[Diagnostic and therapeutic work-up of infected tibial nonunion]. / Diagnostik und Therapie der infizierten Tibia-Pseudarthrose.

BACKGROUND: The failure of bone fracture healing is one of the major complications of fracture treatment, especially of the tibia due to its limited soft tissue coverage and high rate of open injuries. Although implant development is constantly progressing and modern surgical techniques are continuously improving, infected tibial nonunion plays a decisive role in terms of its variable clinical presentation. OBJECTIVE: This article provides guidelines for the successful surgical treatment of infected tibial nonunion. MATERIAL AND METHOD: Strategies are presented to identify infection as a cause of failure of fracture healing and to achieve infection and bone healing. RESULTS: A significant amount of tibial nonunions primarily thought to be aseptic ultimately turn out to be infected nonunions. CONCLUSION: The treatment of infected tibial nonunion requires extensive clinical, radiological and laboratory diagnostics as well as a profound biomechanical and biological understanding of the bone situation. This is the only way to achieve rapid osseous healing with as few revision interventions as possible.

[Infected nonunion: diagnostic and therapeutic work-up]. / Infizierte Pseudarthrose: diagnostischer und therapeutischer Ablauf.

BACKGROUND: Septic nonunion is one of the major complications in fracture healing. The challenge is to identify the infection as the cause of nonunion first and then to achieve healing of the infection and the bone. OBJECTIVE: Because of the more heterogeneous appearance of an infected nonunion, the prevalence of germ detection in surgical nonunion revision is often underestimated. MATERIAL AND METHODS: In a retrospective study between 2010 and 2017, 86 patients with radiologically confirmed femoral shaft nonunion without clinical evidence and unremarkable medical history of a florid infection as the cause of nonunion, who had undergone primary single-stage surgical nonunion revision were analyzed. At least four intraoperatively obtained samples were evaluated for microbiological diagnosis. A distinction was made between tissue samples with subsequent 48­h short-term incubation and tissue samples with 14-day long-term cultivation. The finding "germ detection" was made if at least two of the samples demonstrated bacterial growth. RESULTS: In 18 of 86 patients with a nonunion preoperatively judged to be aseptic, positive bacterial evidence was obtained after short-term incubation. After long-term cultivation, positive bacterial detection was possible in 38 of 86 patients with a femoral shaft nonunion initially classified as aseptic. Regarding potential risk factors, the two groups demonstrated no relevant differences. In 29 patients, 1 pathogen was isolated from the obtained samples, whereas in the remaining 9 patients, a mixed culture with an average of 2.9 ± 0.5 different bacteria was detected. Identification revealed mainly low-virulence bacteria, most commonly Staphylococcus epidermidis. CONCLUSION: If the preoperative diagnostics including clinical, laboratory and radiological examination as well as a careful anamnesis reveal indications of a possible infectious event, the surgical nonunion revision should be performed in two stages with specimen collection before definitive nonunion revision. For microbiological diagnosis, several representative tissue samples should independently be obtained from the nonunion site and incubated for 14 days. Only in the absence of evidence of septic nonunion is a single-stage procedure suggested.

Predicting fracture healing with blood biomarkers: the potential to assess patient risk of fracture nonunion.

Fracture non-union is a significant orthopaedic problem affecting a substantial number of patients yearly. Treatment of nonunions is devastating to patients and costly to the healthcare system. Unfortunately, the diagnosis of non-union is typically made in a reactionary fashion by an orthopaedic surgeon based on clinical assessment and radiographic features several months into treatment. For this reason, investigators have been trying to develop prediction algorithms; however, these have relied on population-based approaches and lack the predictive capability necessary to make individual treatment decisions. There is also a growing body of literature focussed on identifying blood biomarkers that are associated with non-union. This review describes the research that has been done in this area. Further studies of patient-centered, precision medicine approaches will likely improve fracture non-union diagnostic/prognostic capabilities.

Prediction of Nonunion After Nonoperative Treatment of a Proximal Humeral Fracture.

