Background. Fractures of the metatarsal bones are the most frequent fracture of the foot. Up to 70% involve the fifth metatarsal bone, of which approximately eighty percent are located proximally. Low-intensity pulsed ultrasound (LIPUS) has been shown to be a useful adjunct in the treatment of delayed fractures and non unions. However, there is no study looking at the success rate of LIPUS in fifth metatarsal fracture delayed unions. Objectives. The aim of our study was to investigate the use of LIPUS treatment for delayed union of fifth metatarsal fractures. Study Design & Methods. A retrospective review of patients who were treated with LIPUS following a delayed union of fifth metatarsal fracture was conducted over a three-year period (2013 – 2015). Delayed union was defined as lack of clinical and radiological evidence of union, bony continuity or bone reaction at the fracture site if 3 months has elapsed from the initial injury. Results. There were thirty patients (9 males, 21 females) in our cohort. The average age was 39.3 years. Type 2 fractures made up 43% of our cohort. Twenty-seven (90%) patients went on to progress to union clinically and radiologically following LIPUS treatment. Smoking (p=0.014) and size of fracture gap (p=0.045) were predictive of non-union. Conclusions. This is the first study looking at the use of LIPUS in the treatment of delayed union of fifth metatarsal fractures. We report a success rate of 90%. There is a role in the use of LIPUS in delayed union of fifth metatarsal fractures and can serve as an adjunct prior to consideration of surgery

Delayed union and non-union are complications of fracture healing associated with pain and with functional and psychosocial disability. This study compares the effect on self-reported health outcomes of delayed union or non-union of femoral and tibial shaft fractures treated at two major metropolitan trauma centres in Victoria. Patients admitted to the Royal Melbourne Hospital and The Alfred with extra- articular femoral and tibial shaft fractures during 2003-2004 and 2005-2006, and followed up by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) were included. Hospital medical records were reviewed to identify the outcome of each fracture. Fracture healing was assessed by the need for unplanned revision surgery for delayed union or nonunion, and clinical and radiological evidence of union. Prospectively-gathered VOTOR health outcome measurements included the Short Form 12-Item Health Survey (SF-12), and return to work and pain status at 6 and 12 months post injury. Of the 520 patients, 260 femoral and 282 tibial shaft fractures were included. In total, 285 fractures progressed to union, 138 fractures developed delayed union or non-union and 119 fractures had an unknown outcome. Factors that were significantly different between the union and delayed union or non-union groups included: fund source, mechanism of injury, other injuries, wound and Gustilo type, and fixation method. On linear regression modelling, an inverse relationship was demonstrated between delayed union or nonunion and the Physical and Mental Component Summary scores of the SF-12. This was statistically significant at both 6 and 12 months post injury unadjusted and adjusted for age, gender and other injuries. On logistic regression modelling, patients with delayed union or non-union showed unadjusted and adjusted risk ratios of 0.85 and 0.82, respectively at 6 months, and 0.82 and 0.76, respectively at 12 months to return to work. Similarly, patients with delayed union or nonunion had unadjusted and adjusted risk ratios of 1.09 and 1.11, respectively at 6 months, and 1.33 and 1.37, respectively at 12 months to have pain. Both were statistically significant at 12 months post injury unadjusted and adjusted for age, gender and other injuries. Patients with delayed union or non-union of femoral and tibial shaft fractures have poorer physical and mental health at 6 and 12 months post injury. In addition, they are less likely to have returned to work and more likely to still have pain at 12 months post injury

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.

Aims An estimated 5–10% of fractures fail to heal adequately. Novel therapies in the treatment of problem fractures include the use of culture expanded cells. An animal model of delayed fracture union is required to parallel the clinical scenario so that variations in cell therapy techniques can be rapidly assessed.

