cause of the nonunion. Nonunion occurring after foot and ankle arthrodesis is a severe complication, leading to additional revision arthrodesis. Low-grade infection should be considered as possible explanation of the nonunion, despite the lack of local inflammatory signs. As 18% of the nonunions were unexpectedly caused by low-grade infection, we strongly recommend obtaining at least 5 tissue samples for culture during revision arthrodesis. The outcome of unexpected infection as cause of nonunion is good, when treated with targeted antibiotics for 12 weeks

Introduction and Objective. Nonunion is incomplete healing of fracture and fracture that lacks potential to heal without further intervention. Nonunion commonly presents with persistent pain, swelling, or instability. Those symptoms affect patient quality of life. It is known that using low intensity pulsed ultrasound (LIPUS) for fresh fractures promotes healing. However, effectiveness of LIPUS for nonunion is still controversial. If LIPUS is prove to be effective for healing nonunion, it can potentially provide an alternative to surgery. In addition, we can reduce costs by treating nonunion with LIPUS than performing revision surgery. Materials and Methods. The two authors carried out a systematic search of PubMed, Ovid MEDLINE, and the Cochrane Library. Meta-analysis of healing rate in nonunion and delayed union patients who underwent LIPUS was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) instruction method using a random effects model. Results. The initial search identified 652 articles. Of these, 541 were excluded on the basis of the title because they were either a review paper or covered an unrelated topic. The abstracts of the remaining 111 articles were examined further. That review resulted in a sample of 12 articles. We performed a meta-analysis with a random effects model using Open Meta Analyst software. The result of pooled effect size of healing rate was 73.4% (95%CI: 65.3–81.6%). Due to the fact that nonunion lacks potential to heal without further intervention, we suggest that the therapeutic effect of 73.4% from LIPUS is sufficiently effective. As far as we know, there are no trials comparing the therapeutic effectiveness of surgery and LIPUS, so it cannot be said which is more advantageous. However, the healing rate of revision surgery was reported between 68–96%; therefore, our result is within that range. Thus, if surgery is difficult due to complications, we can recommend LIPUS. Conclusions. Meta-analysis of healing rate of nonunion treated by low-intensity pulsed ultrasound is 73.4%, which suggests sufficient therapeutic effectiveness. Furthermore, we can say that LIPUS may provide an alternative treatment for nonunion patients who cannot tolerate revision surgery due to complications

The primary aim was to identify patient and injury factors independently associated with humeral diaphyseal fracture nonunion after non-operative management. The secondary aim was to determine the effect of management (operative/non-operative) on nonunion. Over a ten-year period, 734 humeral diaphyseal fractures (732 consecutive patients) were retrospectively identified from a trauma database. Follow-up was available for 663 fractures (662 patients; median age 57yrs [16–96], 54% female [n=359/662]) which formed the study cohort. Patient and injury characteristics were recorded. There were 523 patients (79%) managed non-operatively and 139 (21%) managed operatively. Outcome (union/nonunion) was determined from medical records and radiographs. Median follow-up was five months (1.2–74). Nonunion occurred in 22.7% of non-operatively managed injuries (n=119/524). Multivariate analysis demonstrated pre-injury NSAIDs (adjusted OR [AOR] 40.8, 95% CI 2.6–632.3; p=0.008), being underweight (BMI <18.5kg/m2; AOR 7.3, 95% CI 1.3 to 40.2; p=0.022), overweight (BMI 25–29.9kg/m2; AOR 2.5, 95% CI 1.1 to 5.9; p=0.034) and class II obesity (BMI 35–39.9kg/m2; AOR 4.5, 95% CI 1.4 to 15.5; p=0.014) were independently associated with an increased risk of nonunion. Operative fixation was independently associated with a lower risk of nonunion (2.9%, n=4/139) than non-operative management (AOR for non-operative/operative 11.0, 95% CI 2.8 to 43.6; p=0.001). Based upon these results, five patients would need to undergo operative fixation to avoid one nonunion. Pre-injury NSAIDs and BMI were independently associated with nonunion following non-operative management of a humeral diaphyseal fracture. Operative fixation was the independent factor most strongly associated with a lower risk of nonunion