BACKGROUND: The prevalence of nonunion after a proximal humeral fracture (PHF) and the risk factors for its occurrence are poorly defined. We aimed to estimate the rate of nonunion in nonoperatively treated patients and to produce a clinical model for its prediction. METHODS: Two thousand two hundred and thirty adult patients (median age, 72 years [range, 18 to 103 years]; 75.5% were female) with a PHF underwent assessment of fracture union using standard clinical evaluation and conventional radiographs. We assessed the prevalence of nonunion and measured the effect of 19 parameters on healing. Best statistical practices were used to construct a multivariate logistic regression model. The PHF assessment of risk of nonunion model (PHARON) was externally validated in a subsequent prospectively collected population of 735 patients, treated by the same protocol in our institution. RESULTS: Overall, 231 (10.4%) of 2,230 patients developed nonunion. Only 3 (0.8%) of 395 patients with a head-shaft angle (HSA) of >140° developed nonunion; in this cohort, none of the measured candidate variables were independently predictive of nonunion on multivariate logistic regression analysis. In the larger cohort of 1,835 patients with an HSA of ≤140°, 228 (12.4%) developed nonunion. Decreasing HSA, increasing head-shaft translation (HST), and smoking were independently predictive of nonunion on multivariate analysis. The prevalence of nonunion was very low (1%) in the majority with both an HSA of >90° and HST of <50%, whereas the risk was much higher (83.7%) in the 8.3% with an HSA of ≤90° and HST of ≥50%. In both groups, the prevalence of nonunion was much higher in smokers. CONCLUSIONS: The prevalence of nonunion after PHF is higher than previously reported. Most patients have favorable risk-factor estimates and a very low risk of this complication, but a smaller subgroup is at much higher risk. The risk can be accurately estimated with PHARON, using standard clinical assessment tools. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The AMANDUS Project PART II-Advanced Microperfusion Assessed Non-Union Diagnostics with Contrast-Enhanced Ultrasound (CEUS): A Reliable Diagnostic Tool for the Management and Pre-operative Detection of Infected Upper-Limb Non-unions.

The management of upper-limb non-unions can be challenging, especially when infection is existent. Thus, pre-operative detection of infection plays a relevant role in non-union treatment. This study investigated in a large cohort the diagnostic potential of contrast-enhanced ultrasound (CEUS) as stand-alone method for differentiating between aseptic and infected upper-limb non-unions. Osseous perfusion of 50 upper-extremity non-unions (radius/ulna, n = 20; humerus, n = 22; clavicle, n = 8) was prospectively assessed with CEUS before revision surgery. The perfusion was quantified via time-intensity curves and peak enhancement (in arbitrary units). Significant perfusion differences between aseptic and infected non-unions could be detected (peak enhancement, p < 0.001). The sensitivity and specificity for the detection of infected upper-limb non-unions were 80% and 94.3% (cutoff peak enhancement: 130.8 arbitrary units). CEUS reliably differentiates between aseptic and infected upper-limb non-unions. Consequently, CEUS should be integrated into the daily diagnostic routine algorithm to plan non-union revision surgery more precisely as a single- or multi-step procedure.

Endoscopic resection of scar tissues and bone graft with an intramedullary nail left in situ for distal femoral nonunion after nailing: A case report.

Femoral shaft nonunion after the intramedullary nailing has been successfully treated with advances in surgical technique. Nonetheless, the techniques cause morbidity to periosteum at the fracture site. We report the case of a 67-year-old man who underwent endoscopic surgery for refractory nonunion following the fracture of the distal femoral shaft, despite two fixations using an interlocking nail. In addition, the patient had uncontrolled diabetic mellitus. Endoscopy allowed us to acquire a clear view of the nonunion site, in which the resection of scar tissues and the packing of the cancellous bone were performed. At the final follow-up, bone healing was observed, and the patient was able to return to normal daily and social activity.

Tibial Fracture Healing Score: A Novel Tool to Predict Tibial Nonunion.

