Arthroscopic assisted versus open non-vascularized bone grafting in delayed union and nonunion of the scaphoid: a systematic review and meta-analysis.

BACKGROUND: Delayed union and nonunion of the scaphoid is a common complication often requiring surgical reconstruction and bone grafting. Our goal was to systematically assess the healing time and clinical outcomes following arthroscopic-assisted versus open non-vascularized bone grafting of the scaphoid. METHODS: A comprehensive search of the MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Cochrane Central databases was completed from inception to September 2023. We included randomized trials and observational studies that reported outcomes following scaphoid delayed union/nonunion comparing arthroscopic-assisted vs. open non-vascularized bone grafting. Two reviewers independently extracted data and assessed the risk of bias. One investigator assessed certainty of evidence and a senior investigator confirmed the assessment. We pooled effects using random-effects models, when possible, for all outcomes reported by more than 1 study. RESULTS: Overall, 26 studies and 822 patients were included in the study. Very low certainty evidence demonstrated that arthroscopic-assisted surgery may decrease healing time compared to open surgery (weighted mean difference [WMD] -7.8 weeks; 95%CI -12.8 to -2.8). Arthroscopic bone grafting did not result in an improvement in union rate (relative risk 1.01; 95%CI 0.9 to 1.09). The pooled data in arthroscopic graft group showed mean time to union of 11.4 weeks (95%CI: 10.4 to 12.5) with union rate of 95% (95%CI 91-98%). A single comparative study reported very low certainty evidence that arthroscopy-assisted vs. open surgery may not have an effect on pain relief (MD 0 cm, 95%CI -0.4 to 0.5 on VAS 10 cm for pain) or improving function (MD -1.2, 95% CI -4.8 to 2.3 on 100 points DASH). CONCLUSION AND FUTURE DIRECTIONS: Our results suggest that arthroscopic-assisted non-vascularized bone grafting may be associated with improved average weeks to heal in comparison with open surgery for scaphoid delayed union/nonunion reconstruction with overall comparable union rates. There is insufficient evidence to assess the effects of arthroscopic-assisted reconstruction on union rate, time to union, and patient-reported outcomes in patients with other important nonunion characteristics such as established humpback deformity.

Effect of postoperative fracture gap on bone union: A retrospective cohort analysis of simple femoral shaft fractures.

BACKGROUND: Intramedullary nailing (IMN) is considered the gold-standard treatment for femoral shaft fractures. The post operative fracture gap is commonly recognized as a risk factor for nonunion. However, no evaluation standard for measuring the fracture gap size has yet been established. In addition, the clinical implications of the fracture gap size have also not been determined so far. This study aims to clarify how we should evaluate fracture gaps when assessing simple femoral shaft fractures with radiographs and to determine the acceptable cut-off value of the fracture gap size in simple femoral shaft fractures. METHOD: A retrospective observational study with a consecutive cohort was conducted at the trauma center of a university hospital. We investigated the fracture gap using postoperative radiography and the postoperative bone union of transverse and short oblique femoral shaft fractures fixed by IMN. The receiver operating characteristic curve analysis was conducted to obtain the fracture gap's mean, minimum, and maximum cut-off values. Fisher's exact test was used at the cut-off value of the most accurate parameter. RESULTS: In the four nonunions among the 30 cases, the analysis using ROC curves revealed that the maximum value had the highest accuracy among the maximum, minimum, and mean values of fracture-gap size. The cut-off value was determined to be 4.14 mm with high accuracy. Fisher's exact test showed that the incidence of nonunion was higher in the group with a maximum fracture gap of 4.14 mm or greater (risk ratio = not applicable, risk difference = 0.57, P = 0.001). CONCLUSION: In simple transverse and short oblique femoral shaft fractures fixed with IMN, the fracture gap on radiographs should be evaluated by the maximum gap in the AP and lateral views. The remaining maximum fracture gap of ≥4.14 mm would be a risk factor for nonunion.

Ketorolac and bone healing: a review of the basic science and clinical literature.