Material and Methods A simple unilateral external fixator was designed for use in the rat. The fixator was applied following open osteotomy of the femur and a reproducible externally fixated femoral fracture model was established (n=41). Fracture union was assessed by digital radiography, histology and biomechanical strength testing (four point bending) at weeks 4, 6 and 8. Histological examination was also undertaken at day 4 and weeks 1 and 2. A delayed union in the fracture model was created by periosteal and endosteal stripping (n=14). Radiography and biomechanical strength testing were performed at week 8. The use of cell therapy was tested in the delayed union model. Osteogenic cells were culture expanded for 6 weeks before re-implantation. Reimplantation was facilitated by the use of a drill hole through the fracture site . Animals were randomized to one of three groups – i) drill hole & cells in a carrier ii) drill hole & carrier only iii) no drill hole, cells or carrier.

Results In the fracture model radiological and histological evidence of fracture union was apparent at week 6. Biomechanical testing showed a significant difference in load to failure and stiffness of the fracture between weeks 4 and 8 (p=0.009 and 0.008 respectively). There was also a significant difference in biomechanical properties between the fracture model and the delayed union model at week 8. Drilling with the injection of a carrier significantly improved the biomechanical properties (p=0.03) of a delayed union at week 14. Surprisingly this effect was negated by the introduction of cells.

Conclusion A fracture and delayed union model in the rat has been established for the testing of cell therapy. The application of cell therapy to a delayed union has been less advantageous in improving union than expected. This prompts the need for further work required in optimising cell culture techniques and cell delivery.

Introduction: For a period of 7 years were treated in Emergency Hospital Pirogov 205 patients with humeral shaft fracture (HSF)–125 with interlocking nailing (ILN), 80 with AO plates, these include 55 delayed unions (DU) and nonunions (NU).

Material and methods: We treated 15 DU (2–4 months), 19 NU after conservative treatment (4–12 months), 15 NU after operative treatment and 6 recalcitrant NU. 23 of the cases were men at the average age of 43.9 (18–74) and 32–women, at the average age of 64.7 (43–88). NU according to Weber-Cech were–2 hypertrophic, 18 olygotrophic and 20 atrophic, as 7 of them were infected. The initial trauma in 14 cases was high energy. The most common predisposing factors at DU are: poor bone contact–distraction 11 cases, soft tissue interposition 8 cases. At NU after conservative treatment: soft tissue interposition 13 cases and inadequate vascularity–severe injury 6 cases, and at NU after operative treatment: mechanical instability–inadequate fixation 18 cases and excessive soft tissue striping 11 cases. The usual contributing factors are: metabolic bone disease 23 cases; obesity 18 cases; poor functional level 14 cases; smoking 14 cases; advanced age 11 cases. Osteosynthesis with AO plate were 23 cases and the remaining 32–interlocking nails. Bone grafting was done in 23 cases, decortications in 12 cases, and channel reaming–in 20 cases.

Results: All the cases that were treated with AO plates consolidated for the average period of 103 days (70–150) and the cases with interlocking nails (with the exception of 3–9%) for the average period of 108 days (160–240). As post-operative complications we had 6 (26%) cases of iatrogenic neurological injury with plate ostheosynthesis, 3 (10%) cases of shoulder impingements with ILN, one case of shaft fracture and infection in both methods. The patients were followed for minimum 12 months after bone union–clinical and X-ray examinations (12–60) months. We rated the final functional result according to Rommens score: excellent–29, very good–13, good–8, satisfactory–2, bad–3.

Conclusion: We think that DU are more appropriate for interlocking nailing. The cases that NU are a result of unsuccessful conservative treatment, because intramedullary channel was obstructed, is better to be treated by ostheosynthesis with plate. And the contrary–it is suitable to replace ostheosynthesis with AO plate with interlocking nails after extraction of the implants in addition to bone grafting.

Ten patients with humeral shaft fractures and no clinical or radiographic signs of healing after at least six weeks' immobilisation were treated by flexible intramedullary nailing using a closed retrograde technique. Bone grafting was not performed, and active movement was encouraged after operation. Nine fractures healed; the mean time to union was 10.5 weeks (range 6 to 22 weeks). One patient needed compression plating and bone grafting at 22 weeks, and another required re-operation for distal migration of the rods. There were no infections, nerve palsies or other complications. Stiffness of the shoulder which had developed during early treatment improved after operation.