The aim of the study was to investigate the utility of a simple office-based tool in predicting the need for secondary intervention to obtain union in patients with tibial fractures. All patients 18 years and older with isolated tibial shaft fractures (OTA 41A, 42A-C, and 43A) treated with intramedullary nailing from 2013 to 2017 were screened. Eighty-seven patients met enrollment criteria. Surgeon assessment of the following 3 clinical parameters was performed at routine office visits and scored as follows: (1) pain (none/mild/decreased=1, no change/increased=0); (2) function (minimal limp/able to perform a single-leg stance=1, significant limp/unable to perform single-leg stance=0); and (3) examination (no/minimal pain with manipulation=1, pain with manipulation=0). Radiographic healing was assessed by the adjusted radiographic union scale in tibial fractures (aRUST). The tibial fracture healing score (TFHS) is the sum of 3 clinical scores (0 to 3) and aRUST score (1 to 3) at 3 months postoperatively. The overall nonunion rate was 11%. A RUST score of 5 or less and a sum of the 3 clinical scores of less than 2 at 3 months were found be predictive of nonunion. A TFHS of less than 3 at 3 months was more reliable in identifying patients requiring nonunion repair, especially for those with minimal radiographic healing (RUST score 6 or 7) at 3 months. The TFHS is a simple office-based clinical tool that may identify patients at high risk of nonunion (TFHS <3) following isolated tibial shaft fracture more effectively than clinical examination or radiographic assessment alone. [Orthopedics. 2020;43(4);e323-e328.].

Bioinformatic analysis and experimental identification of blood biomarkers for chronic nonunion.

BACKGROUND: Incomplete fracture healing may lead to chronic nonunion; thus, determining fracture healing is the primary issue in the clinical treatment. However, there are no validated early diagnostic biomarkers for assessing chronic nonunion. In this study, bioinformatics analysis combined with an experimental verification strategy was used to identify blood biomarkers for chronic nonunion. METHODS: First, differentially expressed genes in chronic nonunion were identified by microarray data analysis. Second, Dipsaci Radix (DR), a traditional Chinese medicine for fracture treatment, was used to screen the drug target genes. Third, the drug-disease network was determined, and biomarker genes were obtained. Finally, the potential blood biomarkers were verified by ELISA and qPCR methods. RESULTS: Fifty-five patients with open long bone fractures (39 healed and 16 nonunion) were enrolled in this study, and urgent surgical debridement and the severity of soft tissue injury had a significant effect on the prognosis of fracture. After the systems pharmacology analysis, six genes, including QPCT, CA1, LDHB, MMP9, UGCG, and HCAR2, were chosen for experimental validation. We found that all six genes in peripheral blood mononuclear cells (PBMCs) and serum were differentially expressed after injury, and five genes (QPCT, CA1, MMP9, UGCG, and HCAR2) were significantly lower in nonunion patients. Further, CA1, MMP9, and QPCT were markedly increased after DR treatment. CONCLUSION: CA1, MMP9, and QPCT are biomarkers of nonunion patients and DR treatment targets. However, HCAR2 and UGCG are biomarkers of nonunion patients but not DR treatment targets. Therefore, our findings may provide valuable information for nonunion diagnosis and DR treatment. TRIAL REGISTRATION: ISRCTN, ISRCTN13271153. Registered 05 April 2020-Retrospectively registered.

Rib Plating Offers Favorable Outcomes in Patients With Chronic Nonunion of Prior Rib Fractures.

