Aim. Treatment algorithms for fracture-related
Aims. Excision of chronic osteomyelitic bone creates a dead space which must be managed to avoid early recurrence of infection. Systemic antibiotics cannot penetrate this space in high concentrations, so local treatment has become an attractive adjunct to surgery. The aim of this study was to present the mid- to long-term results of local treatment with gentamicin in a bioabsorbable ceramic carrier. Methods. A prospective series of 100 patients with Cierny-Mader Types III and IV chronic ostemyelitis, affecting 105 bones, were treated with a single-stage procedure including debridement, deep tissue sampling, local and systemic antibiotics, stabilization, and immediate skin closure. Chronic osteomyelitis was confirmed using strict diagnostic criteria. The mean follow-up was 6.05 years (4.2 to 8.4). Results. At final follow-up, six patients (six bones) had recurrent infection; thus 94% were infection-free. Three infections recurred in the first year, two in the second year, and one 4.5 years postoperatively. Recurrence was not significantly related to the physiological class of the patient (1/20 Class A (5%) vs 5/80 Class B (6.25%); p = 0.833), nor was it significantly related to the aetiology of the infection, the organisms which were cultured or the presence of
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
Aim. Differentiation of infected (INF)
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
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
The pathogenesis of non-union is multifactorial. Path biological factors, mechanical factors, and low-grade-infection contribute to impaired bone healing. Aim of this study was to determine the rate of low-grade-infection in patients with long bone non-union of the lower extremity without signs of acute infection, the influence of CRP (C-reactive protein), and the outcome. In a retrospective study (2003–2013), all patients who underwent surgery for treatment of tibial- or femoral-shaft-non-union without any clinical evidence of infection were assessed. Bacterial cultures harvested during non-union revision, the CRP and WBC (white blood cells) values at hospital admission, the outcome, and epidemiological data were analysed.Aim
Method
The Radiographic Union Score for Hip (RUSH) is an outcome instrument designed to describe radiographic healing of femoral neck fractures. The ability to identify fractures that have not healed is important for defining non-union in clinical trials and predicting patients that likely require additional surgery to promote fracture healing. We sought to determine a RUSH threshold score that defines
Non-union is an unfortunate outcome of the fracture healing process for some patients; with an estimated annual incidence of 17.4- 18.9 per 100,00. The management of these patients depicts a significant clinical challenge for surgeons and financial burden to health services. External ultrasound stimulation devices (ExogenTM) have been highlighted as a novel non invasive therapy to achieve union in cases of delayed and non-union. The aim of the current study was to assess the rate of union in patients using ExogenTM therapy for delayed fracture union in a district general hospital. This is a single centre retrospective continuous cohort study. Patients were identified from a prospective database of all patients prescribed ExogenTM therapy between June 2013- September 2021 in a district general hospital. Patient data was collected retrospectively using electronic patient records. Fracture union was assessed both clinically and radiographically and recorded in patient records. Failure of treatment was defined as progression to operative treatment due to lack of progression with ultrasound therapy or established asymptomatic non-union. Patient were excluded from the study if ExogenTM therapy was prescribed within 6 weeks of injury.Introduction
Materials & Methods
Despite the increase of surgical procedures for extremities injuries and improvement of various fixation devices and surgical methods, the number of unsatisfactory osteosynthesis results reaches 2–7%. Chronic osteomyelitis after lower extremities long bones osteosynthesis occurs in 1.3–23% of cases, and the percentage of bone
Infected big gap non-union of femur and tibia are difficult to treatment because of infection, bone loss, shortening, poor sift tissue over and deformity. Step by step management and definitive treatment by Ilizarov fixator was achieved in our cases. A long defect which is more than 10cm in femur and tibia because of infection and gap, tumor resection, traumatic loss, which is very difficult to treat by conventional method and that's why we treated that type defect by Tibialization of fibula with Ilizarov technique. Management of infected big gap non-union of the femur include debridement and bone transport by Ilizarov technique by using Ilizarov fixator we can correct deformities, regenerate new bone without bone grafting, correct LLD and patient can weight bear during the course of treatment. We retrospectively reviewed records of 246 consecutive patients who underwent distraction osteogenesis using Ilizarov compression-distraction device for infected big gap INU of femur and tibia from 2000 to 2020.Introduction
Materials and Methods
Fracture neck of femur is aptly called as “the fracture of necessity” owing to the various factors responsible for its non-union. Pauwel's inter-trochantric valgus osteotomy is a useful approach to deal with such fractures. The aim of this study is to evaluate the functional outcome of valgus osteotomy in treatment of neglected and non-union fracture neck of femur using Harris Hip Scoring system (HHS).Abstract
INTRODUCTION
AIM
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