Although the efficacy of ketorolac in pain management and the short duration of use align well with current clinical practice guidelines, few studies have specifically evaluated the impact of ketorolac on bony union after fracture or surgery. The purpose of this study was to review the current basic science and clinical literature on the use of ketorolac for pain management after fracture and surgery and the subsequent risk of delayed union or nonunion. Animal studies demonstrate a dose-dependent risk of delayed union in rodents treated with high doses of ketorolac for 4 weeks or greater; however, with treatment for 7 days or low doses, there is no evidence of risk of delayed union or nonunion. Current clinical evidence has also shown a dose-dependent increased risk of pseudoarthrosis and nonunion after post-operative ketorolac administration in orthopedic spine surgery. However, other orthopedic subspecialities have not demonstrated increased risk of delayed union or nonunion with the use of peri-operative ketorolac administration. While evidence exists that long-term ketorolac use may represent risks with regard to fracture healing, insufficient evidence currently exists to recommend against short-term ketorolac use that is limited to the peri-operative period. LEVEL OF EVIDENCE V: Narrative Review.

Which non-infection related risk factors are associated with impaired proximal femur fracture healing in patients under the age of 70 years?

BACKGROUND/PURPOSE: Impaired healing is a feared complication with devastating outcomes for each patient. Most studies focus on geriatric fracture fixation and assess well known risk factors such as infections. However, risk factors, others than infections, and impaired healing of proximal femur fractures in non-geriatric adults are marginally assessed. Therefore, this study aimed to identify non-infection related risk factors for impaired fracture healing of proximal femur fractures in non-geriatric trauma patients. METHODS: This study included non-geriatric patients (aged 69 years and younger) who were treated between 2013 and 2020 at one academic Level 1 trauma center due to a proximal femur fracture (PFF). Patients were stratified according to AO/OTA classification. Delayed union was defined as failed callus formation on 3 out of 4 cortices after 3 to 6 months. Nonunion was defined as lack of callus-formation after 6 months, material breakage, or requirement of revision surgery. Patient follow up was 12 months. RESULTS: This study included 150 patients. Delayed union was observed in 32 (21.3%) patients and nonunion with subsequent revision surgery occurred in 14 (9.3%). With an increasing fracture classification (31 A1 up to 31 A3 type fractures), there was a significantly higher rate of delayed union. Additionally, open reduction and internal fixation (ORIF) (OR 6.17, (95% CI 1.54 to 24.70, p ≤ 0.01)) and diabetes mellitus type II (DM) (OR 5.74, (95% CI 1.39 to 23.72, p = 0.016)), were independent risk factors for delayed union. The rate of nonunion was independent of fracture morphology, patient's characteristics or comorbidities. CONCLUSION: Increasing fracture complexity, ORIF and diabetes were found to be associated with delayed union of intertrochanteric femur fractures in non-geriatric patients. However, these factors were not associated with the development of nonunion.

Use of Teriparatide in preventing delayed bone healing and nonunion: a multicentric study on a series of 20 patients.

BACKGROUND: Delayed bone healing and nonunions represent a great challenge for the orthopedic surgeon. In addition to traditional surgical approaches, increasing attention is being given to the use of systemic anabolic therapy with Teriparatide, whose efficacy in preventing osteoporotic fractures is widely validated and whose application as a promoter of bone healing has been described but it is still debated. The aim of the study was to evaluate bone healing in a series of patients with delayed unions or nonunions treated with Teriparatide in conjunction with eventual appropriate surgical procedure. METHODS: Twenty patients with an unconsolidated fracture that were treated at our Institutions from 2011 to 2020 with Teriparatide were retrospectively included into the study. The pharmacological anabolic support was used off-label with a planned duration of 6 months; radiographic healing was evaluated at 1-, 3- and 6-months follow-up outpatient visits over plain radiographs. Also, eventual side-effects were registered. RESULTS: Radiographic signs indicative of favorable evolution of the bone callus were observed as early as at 1 month of therapy in 15% of cases; at 3 months, healing progression was appreciated in 80% of cases and complete healing in 10%; at 6 months, 85% of delayed and nonunions had healed. In all patients, the anabolic therapy was well tolerated. CONCLUSIONS: In accordance to Literature, this study suggests that Teriparatide plays a potentially important role in the treatment of some forms of delayed unions or nou-nions, even in the presence of failure of hardware. The results suggest a greater effect of the drug when associated with a condition in which the bone is in an active phase of callogenesis, or with a "revitalizing" treatment which represents a local (mechanical and/or biological) stimulus to the healing process. Despite the small sample size and the variety of cases, the efficacy of Teriparatide in treating delayed unions or nonunions emerged, highlighting how this anabolic therapy can represent a useful pharmacological support in the treatment of such a pathology. Although the results obtained are encouraging, further studies, particularly prospective and randomized, are needed to confirm the efficacy of the drug, and define a specific treatment algorithm.