BACKGROUND: Although open reduction and internal fixation (ORIF) is an accepted treatment for a proportion of acute rib fractures, The literature on its potential to treat chronic, nonunion fractures is scarce. This study evaluates the outcomes and quality of life of patients who underwent ORIF for chronic, symptomatic, nonunion rib fractures. METHODS: Thirty-two patients were explored for possible ORIF of nonunion rib fractures (≥6 months after injury). After excluding non-English-speaking patients (n = 1), those where no instability was noted at surgery (n = 3), and those deceased at the time of study (n = 4), 24 patients were eligible. Telephone interviews were conducted using a previously published rib fracture pain questionnaire. RESULTS: Seventy percent of eligible patients (19/24) consented and completed the questionnaire at a median of 55 months (interquartile range, 24-62) from surgery. Injuries were classified as multisystem trauma (n = 4) or isolated rib fractures (n = 15). The median pain severity (on a scale of 1 [none/mild] to 10 [severe]) significantly decreased from preoperatively (9; interquartile range, 7-10) to postoperatively (1; interquartile range, 0-2; P < .001). Most patients returned to daily activities, were able to work at their preinjury level, were satisfied with their surgery, and would undergo operative management again. CONCLUSIONS: Patients who underwent ORIF reported a significant decrease in fracture-associated symptoms and pain severity postoperatively. Most returned to daily activities, could work at preinjury levels, and were satisfied with surgery. ORIF should be considered as an option to help patients with symptomatic nonunion rib fractures.

Management of nonunion of humeral medial condyle fracture: A case series and review of the literature.

Pediatric humeral medial condyle fracture (HMCF) is a rare condition and is difficult to detect, especially in young children. The management of late presentation of HMCF is challenging and lacks consensus. Herein, we reported four cases of HMCF nonunion received open reduction and internal fixation (ORIF) or supracondyle osteotomy from our institution. In addition, 12 cases of ORIF and 4 cases of osteotomy reported in the previous studies were also reviewed. The HMCF nonunion can heal after ORIF, but the indication and the optimal techniques need to be clarified. Supracondylar osteotomy alone is an effective and safe treatment option to improve the functional and cosmetic outcomes of HMCF nonunion.

Healing the Index Humeral Shaft Nonunion: Risk Factors for Development of a Recalcitrant Nonunion in 125 Patients.

BACKGROUND: Humeral shaft nonunions are challenging to treat, and those that require >1 surgical procedure in order for a nonunion to heal are termed recalcitrant. Most studies on nonunion have evaluated the union rate independent of the number of procedures required to achieve union. The aims of the present study were (1) to compare the healing rates after the index operation for the treatment of a nonunion with conventional versus locked plating with or without graft augmentation, (2) to report the prevalence of recalcitrant nonunion, and (3) to identify risk factors that predict a recalcitrant nonunion. METHODS: We performed a retrospective analysis of a prospectively collected database of 125 humeral shaft nonunions treated with open reduction and plate fixation by a single surgeon over 25 years. Univariate and multivariate regression analyses were performed to compare healing rates by type of plate fixation and biological augmentation and to identify demographic, injury, and treatment-related risk factors for the development of a recalcitrant nonunion. RESULTS: One hundred and five patients (84%) had healing after the index procedure for the treatment of nonunion. Twenty patients (16.0%) required secondary procedures and were defined as having a recalcitrant nonunion. Eight of these patients (6.4% of the overall group) healed after the secondary interventions, and 12 (9.6% of the overall group) had a failure to unite. There were no significant differences in healing rates between conventional and locked plates or between the types of bone graft (autogenous or recombinant human bone morphogenetic protein). Risk factors for the development of a recalcitrant nonunion were plate fixation of the acute humeral fracture, a history of deep infection, and ≥2 prior procedures. CONCLUSIONS: Plate fixation with bone graft augmentation remains a successful method for the treatment of humeral shaft nonunions. Neither plate type nor graft type reduced the risk of a recalcitrant nonunion. Factors that predicted a recalcitrant nonunion were operative fixation of the acute fracture with a plate, a history of deep infection, and ≥2 surgical procedures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The challenge of the infected pilon tibial non-union: treatment with radical resection, bone transport and ankle arthrodesis.

A significant number of patients with pilon tibial fractures develop complications, the most devastating being a combination of infection and non-union with bone loss. The results of the Ilizarov bone transport technique were retrospectively evaluated in ten patients. All underwent an extensive resection and reconstruction aiming at an ankle arthrodesis. The outcome was registered by clinical and radiographic examination as proposed by Paley's functional and bone results classification. A good healing at the level of the docking site could be obtained in all patients but with a re- intervention in 8 of the 10. In 5 of these patients, re-intervention with a transcalcaneal nailing leaded to the final healing. Other options are debridement of the docking site (2 patients) and a new Ilizarov procedure (1 patient). If patients are prepared to participate in a long-term treatment with the risk of multiple interventions a reconstruction can be performed, resulting in a limb with an acceptable function, allowing all activities of daily life and even a professional occupation. To obtain this final result with a definite union at the docking site a secondary retrograde intramedullary nailing is considered a valuable and safe procedure.

