Histologic Analysis of 2 Alternative Donor Sites of the Ipsilateral Elbow in the Treatment of Capitellar Osteochondritis Dissecans.

PURPOSE: To compare the histologic features of the cartilage from the capitellum with 2 proposed alternative donor sites from the ipsilateral elbow in the treatment of capitellar osteochondritis dissecans (OCD): the nonarticulating part of the radial head and the nonarticulating lateral side of the olecranon tip. METHODS: Ten human cadaveric elbow specimens with macroscopically normal articular surfaces were used to obtain 5-mm osteochondral grafts: 10 from the capitellum (60° anteriorly relative to the humeral shaft), 10 from the radial head (nonarticulating part at 80°), and 4 from the olecranon (lateral side of the olecranon tip). Grafts were fixated in formalin (4% formaldehyde), decalcified, and processed into standard 8-µm-thick hematoxylin and eosin-and Toluidine Blue-stained sections. These were assessed for cartilage thickness, shape of articular surface, and 13 histologic parameters of the International Cartilage Repair Society II. Olecranon scores were excluded from statistical analysis. RESULTS: Mean cartilage thickness was 1.5 ± 0.22 mm at the capitellum; 1.3 ± 0.34 mm at the radial head; and 1.9 ± 1.0 mm at the olecranon. There was no difference in cartilage thickness between the capitellum and radial head (P = .062). All grafts demonstrated a convex articular surface. International Cartilage Repair Society II scores ranged from 82 to 100 for the capitellum, from 81 to 100 for the radial head, and from 67 to 87 for the olecranon tip. There was less chondrocyte clustering at the capitellum (84 ± 14) than in the radial head (94 ± 3.2; P = .019). Mid/deep zone assessment of the capitellum scored higher (97 ± 6.7) than the radial head (91 ± 4.6; P = .038). CONCLUSIONS: This study demonstrates appropriate histologic similarities between the cartilage from the capitellum and 2 alternative donor sites of the ipsilateral elbow in the treatment of capitellar OCD: the nonarticulating part of the radial head and the nonarticulating lateral side of the olecranon tip. CLINICAL RELEVANCE: From an histologic point of view, there seem to be no obstacles to use grafts from these alternative donor sites for reconstruction of the capitellum when performing osteochondral autologous transplantation.

Do Injured Adolescent Athletes and Their Parents Agree on the Athletes' Level of Psychologic and Physical Functioning?

BACKGROUND: Although a parent's perception of his or her child's physical and emotional functioning may influence the course of the child's medical care, including access to care and decisions regarding treatment options, no studies have investigated whether the perceptions of a parent are concordant with that of an adolescent diagnosed with a sports-related orthopaedic injury. Identifying and understanding the potential discordance in coping and emotional distress within the athlete adolescent-parent dyads are important, because this discordance may have negative effects on adolescents' well-being. QUESTIONS/PURPOSES: The purposes of this study were (1) to compare adolescent and parent proxy ratings of psychologic symptoms (depression and anxiety), coping skills (catastrophic thinking about pain and pain self-efficacy), and upper extremity physical function and mobility in a population of adolescent-parent dyads in which the adolescent had a sport-related injury; and (2) to compare scores of adolescents and parent proxies with normative scores when such are available. METHODS: We enrolled 54 dyads (eg, pairs) of adolescent patients (mean age 16 years; SD = 1.6) presenting to a sports medicine practice with sports-related injuries as well as their accompanying parent(s). We used Patient-reported Outcomes Measurement Information System questionnaires to measure adolescents' depression, anxiety, upper extremity physical function, and mobility. We used the Pain Catastrophizing Scale short form to assess adolescents' catastrophic thinking about pain and the Pain Self-efficacy Scale short form to measure adolescents' pain self-efficacy. The accompanying parent, 69% mothers (37 of 54) and 31% fathers (17 of 54), completed parent proxy versions of each questionnaire. RESULTS: Parents reported that their children had worse scores (47 ± 9) on depression than what the children themselves reported (43 ± 9; mean difference 4.0; 95% confidence interval [CI], -7.0 to 0.91; p = 0.011; medium effect size -0.47). Also, parents reported that their children engaged in catastrophic thinking about pain to a lesser degree (8 ± 5) than what the children themselves reported (13 ± 4; mean difference 4.5; 95% CI, 2.7-6.4; p < 0.001; large effect size 1.2). Because scores on depression and catastrophic thinking were comparable to the general population, and minimal clinically important difference scores are not available for these measures, it is unclear whether the relatively small observed differences between parents' and adolescents' ratings are clinically meaningful. Parents and children were concordant on their reports of the child's upper extremity physical function (patient perception 47 ± 10, parent proxy 47 ± 8, mean difference -0.43, p = 0.70), mobility (patient perception 43 ± 9, parent proxy 44 ± 9, mean difference -0.59, p = 0.64), anxiety (patient perception 43 ± 10, parent proxy 46 ± 8, mean difference -2.1, p = 0.21), and pain self-efficacy (patient perception 16 ± 5, parent proxy 15 ± 5, mean difference 0.70, p = 0.35). CONCLUSIONS: Parents rated their children as more depressed and engaging in less catastrophic thinking about pain than the adolescents rated themselves. Although these differences are statistically significant, they are of a small magnitude making it unclear as to how clinically important they are in practice. We recommend that providers keep in mind that parents may overestimate depressive symptoms and underestimate the catastrophic thinking about pain in their children, probe for these potential differences, and consider how they might impact medical care. LEVEL OF EVIDENCE: Level I, prognostic study.