Background:

There is limited evidence regarding HIV infection as a risk factor for delayed union and implants sepsis in patient with fractures treated with surgical fixation. Most studies have included patient with a variety of different fractures and hence very different risks regarding delayed union and implant sepsis. We have looked at a single fracture, closed femoral shaft fractures treated with intramedullary nailing, to see if HIV infection is a risk factor with for the development of delayed union and implant sepsis. We present a prospective study of 160 patients with closed femoral shaft fractures treated with intramedullary nailing. Primary outcomes were delayed union of more than 6 months and implant sepsis in the first 12 months.

Aims: to evaluate the efþcacy of this technique in 46 tibias and 22 femurs with a delayed bone healing (> 6 months) with a minimum follow-up of one year after injection. Methods: Forty-þve injections were performed in a one-day clinic. At least 300 ml autologeous bone marrow is aspirated from the iliac crest using multiple aspiration sites. Through isopyknic centrifugation the mixture of bone marrow and phosphateÐbuffered saline was layered over undiluted Ficoll-Paque. Centrifugation was done for 35 min. at 400 times gravity. An average of 52 cc of mainly myeloid cells were obtained with a nucleated recovery rate of average 62% (27–90%). In 21 cases additional surgery was performed at the moment of bone marrow grafting. Eleven times an implant exchange, seven dynamisations and 3 additional bonegrafting. The bone marrow grafting was performed through cannulated screws seated in the medullary cavity below and above the fracture site. Results: we encounter one postoperative irritation of the pes anserinus tendons due to inþltration. Despite the fact that we aspirated an average of 340 cc of bone marrow no adverse reaction was seen from this nor from the sometimes forceful injection of 50 cc concentrated bone marrow. In eight cases no bone healing occurred. In þve cases, probably due to a lack of stability and implant failure. Conclusions: the use of concentrated bone marrow injected in the medullary cavity near the fracture site is cost effective and seems to give favorable results.

1. A series of 102 cancellous strip grafts for delayed union of long bone fractures has been reviewed.

2. Half of the initial injuries were open.

3. Half of the fractures were butterfly or segmental lesions or were comminuted.

4. After strip grafting 84 per cent of the fractures were united within sixteen weeks, and only four took longer than twenty weeks.

5. Complete failure of union occurred in only one case, a tibial fracture complicated by low-grade pyocyaneus osteomyelitis.

6. A more aggressive attitude to the problem of delayed union is advocated.

Despite continuous advances in the treatment of long bone fractures, disturbances of healing processes remain a difficult challenge. Currently, autologous cancellous bone and bone marrow grafting has become the standard treatment of delayed unions and non-unions. Platelet concentrates rich in growth factors – platelet-rich plasma (PRP) – represent a novel osteoinductive therapy that could be valuable for the treatment of disturbances of bone healing processes.

This article reports the efficiency of percutaneous autologous platelet-leukocyte rich gel (PLRG) injection as a minimally invasive method as alternative to open grafting techniques. Following the outpatient procedure, each of 32 participants was followed up on a regular basis with clinical examinations, roentgenograms, dual-energy x-ray absorptiometry (DEXA) examinations and functional evaluations. In the delayed-union group the average time to union after PLRG injection was 9,3 weeks and the union was achieved in all cases. In the nonunion group, the union was observed in 13 of 20 cases and the average time to union after PLRG injection was 10,3 weeks. Interestingly, in patients with non-union, who a union was not achieved, the ave time from the fracture and/or from the last operation was longer than 11 months. Probably the fibrous tissue in the gap interposing the bone ends becomes more ossified with time and the vascular vessels diminish, so the PLRG is no longer able to induce the bone healing processes in such cases.