Clinical and patient-reported outcomes following Low Intensity Pulsed Ultrasound (LIPUS, Exogen) for established post-traumatic and post-surgical nonunion in the foot and ankle.

BACKGROUND: Biophysical methods including Low Intensity Pulsed Ultrasound (LIPUS) are emerging as potential alternatives to revision surgery for treating established nonunions. We aim to prospectively review the clinical and patient-reported outcomes of patients treated with LIPUS following post-traumatic and post-surgical nonunions in the foot and ankle. METHODS: Forty-seven consecutive patients underwent Exogen treatment. Patient-reported outcome scores included MOXFQ, EQ-5D and VAS. Patients were divided in to 3 groups: fractures (A), hindfoot procedures (B) and midfoot/forefoot procedures (C). RESULTS: Thirty-seven patients (78.7%) clinically united, 4 patients (8.5%) noticed no significant improvement but did not want further intervention and 6 patients (12.8%) underwent revision surgery. The mean duration of Exogen treatment was 6 months. Union rates of 93%, 67% and 78% were noted in the three groups. Significant improvement in functional outcomes and potential cost savings were observed. CONCLUSIONS: Exogen for established nonunion in the foot and ankle is a safe, valuable and economically viable clinical option as an alternative to revision surgery. We observed better results in the fracture and midfoot/forefoot groups and relatively poorer results in the hindfoot fusion group.

Cable plate fixation for Vancouver Type-B1 periprosthetic femoral fractures-Our experience and identification of a subset at risk of non-union.

INTRODUCTION: Management of periprosthetic femoral fractures is challenging. Vancouver classification is universally accepted for fracture description and management algorithm. Guidelines for the treatment of type B1 fracture is open reduction and internal fixation. The difficulty involved in managing this group is evidenced by the array of treatment options described in the literature. METHODS: Thirty two patients with Vancouver type B1 fracture treated with osteosynthesis using cable plate (between 2007 and 2015) were reviewed retrospectively. There were 21 females and 11 males with an average age of 81yrs (56-96 years). The average follow-up was 21 months. All patients were reviewed clinically and radiologically until fracture united or patient re-operated. Postoperative protocol followed was six weeks toe touch weight bearing, 6 weeks partial weight bearing and then full weight bearing if there was no displacement. Post-operative radiographs were evaluated for fracture union. Statistical analysis was done using contingency tables with Fishers exact test and a p-value < 0.05 for significance. RESULTS: In twenty four patients fracture union was achieved. Non-union was recorded in four patients. Comparing the different fracture patterns all non-unions occurred in the fractures which were short oblique or transverse at the cemented stem tip (p = 0.001). Fractures were more common in female patients and associated more with the uncemented femoral stems, but it was not associated with increased rate of non-union (p = 0.68). All failed osteosynthesis were revised successfully using long stem prosthesis. Two patients died within 2 months, one patient died within 4 months, one patient was lost to follow-up. CONCLUSION: Transverse or short oblique periprosthetic fractures around tip of cemented femoral stems can have high failure rates with just internal fixation. Revision arthroplasty may be the preferred option if possible otherwise may need to supplement fixation with cortical onlay graft. We should consider subcategorising Vancouver type B1 periprosthetic fractures into groups based on the pattern and fracture level in relation to the femoral stem.

Delayed Healing in Metatarsal Fractures: Role of Low-Intensity Pulsed Ultrasound Treatment.