Risk Factors for Failure of Nonsurgical Management of Ulnar Shaft Fractures.

PURPOSE: Isolated ulnar shaft fractures are frequently managed nonsurgically. However, rates of nonsurgical treatment failure remain substantial, and risk factors for the failure of nonsurgical management are not well described. This study investigated radiographic and patient-specific risk factors for the failure of nonsurgical management of isolated ulnar shaft fractures. METHODS: A retrospective review of patients with ulnar shaft fractures initially treated nonsurgically was performed at two tertiary referral centers over a 19-year period from 2001 to 2020. Patient- and injury-related variables, surgical interventions, and plain radiographic measurements were recorded. The outcome of interest was failure of nonsurgical management, defined as failure to achieve fracture union nonsurgically within 3 months of injury. RESULTS: One hundred fifty four patients initially treated nonsurgically for isolated ulnar shaft fractures were included. Twenty six patients (17%) experienced failure of nonsurgical management; these included five nonunions, 16 delayed unions, and 10 conversions to surgical management. Patients who experienced failure of nonsurgical management had a higher prevalence of diabetes mellitus, a higher employment rate, and fractures with higher initial median posteroanterior and lateral translations, fracture gap, and angulation; 83% of the patients with an initial fracture gap of ≥4 mm and 41% of the patients with an initial fracture angulation of >10° failed nonsurgical management. CONCLUSIONS: Although most ulnar shaft fractures heal successfully with nonsurgical management, a substantial percentage of these fractures do not. Patients who are currently working, have diabetes mellitus, or have fractures with an initial fracture gap of ≥4 mm or an initial fracture angulation of > 10° may be more likely to fail nonsurgical treatment, although additional studies with larger sample sizes are needed to confirm these associations. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Vitamin D status-associated postoperative complications in patients with hip dysplasia after periacetabular osteotomy: A case-control study.

OBJECTIVES: This study aimed to clarify the relationship between vitamin D status and complications after periacetabular osteotomy. METHODS: A total of 46 hips of 39 patients (3 men and 36 women; mean age at surgery, 41.0 years; mean postoperative follow-up duration, 63 months) were reviewed to obtain the following information: patients' serum 25-hydroxyvitamin D [25(OH)D] status, prevalence of postoperative delayed union of osteotomy sites in the greater trochanter (DUGT) and ischiopubic stress fractures (IPSFs), and risk factors. RESULTS: The mean serum 25(OH)D level was 11.9 ng/ml. DUGT and IPSF were found in four (10.3%) and three (7.7%) patients, respectively. Serum 25(OH)D levels ≤ 11 ng/ml were significantly associated with DUGT in female patients (p = .02). Serum 25(OH)D levels ≤ 9 ng/ml and smoking were significantly associated with IPSF (p = 0.01 and 0.02, respectively). Overall, 21.7% of patients with serum 25(OH)D levels ≤ 11 ng/ml developed at least one complication; no complications occurred when serum 25(OH)D levels were >11 ng/ml. CONCLUSION: Severe vitamin D deficiency was highly prevalent in relatively young patients. Vitamin D deficiency and smoking were independent risk factors for postoperative complications. Proactive supplementation is advisable to reduce postoperative complications, especially in patients with serum 25(OH)D levels ≤ 11 ng/ml.

Larger sagittal inter-screw distance/tibial width ratio reduces delayed union or non-union after arthroscopic ankle arthrodesis.