Non-union is debilitating, costly and affects 2–8% of intramedullary fixed fractures. Clinical data suggest that percutaneous interfragmentary screws offer a less invasive alternative to exchange nailing. This study aimed to assess their efficiency with biomechanical analyses. A tibia was prepared for finite element analysis by creating a fracture of AO classification 42A2b, prior to reaming and insertion of an intramedullary nail. A callus was modelled as granulation tissue and gait loads were applied. The model was validated against published data and with sensitivity studies. The effects of weightbearing, fracture gap and angle, percutaneous screws and exchange nailing were compared through quantification of interfragmentary motion and strain, with the latter used to gauge healing performance via mechano-regulation theory.Introduction
Materials and Methods
Scaphoid non-union can result in pain, altered wrist kinematics leading to a Scaphoid Non-union Advance Collapse, ultimately to symptomatic radio-carpal arthritis. Open techniques have their limitations. We describe the rationale, surgical technique and outcomes of our series of arthroscopic bone-grafting (ABG) and fixation of scaphoid non-union. We performed a prospective single-surgeon series of 22 consecutive patients with clinico-radiologically established scaphoid non-union between March 2015 and April 2019. Data was collected from Electronic Patient Records, Patient Archived Computer system (PACS) and hand therapy assessments. We collected demographic data including age, hand-dominance, occupation and mechanism of injury. The Disabilities of the Arm, Shoulder and Hand Score (Quick DASH), Mayo wrist score, Patient Rated Wrist Evaluation (PRWE) and grip-strength measurements were collected preoperatively and at follow-up appointments.Abstract
Background
Methods
Postoperative peritrochanteric pain, which can be caused by non-union of the greater trochanter in those who have undergone total hip arthroplasty (THA) with trochanteric osteotomy, affects patient satisfaction. We reviewed 89 consecutive cases of primary THA performed with a mini-trochanteric direct lateral approach (Wafer approach), during which the anteroinferior trochanteric fragment (2 cm × 1 cm) attached to the anterior one-third or one-fourth of the gluteus medius muscle insertion and the entire insertion of the gluteus minimus muscle were osteotomized and detached using a curved chisel for exposure, while the origin of the vastus lateralis muscle remained intact. After completion of implantation, the detached fragment was fixed in the original position using 2 parallel braided sutures. If returning the trochanteric fragment to its original position was difficult, the tightened posterior tendinous portion of the gluteus minimus muscle was released to reduce the fragment easily and was then fixed. The surgeries, which included 19 cemented, 7 cementless, and 63 hybrid THAs, were performed between January 2012 and August 2013, and the patients [13 men, 76 women; average age, 65.6 years (38–86 years)] were followed for 6 months. The original diagnosis included primary osteoarthritis in 7 cases, osteoarthritis secondary to dysplasia in 75 cases, and avascular necrosis of the femoral head in 7 cases. X-ray examination including anteroposterior (AP) and lateral hip views was performed at 1, 3, and 6 months postoperatively, and a displacement of > 5 mm of the osteotomized fragment in either the AP or lateral view was considered fragment migration. The Japanese Orthopaedic Association (JOA) pain score was also recorded at 3 and 6 months postoperatively. We examined the possible factors affecting trochanteric migration and JOA pain score, including age, sex, THA type, leg lengthening, Crowe classification, and suture type. We also examined the correlation between trochanteric migration and JOA pain score. There were no peri- or post-operative complications including infection, deep venous thrombosis, dislocation, or periprosthetic fracture. No revision or radiographic loosening occurred in the follow-up period. Average leg lengthening was 9.8 mm (−4–21 mm), measured on the AP X-ray of the hip as the vertical interval between the pre- and postoperative positions of the lesser trochanter. There were 35 cases (39.3%) of trochanteric migration at postoperative 3 months. The Chi-square test and logistic regression analysis indicated that age, sex, Crowe classification, leg lengthening, and suture type did not affect trochanteric migration or JOA pain score. On the other hand, THA type did not affect trochanteric migration but did affect JOA pain score at postoperative 3 months. Patients who underwent cementless THA had worse JOA pain scores than the other patients. There was no correlation between trochanteric migration and JOA pain scores. The results indicated that trochanteric fragment migration often occurred in this series using the Wafer approach. Although the pain score is affected by many factors including thigh pain, hip abductor weakness, and wound irritation in the short term, it did not correlate with the trochanteric