What Is the Relationship of Fear Avoidance to Physical Function and Pain Intensity in Injured Athletes?

BACKGROUND: Fear avoidance can play a prominent role in maladaptive responses to an injury. In injured athletes, such pain-related fear or fear avoidance behavior may have a substantial influence on the recovery process. Specifically, it may explain why some are able to reach their preinjury abilities, whereas others are unable to return to sport. QUESTIONS/PURPOSES: (1) Is fear avoidance in athletes associated with decreased physical function after injury? (2) To what degree is fear avoidance associated with athletes' pain intensity? METHODS: In a cross-sectional study, we recruited injured athletes-defined as patients with sports-related injury, weekly engagement in sport activities, participation in competitive events as part of a team or club, self-identification as an athlete, and a desire to return to sport after recovery-from an orthopaedic sports medicine center at a major urban university hospital. Of 130 approached patients, 102 (84% men; mean ± SD age 25 ± 8.5 years) met the inclusion criteria. Participants completed a demographic questionnaire, the Athlete Fear Avoidance Questionnaire, which assesses injury-related fear and avoidance behavior specifically in an athletic population, the Pain Catastrophizing Scale, the Hospital Anxiety and Depression Scale, and two Patient-Reported Outcomes Measurement Information System measures: Physical Function Computerized Adaptive Testing (CAT) and Pain Intensity CAT. RESULTS: After controlling for age, injury region (upper versus lower extremity), catastrophic thinking, and emotional distress, we found that an increase in athletes' fear avoidance was associated with a decrease in physical function (b = -0.32; p = 0.002). The model explained 30% of the variation in physical function with 7.3% explained uniquely by fear avoidance. After controlling for initial appointment/followup, surgery for the current condition, multiple pain conditions, history of prior sport-related injury/surgery, pain medication prescription, catastrophic thinking, and emotional distress, athletes' fear avoidance was not associated with pain (b = -0.14; p = 0.249). The model explained 40% of the variation in pain intensity and pain catastrophizing (b = 0.30; p = 0.001) uniquely explained 7.1% of this variation. CONCLUSIONS: In injured athletes, fear avoidance is independently associated with decreased physical function, whereas pain catastrophizing is associated with high pain intensity. Both level of an athlete's fear avoidance and catastrophic thinking about pain should be accounted for in clinical interventions aimed at helping athletes improve recovery and return to sport. LEVEL OF EVIDENCE: Level II, prognostic study.

Topographic Analysis of 2 Alternative Donor Sites of the Ipsilateral Elbow in the Treatment of Capitellar Osteochondritis Dissecans.