BACKGROUND: Arthroscopic ankle arthrodesis (AAA) has risks of complications, such as delayed union and non-union. The number and direction of the inserted screws have been reported as important factors affecting the time to union of AAA. However, the ratio of inter-screw distance (ISD) to tibial width (TW) in different planes has not been investigated. Therefore, we aimed to explore the effect of this ratio on bone union following AAA. METHODS: We retrospectively enrolled 63 patients (64 ankles) undergoing AAA from 2013 to 2019. Then, their age, body mass index (BMI), sex, diabetes mellitus (DM) status, Takakura-Tanaka classification, number of screws and radiographic parameters were analysed. RESULTS: The patients had a mean age of 70.3 (range, 45-91) years. Bone fusion was achieved in 57 ankles (89%) in a mean period of 3.3 (range, 2-6) postoperative months. There were four cases of delayed union and three of non-union. No significant differences in age, BMI, sex, DM, Takakura-Tanaka classification, and number of screws could be detected between the groups. However, the sagittal ISD/TW ratio was significantly larger in the union group than in the delayed/non-union group with a cut-off value of 57.0%. CONCLUSION: Larger sagittal ISD/TW ratios result in reduced post-AAA delayed union or non-union. The surgeon should be aware that the anterior and posterior screw widths should be approximately 60% or more of the anteroposterior width of the tibia.

Treatment of scaphoid fractures and pseudarthroses with the human allogeneic cortical bone screw. A multicentric retrospective study.

BACKGROUND: Allograft bone screws are rarely described for the fixation of the scaphoid. When fresh fractures are treated, metal screws are mainly used; when pseudarthrosis is the indication, plates in combination with vascularized or non-vascularized bone grafts are mainly used. The necessity of metallic screw removal is under debate, but it is mandatory for plates because of movement restrictions due to the plate. The use of biomaterials in scaphoid fracture fixation was described as leading to union rates of between 64 and 100%. Brcic showed the incorporation of an allogeneic cortical bone screw at 10 weeks postoperative, along with revascularization and stable osteosynthesis with primary bone healing, without any signs of immunological rejection. The purpose of this retrospective study was to explore the results obtained using an allogenic cortical bone screw (Shark Screw®) in patients with fresh scaphoid fracture fixation and pseudarthroses with respect to union rates and time to union. PATIENTS AND METHODS: We retrospectively analyzed 75 patients: 31 with fresh fractures and 44 pseudarthrosis patients. The Shark Screw® was used for the fixation of the scaphoid in the fresh-fracture and pseudarthrosis patients. We evaluated the union rate, complication rate and time to union. RESULTS: Using the human allogeneic cortical bone screw for scaphoid fracture fixation led to a high union rate (94-96%). There were two nonunions in the fresh fracture group and two nonunions in the pseudarthrosis group. The complication rate was 1.3% (1 patient). Median time to union was 16, 18 and 29 weeks for the fresh-fracture, pseudarthrosis and delayed-union patients, respectively. The treatment of fresh scaphoid fractures and pseudarthroses showed similar union rates to those described in the literature, uses a shorter and less invasive surgical method with no need for hardware removal, and has a low complication rate. CONCLUSION: Using the human allogenic cortical bone screw (Shark Screw®) led to similar union rates in fresh fractures-but better union rates in pseudarthrosis patients-compared to those presented in the literature for other scaphoid fracture fixation techniques, and it enabled a short and low-invasive procedure without any donor site morbidity and without the necessity to remove the hardware in a second surgery. The pseudarthrosis patient group showed a particularly strong benefit from this new procedure. The physiological bone metabolism remodels the cortical bone screw without scars. LEVEL OF EVIDENCE: III: retrospective cohort study, therapeutic investigation of a treatment.

Trochanteric fracture pattern is associated with increased risk for nonunion independent of open or closed reduction technique.

PURPOSE: Soft tissue injury and soft tissue injury as risk factors for nonunion following trochanteric femur fractures (TFF) are marginally investigated. The aim of this study was to identify risk factors for impaired fracture healing in geriatric trauma patients with TFF following surgical treatment with a femoral nail. METHODS: This retrospective cohort study included geriatric trauma patients (aged > 70 years) with TFF who were treated with femoral nailing. Fractures were classified according to AO/OTA. Nonunion was defined as lack of callus-formation after 6 months, material breakage, and requirement of revision surgery. Risk factors for nonunion included variables of clinical interest (injury pattern, demographics, comorbidities), as well as type of approach (open versus closed) and were assessed with uni- and multivariate regression analyses. RESULTS: This study included 225 geriatric trauma patients. Nonunion was significantly more frequently following AO/OTA 31A3 fractures (N = 10, 23.3%) compared with AO/OTA type 31A2 (N = 6, 6.9%) or AO/OTA 31A1 (N = 3, 3.2%, p < 0.001). Type 31A3 fractures had an increased risk for nonunion compared with type 31A1 (OR 10.3 95%CI 2.2 to 48.9, p = 0.003). Open reduction was not associated with increased risk for nonunion (OR 0.9, 95%CI 0.1 to 6.1. p = 0.942) as was not the use of cerclage (OR 1.0, 95%CI 0.2 to 6.5, p = 0.995). Factors such as osteoporosis, polytrauma or diabetes were not associated with delayed union or nonunion. CONCLUSION: The fracture morphology of TFF is an independent risk factor for nonunion in geriatric patients. The reduction technique is not associated with increased risk for nonunion, despite increased soft tissue damage following open reduction.