Many pre-clinical models of atrophic non-union do not reflect the clinical scenario, some create a critical size defect, or involve cauterization of the tissue which is uncommonly seen in patients. Atrophic non-union is usually developed following high energy trauma leading to periosteal stripping. The most recent reliable model with these aspects involves creating a non-critical gap of 1mm with periosteal and endosteal stripping. However, this method uses an external fixator for fracture fixation, whereas intramedullary nailing is the standard fixation device for long bone fractures. To establish a clinically relevant model of atrophic non-union using intramedullary nail and (1) ex vivo and in vivo validation and characterization of this model, (2) establishing a standardized method for leg positioning for a reliable x-ray imaging. Ex vivo evaluation: 40 rat's cadavers (adult male 5–6 months old), were divided into five groups (n=8 in each): the first group was fixed with 20G intramedullary nail, the second group with 18G nail, the third group with 4-hole plate, the fourth group with 6-hole plate, and the fifth group with an external fixator. Tibiae were harvested by leg disarticulation from the knee and ankle joints. Each group was then subdivided into two subgroups for mechanical testing: one for axial loading (n=4) and one for 4-point bending (n=4) using Zwick/Roell® machine. Statistical analysis was carried out by ANOVA with a fisher post-hoc comparison between groups. A p-value less than 0.05 was considered statistically significant. To maintain the non-critical gap, a spacer was inserted in the gap, the design was refined to minimize the effect on the healing surface area. In vivo evaluation was done to validate and characterize the model. Here, a 1 mm gap was created with periosteal and endosteal stripping to induce non-union. The fracture was then fixed by a hypodermic needle. A proper x-ray technique must show fibula in both views. Therefore, a leg holder was used to hold the knee and ankle joints in 90º flexion and the foot was placed in a perpendicular direction with the x-ray film. Lateral view was taken with the foot parallel to the x-ray film. Ex vivo: axial load stiffness data revealed that intramedullary nails are significantly stronger and stiffer than other devices. Bending load to failure showed that 18G nails are significantly stronger than 20G, thus it is used for the in vivo experiments. In vivo: final iteration revealed 3/3 non-union, and in controls with the periosteum and endosteum intact but with the 1mm non-critical gap, it progressed to 3/3 union. X-ray positioning: A-P view in supine position, there was an unavoidable degree of external rotation in the lower limb, thus the lower part of the fibula appeared behind the tibia. To overcome this, a P-A view of the leg was performed with the body in prone rather, this arrangement allowed both upper and lower parts of the fibula to appear clearly in both views. We report a novel model of atrophic non-union, the surgical procedure is relatively simple and the model is reproducible.OBJECTIVES
Introduction and Aims:. The surgical treatment of fractures of the scaphoid with delayed presentation or with established non-union pose a formidable challenge with reported failure rates between 15% and 45%. The aim of this study is to report the results of percutaneous versus open fixation with bone grafting of these fractures. Method:. 34 Consecutive patients who underwent surgery between 2009 and 2013 for delayed presentation and established non-union of scaphoid fractures have been reviewed retrospectively. There were 27 males and 7 females with a mean age of 31 years (15 to 66). The mean delay from time of injury to operation was 12 weeks (4 weeks to 11 months) in the percutaneous fixation group and 19 months (5 months to 6 years) in the open fixation group. 19 Patients were treated with percutaneous screw fixation alone and 15 patients underwent open reduction and internal fixation supplemented with autogenous corticocancellous iliac bone graft. The classification of Slade and Dodds (2009) was used as a guide for surgical treatment and the Mini-Acutrak headless compression screw was used as the fixation device in all cases. Results:. Patients underwent final clinical and radiological assessment with plain radiographs 6 months following their surgery. There was one failed union in the percutaneous fixation group and there was one failed union in the open fixation group. One patient in the open fixation group was lost to follow up. No serious complications were recorded in either group. Conclusion:. The success of percutaneous internal fixation for acute fractures of the carpal scaphoid may be extended to include scaphoid fractures with delayed presentation and fractures of the scaphoid with established
Methicillin– resistant Staphylococcus aureus (MRSA) infected gap non –union of long bones fractures is a challenge to manage. Treatment options are limited such a Ilizarov bone transport, vascularized bone free transfer etc. These techniques have complications and require expertise. We present a rare case with MRSA infected
Non-unions often arise because of high strain environments at fracture sites. Revision fixation, bone grafting and biologic treatments to treat long bone fracture non-union can be expensive and invasive. Percutaneous strain reduction screws (PSRS) can be inserted as a day-case surgical procedure to supplement primary fixation at a fraction of the cost of traditional treatments. Screw insertion perpendicular to the plane of a non-union can resist shear forces and achieve union by modifying the strain environment. A multi-centre retrospective study was undertaken to confirm the results of the initial published case series, ascertain whether this technique can be adopted outside of the developing institution and assess the financial impact of this technique. Retrospective analysis was performed for all PSRS cases used to treat un-united long bone fractures in four level 1 trauma centres from 2016 to 2020. All patients were followed up until union was achieved or further management was required. Demographic data was collected on patients, as were data about their injuries, initial management and timings of all treatments received. A comparative cost analysis was performed comparing patients treated with PSRS and with traditional non-union surgery methods.Introduction
Materials and Methods