PURPOSE: To find the best topographic subchondral bone match between the capitellum and 2 proposed alternative donor sites of the ipsilateral elbow for capitellar osteochondral autologous transplantation: the non-articulating part of the radial head and the lateral olecranon tip. METHODS: In our retrospective database, 20 patients with an unremarkable computed tomography scan of the elbow despite clinical suspicion were identified for analysis. Included were patients aged 11 to 20 years with intact osseous structures and a computed tomography slice thickness of 1.25 mm or less. Three-dimensional polygon models were created using a standard predefined threshold, after which 4 articular surface lesions on the capitellum were created: central 40°, central 60°, lateral 40°, and lateral 60°. In addition, 3 donor locations on the non-articulating part of the radial head (diameter, 5 mm) and the lateral olecranon tip (diameter, 3.5 mm) were created. For each of 24 donor-recipient combinations, the donor graft surface was virtually placed on the recipient surface to quantify the mean distance between surfaces. RESULTS: The group of 20 patients consisted of 16 male and 4 female patients with a mean age of 15.9 years (range, 12-18 years). For a central 40° lesion, the mean distance across all 6 donor-recipient combinations ranged from 0.085 ± 0.023 to 0.118 ± 0.036 mm; for a central 60° lesion, the mean distance ranged from 0.075 ± 0.018 to 0.117 ± 0.062 mm; for a lateral 40° lesion, the mean distance ranged from 0.087 ± 0.030 to 0.182 ± 0.226 mm; and for a lateral 60° lesion, the mean distance ranged from 0.084 ± 0.048 to 0.115 ± 0.045 mm. There were no differences in topographic matching between donor-recipient combinations. CONCLUSIONS: The findings of this study show a less than 0.2-mm difference in the topographic subchondral bone match between 4 common lesion locations on the capitellum and 2 alternative donor sites of the ipsilateral elbow for capitellar osteochondral autologous transplantation: the non-articulating part of the radial head and the lateral olecranon tip. CLINICAL RELEVANCE: These findings suggest that the non-articulating part of the radial head and the lateral olecranon tip may potentially be used as a donor source when treating capitellar osteochondritis dissecans.

Effectiveness of reduction maneuvers in the treatment of nursemaid's elbow: A systematic review and meta-analysis.

BACKGROUND/AIM: Nursemaid's elbow usually occurs in young children when longitudinal traction is placed on the arm. Several manipulative maneuvers have been described, although, the most effective treatment technique is yet unclear. The aim of this systematic review and meta-analysis was to compare the two most commonly performed maneuvers (supination-flexion and hyperpronation) in the treatment of nursemaid's elbow. METHODS: A literature search was performed in PubMed, Embase, and Cochrane databases to identify randomized controlled trials comparing supination-flexion and hyperpronation. Data were extracted and pooled independently by two authors. Methodological quality assessment of included studies was performed. Meta-analysis was performed using a fixed-effect model in case of homogeneity across studies, and using a random-effect model in case of heterogeneity. Heterogeneity was calculated with the χ2 test and inconsistency in study effects across trials was quantified by I2 values. RESULTS: Seven randomized trials, including 701 patients (62% female), were included. A total of 350 patients were treated with the hyperpronation maneuver versus 351 patients who underwent the supination-flexion maneuver. Meta-analysis showed that hyperpronation was more effective than supination-flexion (risk ratio, 0.34; 95% confidence interval, 0.23 to 0.49; I2, 35%). The absolute risk difference between maneuvers was 26% in favor of hyperpronation, resulting in a number needed to treat of 4 patients. Trials lacked blinding of assessors and universal pain measures. CONCLUSIONS: Hyperpronation was more effective in terms of success rate and seems to be less painful compared to the supination-flexion maneuver in children with nursemaid's elbow.

Donor-site morbidity after osteochondral autologous transplantation for osteochondritis dissecans of the capitellum: a systematic review and meta-analysis.