This is our initial experience with the use of PLRG as biologic treatment for delayed union or nonunion. Our investigation showed that percutaneous PLRG injection in delayed union is a sufficient method to obtain union, which is less invasive procedure than bone marrow injection. Also percutaneous PLRG grafting can be an effective method for the treatment of selected cases of nonunion. One critical factor is the average time of PLRG injection to the index operation – the time less than 11 months after initial surgery seems to be critical to achieve good outcomes in percutaneous PLRG injections for nonunion.

Our aim is to study the epidemiology of delayed union and pseudarthrosis of femoral fractures which were treated in our clinic with intramedullary nailing technique and simultaneously to speculate for the application of the method and for the reasons which might guide to these complications.

During a 36 month-period, from 1999 to 2001, 46 patients suffering femoral shaft fractures were treated in our clinic. They were 43 men and 3 women and their average age was 22.8 years. Twenty-eight fractures were in the right leg and 18 in the left. All patients underwent primary closed intramedullary locked nailing with AO type of nail, except 4 patients who also suffered a unilateral intertrochanteric fracture and were treated with AO-PFN nail. Reaming was done in 33 cases. No condition or disease able to inhibit fracture healing was observed. All patients were operated in the first three days after submission by the same team of surgeons. Thirty patients underwent static intranaedullary locked nailing and the rest dynamic from the beginning.

The average time of post-operative follow up, clinical and radiological, was seven months. Thirty-three fractures were healed successfully in six months (mean: 4.2 months). In 10 cases delayed union was observed (mean: 7.2 months) and in the rest three pseudarthrosis. The last group underwent revision of the intramedullary nailing with an AO nail of greater diameter. Reasons for delayed union (21, 74%) and pseudarthrosis (6, 52%) are considered: a)soft tissues enclosed between the bony segments, b)lated nail dynamization, c)factors concerning the technique.

Undoubtfully, closed intramedullary locked nailing is the method of choice for the surgical treatment of femoral fractures. However, fracture healing sometimes exceeds the usual period of 4–6 months. Unfortunately, whereas infrequently, the surgeon also faces pseudarthrosis which is a difficult to solve problem.

Introduction: Goal of study to demonstrate that treatment with low-intensity pulsed ultrasound [LIPUS] results in greater increases in bone density and greater reductions in bone gap area as compared to sham control in tibia fractures with delayed union (no progression of healing for at least four months).

Methods: Two primary effectiveness variables, change of bone density and gap area during treatment, were selected as surrogates for bone healing. Abbreviated treatment period was maximum that sham treatment could be administered ethically. Both variables measured by blinded central reviewers from CT-scans taken before/after termination of treatment. All adverse events recorded, evaluated. Treatment duration was 16wks. Patients instructed to apply device once daily for 20 minutes. Control devices were visually identical but did not transmit ultrasound waves. Neither patients nor physicians could recognize shams.

Results: 101 patients enrolled (51 LIPUS, 50 sham), mean age 42.6 (active) versus 45.1 years (sham). Based on log-transformed data, mean improvement in bone density was 1.34 (90% CI 1.14 to 1.57) times greater for patients randomized to LIPUS compared to sham (p=0.002). A mean reduction in bone gap area also favored LIPUS treatment (p=0.014).

Conclusion: Double-blind, intent-to-treat analyses demonstrated statistically significant superior effectiveness for LIPUS device compared to sham in terms of both endpoints over 16wks of treatment. Estimated increase in bone density among patients randomized to LIPUS treatment was 34% greater than among patients randomized to sham. A significantly greater mean reduction in bone gap area after LIPUS treatment was also shown. Evaluation of adverse events showed that ultrasound therapy is safe.

Introduction

The delay looks radiographically as a fracture callus not very evident or absent 6 months after osteosynthesis. Patients undergo a long period of immobilization and this fact causes the increase the social cost of the disease. The technique we suggest aims to the reduce the period of immobilization and as a consequence the management costs of the disease.

Background

Shockwave therapy has been shown to induce osteoneogenesis in animal models. The mechanism of action is unclear, but experimental evidence suggests micro-fracture formation and increased blood flow as the most likely explanation. Several reports from Europe have suggested good results from the treatment of delayed fracture union with shock-waves. We present the results of a randomised double-blind placebo-controlled pilot study.