Introduction. Our previous study using microarray analysis showed that Rad (Ras associated with diabetes) was highly expressed in nonunion. The purpose of this study is to investigate the gene expression and immunolocalization of Rad, and other Ras-related G proteins: Rem1 and Rem2 in fracture/nonunion site using rat experimental models. Hypothesis. We hypothesized that Rad had a significant role in nonunion formation. Materials & Methods. For standard healing model, K-wire was inserted into the femur and a closed fracture was created. Nonunion model was produced by periosteal cauterization at the fracture site. At post-fracture days 3, 7, 10, 14, 21, and 28, RNA was extracted from callus or fibrous tissue for real-time PCR. At day 14, specimens were harvested for immunohistochemistry. Results. Significant difference of Rad gene expression was not observed between standard healing fracture and nonunion at the earlier time points. In contrast, significantly higher expression in nonunion was observed at the later time points. There were no significant differences between standard healing fracture and nonunion in gene expression of Rem1 and Rem2. In immunohistochemical analysis, Rad and Rem1 were detected in the fracture site, and Rem2 was not detected. On the other hand, Rad was only detected in fibrous tissue in nonunion. Discussion & Conclusion. Our results suggest a significant role of Rad in fracture healing and nonunion formation. Rad may become a target agent for treatment of nonunion

Introduction. Many surgeons assess biological activity of fracture nonunion by the presence or absence of callus using radiograph. However, it is difficult to assess biological activity only by radiographic appearance. Bone scintigraphy reflects blood supply and bone metabolism and is possibly useful to assess biological activity in nonunion cases. Hypothesis. We hypothesized that poor callus visualization did not always mean lack of biological activity. Materials & Methods. Retrospective assessment and comparison of radiographs and Tc-99m bone scintigraphy of 44 patients with uninfected nonunion was done. Results. Uptake was observed at or around the nonunion site in all cases. Three patterns of uptake were noted; Spot type (S): intense uniform uptake, Uneven type (U): uptake with distribution from cold to hot, and Cleft type (C): decreased uptake surrounded by significant uptake on both sides. All 9 cases of hypertrophic nonunion demonstrated the S type. In 21 cases of oligotrophic nonunion, there were 12 S, 5 U and 4 C. In 3 cases of comminuted nonunion, there were 1 U and 2 C. In 5 cases of defect nonunion, there were 1 U and 4 C. In 6 cases of atrophic nonunion, there were 2 U and 4 C. Discussion & Conclusions. Our results suggest that poor callus visualization does not always mean lack of biological activity. The distribution of uptake and the cleft with decreased uptake are helpful findings to assess the necessity of bone graft or other supplementation in nonunion surgery

The aim of our study is to investigate the natural history of scaphoid non-union. Factors affecting the outcome of scaphoid fracture non-union surgery were assessed using data collected retrospectively from 785 cases treated at 18 centres throughout the UK. All cases had undergone this surgery before October 2014, ensuring a minimum period of 2 years between surgery and data collection from the medical records. Smoking status significantly influenced the union rate of 94 proximal pole (non-smokers = 71%, smokers = 44%, p < 0.05) but not waist (non-smokers = 73% non-unions. Type of bone graft did not affect the union rate of the 282 waist nonunions (iliac crest = 69%; non-vascular distal radius = 75% and vascularised distal radius = 70%: P=0.35), but did influence the union rate of the 98 proximal pole nonunions (iliac crest = 58%; non-vascular distal radius = 58% and vascularised distal radius = 82%: P=0.004). Time interval between fracture and non-union surgery did not affect the union rate of 121 proximal pole nonunions (3–6 months = 56%; 6–12 months = 76%; 1–2 years = 69%; 2+years = 54%: P=0.5), but did influence the union rate of 303 nonunions of the waist (3–6 months = 80%; 6–12 months = 82%; 1–2 years = 65%; 2+years = 55%: P=0.02). Non-unions of the proximal pole appear to be influenced by smoking status and bone graft type, whereas non-unions of the scaphoid are influenced by the time to non-union surgery