PURPOSE: To determine the rate of donor-site morbidity after osteochondral autologous transplantation (OATS) for capitellar osteochondritis dissecans. METHODS: A literature search was performed in PubMed/MEDLINE, Embase, and Cochrane Library to identify studies up to November 6, 2016. Criteria for inclusion were OATS for capitellar osteochondritis dissecans, reported outcomes related to donor sites, ≥10 patients, ≥1 year follow-up, and written in English. Donor-site morbidity was defined as persistent symptoms (≥1 year) or cases that required subsequent intervention. Patient and harvest characteristics were described, as well as the rate of donor-site morbidity. A random effects model was used to calculate and compare weighted group proportions. RESULTS: Eleven studies including 190 patients were included. In eight studies, grafts were harvested from the femoral condyle, in three studies, from either the 5th or 6th costal-osteochondral junction. The average number of grafts was 2 (1-5); graft diameter ranged from 2.6 to 11 mm. In the knee-to-elbow group, donor-site morbidity was reported in 10 of 128 patients (7.8%), knee pain during activity (7.0%) and locking sensations (0.8%). In the rib-to-elbow group, one of 62 cases (1.6%) was complicated, a pneumothorax. The proportion in the knee-to-elbow group was 0.04 (95% CI 0.0-0.15), and the proportion in the rib-to-elbow group was 0.01 (95% CI 0.00-0.06). There were no significant differences between both harvest techniques (n.s.). CONCLUSIONS: Donor-site morbidity after OATS for capitellar osteochondritis dissecans was reported in a considerable group of patients. LEVEL OF EVIDENCE: Level IV, systematic review of level IV studies.

Osteochondritis dissecans of the capitellum: lesion size and pattern analysis using quantitative 3-dimensional computed tomography and mapping technique.

BACKGROUND: The goals of this study were to evaluate the reliability of a quantitative 3-dimensional computed tomography (Q3DCT) technique for measurement of the capitellar osteochondritis dissecans (OCD) surface area, to analyze OCD distribution using a mapping technique, and to investigate associations between Q3DCT lesion quantification and demographic characteristics and/or clinical examination findings. METHODS: We identified patients with capitellar OCD who presented to our orthopedic sports medicine practice between January 2001 and January 2016 and who had undergone a preoperative computed tomography scan (slice thickness ≤1.25 mm). A total of 17 patients with a median age of 15 years (range, 12-23 years) were included in this study. Three-dimensional polygon models were reconstructed after osseous structures were marked in 3 planes. Surface areas of the OCD lesion as well as the capitellum were measured. Observer agreement was assessed with the intraclass correlation coefficient (ICC). Heat maps were created to visualize OCD distribution. RESULTS: Measurements of the OCD surface area showed almost perfect intraobserver agreement (ICC, 0.99; confidence interval [CI], 0.98-0.99) and interobserver agreement (ICC, 0.93; CI, 0.86-0.97). Measurements of the capitellar surface area also showed almost perfect intraobserver agreement (ICC, 0.97;CI, 0.91-0.99) and interobserver agreement (ICC, 0.86; CI, 0.46-0.96). The median OCD surface area was 101 mm2 (range, 49-217 mm2). On the basis of OCD heat mapping, the posterolateral zone of the capitellum was most frequently affected. OCDs in which the lateral wall was involved were associated with larger lesion size (P = .041), longer duration of symptoms (P = .030), and worse elbow extension (P = .013). CONCLUSIONS: The ability to quantify the capitellar OCD surface area and lesion location in a reliable manner using Q3DCT and a mapping technique should be considered when detailed knowledge of lesion size and location is desired.

Interobserver reliability of the classification of capitellar osteochondritis dissecans using magnetic resonance imaging.