The most common fracture in primary care is metatarsal fracture, but it is controversial whether to treat this fracture conservatively or surgically. We performed a cohort study to contrast metatarsal fractures that heal normally with fractures that show delayed healing. We analyzed 5% Medicare Standard Analytic Files, selecting all metatarsal fractures in 2011 to 2013, excluding patients with multiple fractures. Delayed healing was defined as treatment >14 days postfracture with either low-intensity pulsed ultrasound or surgery. Treatment for delayed healing was identified using the Current Procedural Terminology and International Classification of Diseases, Revision 9, Clinical Modification codes. Among 9482 metatarsal fractures, 256 (2.7%) showed delayed healing. Patients with delayed healing were younger (p < .0001); more likely to receive specialist referral (p < .001); more likely to have obesity (p = .005), psychosis (p = .003), chronic lung disease (p = .012), or iron deficiency anemia (p = .016); and more likely to receive surgery before ultrasound (p < .0001). Patients more likely to be treated with surgery than ultrasound included younger patients (p < .0001), obese patients (p = .02), and patients who first see a specialist (p < .05).

Diagnosis and management of long-bone nonunions: a nationwide survey.

PURPOSE: There is variability among surgeons on definitions regarding the degree of bone healing of long-bone fractures. A lack of consensus may negatively affect communication between surgeons, and lead to unintended and unwanted variability in treatment of patients suffering from abnormal healing of long-bone fractures. We aimed to identify differences between surgeons regarding their views on the degree of union of long-bone fractures. METHODS: We performed a survey among 114 surgeons who worked at 11 level I trauma centers and 68 level II/III hospitals in the Netherlands. We asked them to represent their institutional colleagues and answer questions regarding their views on the definition, factors influencing bone healing, clinical practice, views on scientific evidence, and the use or need of guidelines for non-union of long-bone fractures. A total of 26 trauma surgeons and 37 orthopedic surgeons responded (59%). RESULTS: Compared to trauma surgeons, more orthopedic surgeons maintain 6 months as the timeframe for classifying a fracture without healing tendencies as a non-union fracture (50 vs 70%; P = 0.019). Compared to orthopedic surgeons, trauma surgeons use the bone scan (46 vs 19%; P = 0.027) and the PET scan (50 vs 5.4%; P < 0.001) more often, and consider medication use to be a factor influencing bone healing more often (92 vs 69%; P = 0.040). Furthermore, they utilize bone marrow aspiration (35 vs 11%; P = 0.029), reaming of long bones (96 vs 70%; P = 0.010), synthetic bone substitutes (31 vs 5.4%; P = 0.012), bone morphogenetic proteins (58 vs 16%; P = 0.001), and the Diamond concept (92 vs 8.1%) more often as treatment modalities for non-union of long-bone fractures. Surgeons agreed on that intramedullary nail osteosynthesis was the treatment option supported by the highest level of evidence. 80% of the respondents feel a need for a clinical guideline on the management of long-bone non-union. CONCLUSION: There is no consensus among surgeons on the definition, factors influencing healing, clinical practice, and scientific evidence regarding non-union of long-bone fractures. The vast majority of surgeons believe that their practice would benefit from (inter)national guidelines on this topic, and efforts should be made to reduce surgeon-to-surgeon variability in treatment recommendations and facilitate more homogenous scientific research on non-union of long-bone fractures. LEVEL OF EVIDENCE: Level V.

Treatment of Young Femoral Neck Fractures.

Femoral neck fractures in the physiologically young patient are challenging injuries to manage. A tenuous blood supply and the intrasynovial nature of the fracture create a challenging biological environment. To make matters worse, the biomechanics are equally problematic. Frequently, these fractures in younger populations are high Pauwel angle fractures that see considerable force, especially shear. These factors combine to make nonunion and avascular necrosis all too common. In the current study, we will highlight the challenges inherent to managing these injuries and will discuss techniques and implants that may help mitigate some of these challenges.

Treatment of scaphoid waist nonunion by one, two headless compression screws or plate with or without additional extracorporeal shockwave therapy.