Aims

This study aims to report the outcomes in the treatment of unstable proximal third scaphoid nonunions with arthroscopic curettage, non-vascularized bone grafting, and percutaneous fixation.

This review is aimed at clinicians appraising preclinical trauma studies and researchers investigating compromised bone healing or novel treatments for fractures. It categorises the clinical scenarios of poor healing of fractures and attempts to match them with the appropriate animal models in the literature.

We performed an extensive literature search of animal models of long bone fracture repair/nonunion and grouped the resulting studies according to the clinical scenario they were attempting to reflect; we then scrutinised them for their reliability and accuracy in reproducing that clinical scenario.

Models for normal fracture repair (primary and secondary), delayed union, nonunion (atrophic and hypertrophic), segmental defects and fractures at risk of impaired healing were identified. Their accuracy in reflecting the clinical scenario ranged greatly and the reliability of reproducing the scenario ranged from 100% to 40%.

It is vital to know the limitations and success of each model when considering its application.

Objectives

Diabetes mellitus (DM) is known to impair fracture healing. Increasing evidence suggests that some microRNA (miRNA) is involved in the pathophysiology of diabetes and its complications. We hypothesized that the functions of miRNA and changes to their patterns of expression may be implicated in the pathogenesis of impaired fracture healing in DM.

Objectives

A successful outcome following treatment of nonunion requires the correct identification of all of the underlying cause(s) and addressing them appropriately. The aim of this study was to assess the distribution and frequency of causative factors in a consecutive cohort of nonunion patients in order to optimise the management strategy for individual patients presenting with nonunion.

Aims. The incidence of atypical femoral fractures (AFFs) continues to increase. However, there are currently few long-term studies on the complications of AFFs and factors affecting them. Therefore, we attempted to investigate the outcomes, complications, and risk factors for complication through mid-term follow-up of more than three years. Methods. From January 2003 to January 2016, 305 patients who underwent surgery for AFFs at six hospitals were enrolled. After exclusion, a total of 147 patients were included with a mean age of 71.6 years (48 to 89) and 146 of whom were female. We retrospectively evaluated medical records, and reviewed radiographs to investigate the fracture site, femur bowing angle, presence of delayed union or nonunion, contralateral AFFs, and peri-implant fracture. A statistical analysis was performed to identify the significance of associated factors. Results. The mean follow-up period was 70.2 months (36 to 191). There were 146 AFFs (99.3%) in female patients and the mean age was 71.6 years (48 to 89). The AFFs were located in the subtrochanter and shaft in 52 cases (35.4%) and 95 (64.6%), respectively. The preoperative mean anterior/lateral femoral bowing angles were 10.5° (SD 5.7°)/6.1° (SD 6.2°). The postoperative mean anterior/lateral bowing values were changed by 8.7° (SD 5.4°)/4.6° (SD 5.9°). Bisphosphonates had been used contemporarily in 115 AFFs (78.2%) for a mean of 52.4 months (1 to 204; SD 45.5) preoperatively. Nailing was performed in 133 AFFs (90.5%), and union was obtained at a mean of 23.6 weeks (7 to 85). Delayed union occurred in 41 (27.9%), and nonunion occurred in 13 (8.8%). Contralateral AFF occurred in 79 patients (53.7%), and the use of a bisphosphonate significantly influenced the occurrence of contralateral AFFs (p = 0.019). Peri-implant fractures occurred in a total of 13 patients (8.8%), and a significant increase was observed in cases with plating (p = 0.021) and high grade of postoperative anterolateral bowing (p = 0.044). Conclusion. The use of a bisphosphonate was found to be a risk factor for contralateral AFF, and high-grade postoperative anterolateral bowing and plate fixation significantly increased the occurrence of peri-implant fractures. Long-term follow-up studies on the bilaterality of AFFs and peri-implant fractures are warranted. Cite this article: Bone Joint J 2021;103-B(11):1648–1655