AIM: (1) To determine the interobserver reliability of magnetic resonance classifications and lesion instability criteria for capitellar osteochondritis dissecans lesions and (2) to assess differences in reliability between subgroups. METHODS: Magnetic resonance images of 20 patients with capitellar osteochondritis dissecans were reviewed by 33 observers, 18 orthopaedic surgeons and 15 musculoskeletal radiologists. Observers were asked to classify the osteochondritis dissecans according to classifications developed by Hepple, Dipaola/Nelson, Itsubo, as well as to apply the lesion instability criteria of DeSmet/Kijowski and Satake. Interobserver agreement was calculated using the multirater kappa (k) coefficient. RESULTS: Interobserver agreement ranged from slight to fair: Hepple (k = 0.23); Dipaola/Nelson (k = 0.19); Itsubo (k = 0.18); DeSmet/Kijowksi (k = 0.16); Satake (k = 0.12). When classifications/instability criteria were dichotomized into either a stable or unstable osteochondritis dissecans, there was more agreement for Hepple (k = 0.52; p = .002), Dipaola/Nelson (k = 0.38; p = .015), DeSmet/Kijowski (k = 0.42; p = .001) and Satake (k = 0.41; p < .001). Overall, agreement was not associated with the number of years in practice or the number of osteochondritis dissecans cases encountered per year (p > .05). CONCLUSION: One should be cautious when assigning grades using magnetic resonance classifications for capitellar osteochondritis dissecans. When making treatment decisions, one should rather use relatively simple distinctions (e.g. stable versus unstable osteochondritis dissecans; lateral wall intact versus not intact), as these are more reliable.

Radiographic Predictors for Short-term Functional Outcome after Radial Head Arthroplasty in Patients with Persistent Symptoms after Treatment for Radial Head.

BACKGROUND: Evaluation of the accurate position after radial head arthroplasty remains a challenge for surgeons. Standard radiographs are used to evaluate the position of the implant, however, results regarding radiographic deficiencies on clinical outcome are not consistent. In this retrospective study our main aim was to determine if subtle radiographic deficiencies after radial head arthroplasty can predict functional outcomes measured with the Mayo Elbow Performance Score (MEPS). METHODS: A total of 24 patients, that had a press-fit bipolar radial head arthroplasty because of persistent symptoms after treatment of a radial head fracture, were included. The mean follow-up time was 27 months and the MEPS was assessed at the final follow-up. Three upper extremity orthopaedic surgeons evaluated 12 potential deficiencies on anteroposterior and lateral radiographs in consensus agreement. RESULTS: The median MEPS was 97.5 (Interquartile Range 82.5-100). No association was found between the presence of subtle radiographic deficiencies and MEPS. CONCLUSION: Functional outcome of the elbow after uncemented press-fit bipolar radial head arthroplasty is not associated with subtle radiographic deficiencies. Therefore, surgeons might accept small imperfections on postoperative radiographs.

Interobserver reliability of radiographic assessment after radial head arthroplasty.

BACKGROUND: Radiographs are part of routine clinical care after radial head arthroplasty (RHA). Therefore, the aim of this diagnostic study was to assess the interobserver reliability of radiographic assessment following RHA. METHODS: Anteroposterior (AP) and lateral radiographs of 24 consecutive patients who underwent press-fit bipolar RHA were evaluated with respect to 14 parameters by 14 orthopaedic surgeons specializing in the elbow: shaft loosening (AP, lateral), subcollar bone resorption, nonbridging heterotopic ossification, capitellar erosion, capitellar osteopenia, implant size, ulnohumeral joint gapping, ulnohumeral joint degeneration, proximal radio-ulnar joint congruency, stem size, stem positioning (AP, lateral) and component dissociation or polyethylene wear of the head with increased angulation. Observer agreement was evaluated using the multirater kappa (κ) measure. RESULTS: Nine of 14 parameters had poor interobserver agreement [κ = 0.0 to 0.20, confidence interval (CI) = 0.0 to 0.31). Four parameters had fair agreement: subcollar bone resorption (κ = 0.27, CI = 0.12 to 0.40), capitellar erosion (κ = 0.30, CI = 0.20 to 0.40), ulnohumeral joint degeneration (κ = 0.35, CI = 0.22 to 0.51) and stem positioning in AP view (κ = 0.24, CI = 0.14 to 0.36). One parameter had moderate agreement: nonbridging heterotopic ossification (κ = 0.47, CI = 0.31 to 0.64). CONCLUSIONS: The overall interobserver reliability of radiographic assessment following press-fit bipolar RHA was poor among experienced elbow surgeons. Therefore, radiographic evaluation after RHA should be interpreted with caution when making treatment decisions.