Introduction. what size of defect is optimal for creating an atrophic nonunion animal model has not been well defined. Our aim in this study was to establish a clinically relevant model of atrophic nonunion in rat femur by creation of a bone defect to research fracture healing and nonunion. Materials and methods. We used 30 male Fischer 344 rats (aged 10–11 weeks), which were equally divided into six groups. The segmental bone defects to a single femur in each rat were performed by double transverse osteotomy, and different sized defects were created by group for each group (1 mm, 2 mm, 3 mm, 4 mm, 5 mm and 6 mm). The defects were measured and maintained strictly by using an original external fixator. The periosteum for each defect was stripped both proximally and distally. Thereafter, these models were evaluated by radiology and histology. Radiographs were taken at baseline and at intervals of two weeks over a period of 8 weeks. Atrophic nonunion was defined as a lack of continuity and atrophy of both defect ends radiologically and histologically at eight weeks. Results. In the 1 mm defect group, all defects had healed. In the 2 mm group, one-fifth remained atrophic nonunion. In the 3 mm group, three-fifths had atrophic nonunion, and all of the defects of groups of 4 mm and over were atrophic nonunion. Conclusion. This study showed that we were able to predictively produce an atrophic nonunion animal model by creating defects of at least 4 mm in the Fischer 344 rat femur

Introduction:. Vitamin D plays an important role in bone turnover. Deficiency (including borderline deficiency, or insufficiency) has a known association with fractures and has been linked to delayed or nonunion of fractures. We therefore routinely test vitamin D in cases of nonunion. Noting a high rate of vitamin D deficiency in this group, we instituted a policy to routinely screen for and treat vitamin D deficiency in both post-operative and pre-operative patients. We hypothesised that, in the post-operative patients, levels would correlate with rates of union. Methods:. We sent serum vitamin D levels on consecutive post-operative patients seen in clinics between January and May 2014. They included those with an arthrodesis of the ankle, triple joint or first MTPJ. Union was deemed to have occurred when the patient was comfortable full weight bearing and radiographs showed trabeculae crossing the fusion site. Nonunions were all confirmed with computed tomography. Results:. Ten patients were treated for nonunion, and had a mean serum vitamin D of 58nmol/L. Fourteen patients (collected over a shorter time period) had confirmed union, with a mean vitamin D of 90nmol/L. This was statistically significant on a one tailed Student's t test (p=0.038). Vitamin D was deficient in five (50%) of nonunions and in three (21%) of unions, giving an odds ratio of 3.67. Conclusions:. Our early results show a significant association of serum vitamin D levels with likelihood of nonunion, and we continue to collect data. There is a high prevalence of vitamin D deficiency in our patient population. This is of concern both for the outcome of their surgery and for their lifetime fracture risk. We recommend either screening for or presumptively treating vitamin D deficiency

Osteomyelitis is an inflammatory condition accompanied by the destruction of bone and caused by an infecting microorganism. Open contaminated fractures can lead to the development of osteomyelitis of the fractured bone in 3-25% of cases, depending on fracture type, degree of soft-tissue injury, degree of microbial contamination, and whether systemic and/or local antimicrobial therapies have been administered. Untreated, infection will ultimately lead to non-union, chronic osteomyelitis, or amputation. We report a case series of 10 patients that presented with post-operative infected non-union of the distal femur with or without prior surgery. The cases were performed at Padmashree Dr. D. Y. Patil Hospital, Nerul, Navi Mumbai, India. All the patients’ consents were taken for the study which was carried out in accordance with the Helsinki Declaration. The methodology involved patients undergoing a two-stage procedure in case of no prior implant or a three-stage procedure in case of a previous implant. Firstly, debridement and implant removal were done. The second was a definitive procedure in form of knee arthrodesis with ring fixator and finally followed by limb lengthening surgery. Arthrodesis was planned in view of infection, non-union, severe arthritic, subluxated knee, stiff knee, non-salvage knee joint, and financial constraints. After all the patients demonstrated wound healing in 3 months along with good radiographic osteogenesis at the knee arthrodesis site, limb lengthening surgeries by tibial osteotomy were done to overcome the limb length discrepancy. Distraction was started and followed up for 5 months. All 10 patients showed results with sound knee arthrodesis and good osteogenesis at the osteotomy site followed by achieving the limb length just 1-inch short from the normal side to achieve ground clearance while walking. Our case series is unique and distinctive as it shows that when patients with infected nonunion of distal femur come with the stiff and non-salvage knee with severe arthritic changes and financial constraints, we should consider knee arthrodesis with Ilizarov ring fixator followed by limb lengthening surgery