INTRODUCTION: Scaphoid nonunion remains challenging for hand surgeons. Several treatment options are available such as: non-vascularized or vascularized bone grafting, with or without additional stabilization. In the last few decades, extracorporeal shockwave therapy (ESWT) has become an established procedure for treating delayed and nonunions. Purpose of this retrospective follow-up study was (a) to investigate union rate and clinical outcome of the different implants [either one/two headless compression screws (HCS) or a plate] and (b) union rate and clinical outcome using only surgery, or a combination of surgery and ESWT. MATERIALS AND METHODS: The study included 42 patients with scaphoid nonunions of the waist with a mean follow-up of 52 months. All patients received a non-vascularized bone graft from the iliac crest and stabilization was achieved by using one, two HCS or a plate. ESWT was performed with 3000 impulses, energy flux density per pulse 0.41 mJ/mm2 within 2 weeks after surgery. Clinical assessment included range of motion (ROM), pain according to the Visual Analog Scale (VAS), grip strength, Disability of the Arm Shoulder and Hand Score, Patient-Rated Wrist Evaluation Score, Michigan Hand Outcomes Questionnaire and modified Green O'Brien (Mayo) Wrist Score. In addition, each patient had a CT scan of the wrist. RESULTS: A total of 33/42 (79%) patients showed union at the follow-up investigation. Patients treated with additional ESWT showed bony healing in 21/26 (81%) and without ESWT in 12/16 (75%). Patients that were stabilized using one HCS showed bony healing in 6/10 (60%), with two HCS 10/12 (83%) and by plate 17/20 (85%). The ESWT group had a significantly lower pain score according to the VAS and better modified Green O'Brien (Mayo) Score. No differences could be found in respect of ROM, grip strength, functional outcome score depending of which stabilization method was used. CONCLUSIONS: Stabilization of scaphoid waist nonunions with two HCS or plate showed higher union rates than a stabilization using only one HCS. In addition, ESWT combined with a nonvascularized bone graft from the iliac crest seems a suitable option for treating scaphoid nonunions.

Chemokine analysis as a novel diagnostic modality in the early prediction of the outcome of non-union therapy: a matched pair analysis.

BACKGROUND: Despite the regenerative capability of skeletal tissue fracture, non-union is common. Treatment of non-unions remains challenging, and early determination of the outcome is impossible. Chemokines play an important role in promoting the formation of new bone and remodeling existing bone. Despite their importance regarding the regulation of bone biology, the potential of chemokines as biological markers reflecting osseous regeneration is unknown. The purpose of this study was to determine (1) if serum chemokine expression levels correlate with the outcome of non-union surgery and (2) if chemokine expression analysis can be used to identify patients at risk for treatment failure. METHODS: Non-union patients receiving surgical therapy in our institution between March 2012 and March 2014 were prospectively enrolled in a clinical observer study. Regular clinical and radiological follow-up was conducted for 12 months including collection of blood during the first 12 weeks. Based on the outcome, patients were declared as responders or non-responders to the therapy. To minimize biases, patients were matched (age, sex, body mass index (BMI)) and two groups of patients could be formed: responders (R, n = 10) and non-responders (NR, n = 10). Serum chemokine expression (CCL-2, CCL-3, CCL-4, CXCL-10, CCL-11, and interferon gamma (IFN-γ)) was analyzed using Luminex assays. Data was compared and correlated to the outcome. RESULTS: CCL-3 expression in NR was significantly higher during the course of the study compared to R (p = 0.002), and the expression pattern of CCL-4 correlated with CCL-3 in both groups (NR: p < 0.001 and r = 0.63). IFN-γ expression in NR was continuously higher than in R (p < 0.001), and utilization of CCL-3 and IFN-γ serum expression levels 2 weeks after the treatment resulted in a predictive model that had an AUC of 0.92 (CI 0.74-1.00). CONCLUSION: Serum chemokine expression analysis over time is a valid and promising diagnostic tool. The chemokine expression pattern correlates with the outcome of the Masquelet therapy of lower limb non-unions. Utilization of the serum analysis of CCL-3 and IFN-γ 2 weeks after the treatment resulted in an early predictive value regarding the differentiation between patients that are likely to heal and those that are prone to high risk of treatment failure.