Efficacy of adjuvant treatment for fracture nonunion/delayed union: a network meta-analysis of randomized controlled trials.

BACKGROUND: Fracture nonunion/delayed union seriously affects physical and mental health and quality of life. The aim of this study was to evaluate the relative efficacy of different adjuvant treatments for nonunion/delayed union by network meta-analysis. METHODS: A comprehensive search was performed to identify randomized controlled trials (RCTs) evaluating adjuvant treatment in the management of nonunion/delayed union. A network meta-analysis reporting on healing rate, healing time, and adverse effect (AE) outcomes was conducted to assess and compare different interventions. RESULTS: Thirty studies were included in the analysis. For the healing rate outcome, bone marrow aspirate (BMA) + autologous cancellous bone (ACB) was found to be significantly better than ACB alone (odds ratio: 0.12; 95% confidence interval: 0.03, 0.59). In the ranking results, BMA+ platelet-rich plasma (PRP) (96%), BMA + ACB (90%), and BMA alone (82%) showed relative advantages in the healing rate. Low-intensity pulsed ultrasonography (LIUS) intervention significantly shortened the healing time compared with ACB (SMD: -9.26; 95% CI: - 14.64, - 3.87). LIUS (100%), BMA + PRP (74%), and bone morphogenetic proteins (BMPs) (69%) have relative advantages. Compared with the control, electromagnetic field (EMF) (OR: 13.21; 95% CI: 1.58, 110.40) and extracorporeal shock wave (ESWT) (OR: 4.90; 95% CI: 1.38, 17.43) had a higher AE risk. CONCLUSIONS: Among the current intervention strategies, BMA in combination with PRP and ACB can improve the healing rate of nonunion/delayed union. LIUS can significantly shorten the healing time. EMF and ESWT may have a high risk of AE. However, large-scale, well-designed studies are still needed to confirm the results. TRIAL REGISTRATION: Retrospectively registered.

Development and characterization of a predictive microCT-based non-union model in Fischer F344 rats.

INTRODUCTION: Non-unions remain a clinical problem and are characterised by the failure to heal after a defined period of time. Current preclinical non-union models apply a wide variety of techniques to diminish intrinsic healing potential deviating from the clinical situation. The aim of this study was to develop and characterise a non-union model in rats using internal plate fixation without the need for additional healing insults, whereby bone healing can be longitudinally assessed using microCT. It was hypothesized that healing/non-unions can be accurately predicted at early time points by microCT. MATERIALS AND METHODS: Female, skeletally mature Fischer F344 rats received a 2 mm or 1 mm femoral osteotomy, stabilized with either a 2 mm thick plate or a 1.25 mm thick plate. Healing was monitored by microCT over 14 weeks and histological analysis at euthanasia. The mechanical environment was characterised using finite element (FE) modelling and biomechanical testing. RESULTS: The majority of animals receiving the 2 mm thick plate displayed poor healing responses in both the 2 mm and 1 mm defect size groups. Bone and cartilage formation were markedly improved using the 1.25 mm thick plate. MicroCT could accurately predict bone forming capacity at early time points (3-4 weeks). CONCLUSIONS: The 2 mm thick plating system confers poor healing responses in female Fischer F344 rats, comparable to atrophic non-unions. By reducing plate thickness to increase interfragmentary strain within the defect site healing is improved, leading to borderline healing situations or increased abundance of cartilage tissue present in the defect site with ultimate failure to bridge the defect (hypertrophic non-union). Furthermore, microCT can reliably identify delayed/non-healing animals within 4 weeks, thereby allowing their selective targeting for the testing of novel, clinically relevant treatment strategies in different clinical situations aimed at restoring impaired bone healing.