Decreased Defect Size and Partial Restoration of Subchondral Bone on Computed Tomography After Arthroscopic Debridement and Microfracture for Osteochondritis Dissecans of the Capitellum.

BACKGROUND: Arthroscopic debridement and microfracture are considered the primary surgical treatment for capitellar osteochondritis dissecans (OCD). Healing of the subchondral bone plays an essential role in cartilage repair, while lack of healing is related to the development of osteoarthritis. To date, it is unknown to what extent healing of the subchondral bone occurs after this technique in the elbow. PURPOSE: To analyze defect size changes and subchondral bone healing with computed tomography (CT) after arthroscopic debridement and microfracture for advanced capitellar OCD. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between 2009 and 2016, 67 patients underwent arthroscopic debridement and microfracture for advanced capitellar OCD. Fifty-four patients (81% follow-up rate) with CT scans were included (mean ± SD: preoperative, 4.0 ± 1.7 months; postoperative, 29 ± 9.0 months). OCD defect size was assessed by measuring the largest diameter in 3 directions: medial-lateral direction (coronal plane) and anterior-posterior direction and depth (both in sagittal plane). Healing of the OCD was divided into 3 categories: good-complete osseous union or ossification; fair-incomplete osseous union or ossification but improved; poor-no changes between pre- and postoperative scans. Postoperative clinical outcome was assessed with the Oxford Elbow Score (OES) at the same time as the postoperative CT scan. RESULTS: There were 30 female and 24 male patients (age, 15.7 ± 3.2 years). Defect size decreased ( P < .001) in all 3 directions (medial-lateral × anterior-posterior × depth) at 29 ± 9.0 months: preoperatively, 7.9 ± 2.8 × 8.0 ± 3.2 × 4.1 ± 1.5 mm; postoperatively, 3.5 ± 3.3 × 4.0 ± 3.5 × 1.6 ± 1.4 mm. Healing of the subchondral bone was graded as good in 19 defects (35%), fair in 27 (50%), and poor in 8 (15%). The mean postoperative OES score was 40 ± 8.4. Neither postoperative defect size nor healing grade correlated with the OES ( P > .05). CONCLUSION: Arthroscopic debridement and microfracture for advanced capitellar OCD result in improved (ie, decreased) defect size at a mean follow-up of 29 months, both in width and in depth. Healing of the subchondral bone was either good or fair in 85%. Interestingly, CT findings did not correlate with clinical outcomes.

Clinical Outcome After Arthroscopic Debridement and Microfracture for Osteochondritis Dissecans of the Capitellum.

BACKGROUND: Various surgical treatment techniques have been developed to treat capitellar osteochondritis dissecans; however, the optimal technique remains the subject of ongoing debate. PURPOSE: To evaluate clinical outcomes after arthroscopic debridement and microfracture for advanced capitellar osteochondritis dissecans. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between 2008 and 2015, the authors followed 77 consecutive patients (81 elbows) who underwent arthroscopic debridement and microfracture, and loose body removal if needed, for advanced capitellar osteochondritis dissecans. Seventy-one patients (75 elbows) with a minimum follow-up of 1 year were included. The mean age was 16 years (SD, ±3.3 years; range, 11-26 years) and the mean follow-up length was 3.5 years (SD, ±1.9 years; range, 1-8.2 years). Based on CT and/or MRI results, 71 lesions were classified as unstable and 4 as stable. Clinical elbow outcome (pain, function, and social-psychological effect) was assessed using the Oxford Elbow Score (OES) at final follow-up (OES range, 0-48). Range of motion and return to sports were recorded. Multivariable linear regression analysis was performed to determine predictors of postoperative OES. RESULTS: Intraoperatively, there were 3 grade 1 lesions, 2 grade 2 lesions, 10 grade 3 lesions, 1 grade 4 lesion, and 59 grade 5 lesions. The mean postoperative OES was 40.8 (SD, ±8.0). An open capitellar physis was a predictor of better elbow outcome (5.8-point increase; P = .025), as well as loose body removal/grade 4-5 lesions (6.9-point increase; P = .0020) and shorter duration of preoperative symptoms (1.4-point increase per year; P = .029). Flexion slightly improved from 134° to 139° ( P < .001); extension deficit slightly improved from 8° to 3° ( P < .001). Pronation ( P = .47) and supination did not improve ( P = .065). Thirty-seven patients (55%) returned to their primary sport at the same level, and 5 patients (7%) returned to a lower level. Seventeen patients (25%) did not return to sport due to elbow-related symptoms, and 10 patients (13%) did not return due to non-elbow-related reasons. No complications were recorded. CONCLUSION: Arthroscopic debridement and microfracture for advanced capitellar osteochondritis dissecans provide good clinical results, especially in patients with open growth plate, loose body removal, and shorter duration of symptoms. However, only 62% of patients in this study returned to sports.