Aim. Although non-unions being one of the most common complication after long-bone fracture fixation, the definition of this entity remains controversial and varies widely among authors. A clear definition is crucial, not only for the evaluation of published research data but also for the establishment of uniform treatment concepts. The aim of this systematic review was to identify the definitions and different criteria used in the scientific literature to describe non-unions after long bone fractures. Method. A comprehensive literature search was performed in PubMed, Cochrane Library, Web of Science, and Embase. according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Prospective therapeutic and diagnostic clinical studies in which adult long-bone fracture non-unions were investigated as main subject were included in this analysis. Results. One hundred fifty-two studies investigating 6432 long-bone non-unions met inclusion criteria for this analysis. In total 49% (75/152) of included studies did not define non-union at all, even though non-union was their main study subject. A definition of non-union on either clinical, radiologic or time criteria could be found in 51% (77/152) of the included studies. Non-union was defined based on time criteria in 83% (64/77), on radiographic criteria in 65% (50/77), and on clinical criteria in 43% (33/77). A combination of clinical, radiologic and time criteria for definition was only found in 35% (27/77) of all the included studies that defined non-union. The time point when authors defined an unhealed fracture as a nonunion showed a considerable heterogeneity, ranging from four to 24 months. Conclusions. In the current orthopaedic trauma literature, we found a lack of consensus with regard to the definition of long bones non-unions. Therefore, a standardized definition of non-union remains unclear. Without valid and reliable definition criteria of non-unions, the establishment of standardized diagnostic and treatment algorithms as well as the comparison of studies remain difficult. The lack of a clear definition emphasizes the need for consensus-based definition of fracture non-unions based on clinical, radiographic and time criteria

Background. Subtalar nonunion has a detrimental effect on patients' function, and pose a significant challenge for surgeons particularly in the setting of higher risk factors. Methods. We retrospectively analyzed a consecutive series of 49 subtalar nonunions between October 2001 and July 2013. Patient records and radiographs were reviewed for specific patient demographics and comorbidities, subsequent treatments, revision fusion rate, use of bone graft, complications, and clinical outcome. Results. Forty-nine patients with a mean age of 49 years (range 23–80) were included. Sixteen (32%) were heavy smokers (>1 pack per day) and five (10%) had diabetes. Forty one (84%) of the nonunions were symptomatic and underwent a revision procedure at a mean of 16 months (range 2.8 to 57) from the time of the primary arthrodesis. Four of these patients required a triple arthrodesis at the time of revision. Bone graft was used in all cases, and in 25 cases (61%) additional adjuvant orthobiologics. Thirty-two (78%) of the patients achieved a solid arthrodesis at a mean of 3.4 months (range 1.4 to 7.6). Patients who were diabetic and smokers as a group had a 68% rate of union. Of the nine nonunions following a revision arthrodesis, five were in the setting of a prior ankle arthrodesis, three were complicated by a deep infection, and one had no obvious risk factors. Four of the repeat nonunions elected to not undergo an additional procedure, two had a successful third attempt at arthrodesis, one had an additional nonunion followed by a successful fourth attempt at arthrodesis, one had a successful tibiotalocalcaneal arthrodesis, and one ultimately required a below-knee amputation. Discussion. Management of subtalar nonunions pose a significant challenge with a low rate of arthrodesis at 78% fusion rate, but which can be achieved with rigid fixation and utilization of bone graft and orthobiologics