Single-Stage Treatment Protocol for Presumed Aseptic Diaphyseal Nonunion.

INTRODUCTION: This article describes the general surgical technique for treating presumed diaphyseal nonunion with a one-stage procedure involving intraoperative removal of specimens for culture, revision open reduction and internal fixation (ORIF) with a plate or nail, and bone-grafting. STEP 1 PREOPERATIVE EVALUATION: Take a careful history, evaluate the extremity and wound, and note comorbidities and medications. STEP 2 PREOPERATIVE PLANNING: Preoperative planning is essential before revision nonunion surgery. STEP 3 DEBRIDEMENT IMPLANT REMOVAL AND CULTURES: Debride the nonunion site, remove all failed and loose implants, and take specimens for culture; withhold antibiotics until all culture specimens have been obtained. STEP 4 OPEN REDUCTION AND INTERNAL FIXATION: Reduce the fracture and use interfragmentary fixation and/or compression, or a bridging plate. STEP 5 POSTOPERATIVE CARE: If any of the five cultures are positive, consult an infectious disease specialist with experience in treating musculoskeletal infections. RESULTS: We have used this protocol at our institution for patients with prior fracture surgery who subsequently developed a nonunion, with or without implant failure, that had no obvious infectious etiology.IndicationsContraindicationsPitfalls & Challenges.

A single-stage treatment protocol for presumptive aseptic diaphyseal nonunions: a review of outcomes.

OBJECTIVE: To review the results of a single-stage treatment protocol for presumptive aseptic diaphyseal nonunion with a well-healed wound and no infection history. DESIGN: Retrospective comparative study. SETTING: Tertiary referral center. PATIENTS AND METHODS: We retrospectively reviewed all presumptive aseptic diaphyseal nonunions treated by a single-stage protocol. There were 104 patients who met the inclusion criteria. Eighty-seven patients were available for follow-up through to complete healing (83.7% follow-up rate). INTERVENTION: The protocol entails withholding preoperative antibiotics, removing the implant, performing open debridement or canal reaming, taking 5 cultures of the nonunion site or canal reamings, followed by antibiotic administration, and revision open reduction and internal fixation or exchange nailing. If intraoperative cultures are positive, long-term antibiotics are begun specific to organism sensitivities. MAIN OUTCOME MEASUREMENTS: To analyze the rate of positive cultures and to compare the rate of secondary surgery to promote healing in positive and negative culture groups. RESULTS: Intraoperative cultures were positive in 28.7% (25/87) of patients with complete follow-up. The overall rate of secondary surgery for persistence of nonunion was 12.6% (11/87). In patients with positive intraoperative cultures, rate of secondary surgery was 28% (7/25) versus 6.4% (4/62) in the group without positive intraoperative cultures (P = 0.01). CONCLUSION: A single-stage treatment protocol for presumptive aseptic diaphyseal nonunions was effective in obviating further revision surgery in 93.6% of truly aseptic cases and in 72% of positive culture cases and is still employed at our institution.