Purpose. To assess the efficacy of the treatment of the aseptic hypertrophic nonunion of the tibia and the secondary deformities by distraction-osteogenesis. Material Methods: Between 1998 and 2006, 28 patients with a hyperthrophic tibia nonunion were treated by distraction or compression-distraction depending on the mobility of the nonunion. The mean age of the patients was 37.5 years (range 24 to 68) and the average number of previous surgeries on the affected limb was 2 (from 1 to 4). No active bone infection or history of infection was recorded in this series. Closed distraction was applied in 11 patients, closed distraction – compression in 8 and osteoclasis following by distraction in 9 patients. In all cases an external fixation device (19 circular, 11 monolateral external frames) modified to meet the nonunion requirements was used. Results: Distraction or distraction-compression resulted in solid union in all patients (mean time to union 8.4 months, mean follow up 5 years). The external fixator remained in place for an average of 8.2 months (range 7 to 11.5 months). Mean leg length discrepancy 2.5 cm and mean angular deformity 12° were also corrected on the same procedure. Conclusions: Treatment of the tibia nonunion by callus distraction or distraction – compression leads to successfully results. The procedure and the frame have to be individualized according to the nonunion pathology and the secondary tibia deformities

Purpose: Nonunion of the trochanter after total hip arthroplasty using the transtrochanteric approach is a serious complication. Incidence is estimated at 3%. Failure after simple cerclage reaches 40%. A plate was therefore designed specifically for fixation of trochanteric fractures. The purpose of this retrospective analysis was to assess outcome in a continuous series of trochanteric fractures treated with this plate. Material and methods: The series included 72 nonunions in 71 patients treated between 1986 and 1999. Mean age was 66 years. Most of the arthroplasties had been performed for primary degenerative joint disease or for hip dysplasia. The time interval between artrhoplasty and treatment of the nonunion was eight months on the average. The trochanter was fixed with a plate alone in 47 hips and in combination with a frontal wire in 25. The primary outcome criterion was trochanter healing scored as: union (pain free hip, radiological fusion and stability), nonunion (lack of radiological fusion and/or presence of an instability), and doubtful union (moderate pain, no instability, radiological fusion difficult to affirm). Results: Mean follow-up was 47 months (range 12 – 14). Mean functional score at last follow-up was 15/9 compared with 13.5 preoperatively (paired test, p < 10–4) with 51 unions, 12 nonunions and 9 doubtful unions. Among the factors studied, trochanter fixation technique was the only factor predictive of outcome. Results were as follows for plate fixation alone: union 62%, doubtful union 13% and failure 25%. For hips with wire and plate fixation, the results were union 87.5%, doubtful union 12/5%, failure 0%. The difference was highly significant (chi-square, p = 0.006) in favour of wire-plate fixation of trochanteric fractures. Discussion and conclusion: This study leads to the conclusion that the treatment of choice for trochanteric nonunion is wire-plate fixation which provides more than 90% good and very good results

INTRODUCTION. In the treatment of nonunions, and other complications of bone repair, an attractive alternative to bone autografts would be the use of a combination of autologous mesenchymal progenitors cells (MSCs), biomaterials and growth factors. Our goal was to determine the therapeutic potential and contribution to the repair process of different sources of mesenchymal stem cells for the treatment of nonunions. METHODS. The right femur of Sprague-Dawley (SD) rats was stabilized with an aluminum plate (20 mm long, 4 mm wide, 2 mm thick) and four screws (1.5 mm diameter, 8 mm long). A diaphyseal critical size defect was performed (5 mm). Six groups (n=6–8 animals each) were created. A nonunion group (Control group, empty defect); LBA group, live bone allograft; BMP2 group, rhBMP-2 (2 μg) in collagen sponge; PCL group, polycaprolactone scaffold; PMSCs group, PCL scaffold loaded with 5×10. 6. periosteum-derived MSCs; and BMSCs group, PCL scaffold loaded with 5×10. 6. bone marrow-derived MSCs. For cell tracking purposes, LBA and MSCs were derived from SD-GFP transgenic rats. The repair process was followed up by x-rays up to sacrifice, week 10. After sacrifice, femurs were analyzed by micro computed tomography (μCT), histology and immunohistochemistry. For multiple comparisons one-way ANOVA followed by Dunnett”s test for single comparisons was used. Statistical significance was established for p<0.05. RESULTS. Control group did not show healing during follow up or by μCT and histological analysis. Treatment groups BLA and BMP2 showed full healing by week 10 (LBA, 6 out of 6 animals; BMP2, 4 out of 6 animals). The repair callus was quantified by mCT, Control group showed limited formation of bone (11.47±2.01 mm. 3. ) while both LBA and BMP2 groups showed increased bone formation by week 10 when compared with control group (LBA, 35.36±2.24 mm. 3. , p=0.0022; BMP2, 33.32±1.84 mm. 3. , p=0.0022). Histological and μCT analysis confirmed the experimental nonunion model. In PCL treated groups a low number of animals showed radiographic healing: PCL group 1 out of 8 animals; PMSCs group, 2 out of 6 animals; BMSCs group, 0 out of 6 animals. Interestingly, quantification of the repaired callus showed that only PMSCs group produced a significant volume of bone when compared with the Control group (PMSCs, 24.97±6.03 mm. 3. , p=0.0411). PCL and BMSCs groups do not produced significant amount of bone in the repair callus (PCL, 19.00±4.25 mm. 3. , p=0.3095; BMSCs, 12.88±2.38 mm. 3. , p=0.9372). Healing was confirmed by histology and μCT analysis. Finally, the engraftment of transplanted cells was analysed by immunohistochemistry (anti-GFP antibody). Of the three groups receiving cells only the LBA group showed positive signal for GFP at week 10-post surgery. CONCLUSIONS. In conclusion, periosteum-derived progenitor cells are suitable for mimetic autograft design although integration is not yet achieved

Purpose of the study: The aim of this work was to assess results after treatment by nailing of nonunion of the humeral shaft. In particular, we focused on consolidation and factors predictive of failure. Material and method: A prospective study was conducted in 13 consecutive patients presenting aseptic nonunion of the humeral diaphysis. There were five cases after orthopedic treatment and eight cases after internal fixation. Two patients had iterative nonunions. Locked nailing was performed with three successive types of nails: the Seidel nail in four cases, the Russel Taylor nail in seven, and the ACE nail in two. Anterograde nailing was used for the first three cases and retrograde nailing for the others. All patients were followed regularly in our department. Last follow-up was one to seven years after nailing. Results: Five nonunions (38%) did not consolidate after locked nailing. Consolidation was achieved in the other patients after four to 18 months. The anatomic result was good in these patients. Between the success and failure groups, there was no significant difference in age, gender, type of fracture, first intention treatment, delay from fracture to nailing, type or diameter of the nail, surgical access or not to the fracture site during nailing, or duration of complementary fixation. Anterograde nail insertion, used in our first three patients in this series, appeared to affect shoulder function. The retrograde route was used in other patients and did not appear to have any impact on the elbow itself or the elbow region. Discussion: This clinical study was unable to identify clinical factors explaining failures but did provide several arguments suggesting that defective primary stability of the initial fixation could be incriminated in the failures. Conclusion: Centromedullary locked nailing is a simple technique with potential for resolving difficult problems of nonunion. Good functional outcome can be obtained when consolidation is achieved. Rather than abandoning this technique, it would be advisable to conduct further research to determine what factors are determinant in its failures

There is still some controversy about the treatment of nonunion of the lateral humeral condyle in children. Twelve patients with symptomatic long standing nonunion of the lateral humeral condyle were treated by internal fixation with iliac bone graft. The age range of the patients 8 years to 25 years. There were 10 males and 2 females. The time from the original fracture to nonunion ranged from 2 years 6 months to 13 years averaging 6 years 3 months. The indication for surgery was pain and deformity and weakness in elbow. Follow up ranged from 16 months to 6 years averaging 32 months. Bony union was achieved in all cases. Strength of the elbow were restored in all cases. All patients were painfree in the elbow strenuous activities. Postoperative elbow motion was decreased in four patients with an average loss of 10.5 degree of the motion present before surgery. The valgus deformity was improved. Surgical osteosynthesis for long standing nonunion of the lateral humeral condyle is recommendable method