Predicting Nonunions in Ankle Fractures Using Quantitative Tibial Hounsfield Samples From Preoperative Computed Tomography: A Multicenter Matched Case Control Study.

The aim of this study is to use tibial Hounsfield unit measurements from preoperative computed tomography scans of ankle fractures to predict delayed union and nonunion. We hypothesize that patients with lower Hounsfield unit averages, an indirect measure of lower bone mineral density, in the distal tibia are more likely to develop delayed union and nonunion complications after ankle fracture surgery. Patient data from January 2010 to January 2020 were retrospectively analyzed from 2 institutions. Exposure cases of delayed union or nonunion that had preoperative computed tomography were compared to 5 controls matched for sex, age, and classification. 3 measurements were taken from the tibia on axial computed tomography and averaged to create a summative measure for overall bone health. Statistical analysis was used to analyze the relationship between the groups. 19 exposure patients were compared to 95 control patients. There were 16 females and 3 males in the exposure group aged from 30 to 88 years. Average follow-up was 1.6 years. The average exposure and control Hounsfield measurements were 186 (161-210) and 258 (248-269), respectively. Significant differences were found for all measured averages. This is the first study to our knowledge relating preoperative tibial Hounsfield measurements to healing rates of ankle fractures. Measurements taken from any of the 3 sites or the average could be an indicator of overall bone health. Using this technique on preoperative imaging will help surgeons adjust their perioperative planning for patients at higher risk for delayed union and nonunion.

Prediction of delayed union of tibial shaft fracture treated with intramedullary nailing: multicenter-study analysis and literature review -the TRON study.

PURPOSE: We aimed to 1) identify predictors of delayed and nonunion of tibial shaft fractures in patients treated with intramedullary nailing (IMN), including patient demographics and surgical factors, and 2) determine whether the nail/shaft ratio is associated with delayed and nonunion. METHODS: This retrospective, multicenter study included 315 patients with tibial shaft fracture treated with IMN between 2014 and 2019 and excluded patients with insufficient follow-up for 12 months, lost data and inadequate radiographs. Finally, we analyzed 258 patients (184 males; 74 females). Main outcome measurements were delayed union at 6 and nonunion at 12 months after surgery as determined on anteroposterior and lateral radiographs. We extracted the following as risk factors of delayed and nonunion: age, sex, BMI, fracture site, fracture type, injury energy, smoking history, and nail/shaft ratio. We conducted logistic regression analysis to investigate risk factors of delayed and nonunion using these extracted items as explanatory variables. RESULTS: Type C fracture was independently associated with delayed union (odds ratio 2.9, 95% confidential interval: 1.04-8.09, P = 0.04). Nail/shaft ratio was not an independent factor of delayed union. No independent explanatory factors were related to nonunion. CONCLUSIONS: Type C fractures, which were unstable and fragmented, was associated with delayed union in tibia fractures treated with IMN, whereas nail thickness was not associated with delayed or nonunion fractures.

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.

Extracorporeal shock wave therapy accelerates endochondral ossification and fracture healing in a rat femur delayed-union model.

Extracorporeal shock wave therapy (ESWT) has been demonstrated to accelerate bone healing; however, the mechanism underlying ESWT-induced bone regeneration has not been fully elucidated. This study aimed to examine the effects of ESWT and the process of fracture healing. A rat model of femur delayed-union was established by cauterizing the periosteum. ESWT treatment at the fracture site was performed 2 weeks after the operation and the site was radiographically and histologically evaluated at weeks 4, 6, and 8. The bone union rate and radiographic score of the ESWT group were significantly higher than those of the control group at 8 weeks. Histological evaluation revealed enhanced endochondral ossification at the fracture site. The effects of ESWT on ATDC5 cells were examined in vitro. ESWT promoted chondrogenic differentiation without inhibiting the proliferation of ATDC5 cells. ESWT may induce significant bone healing by promoting endochondral ossification at the fracture site.

Hip displacement in Wolf-Hirschhorn syndrome: Report on three cases and review of associated musculoskeletal pathologies.

Wolf-Hirschhorn syndrome is a rare genetic disease caused by a chromosomal deletion of the distal short arm of Chromosome 4. It is associated with multisystem abnormalities, including delayed growth, characteristic facial features, epilepsy, and skeletal abnormalities. We report three patients who developed hip displacement, and describe the occurrence of delayed and nonunion in patients who underwent corrective proximal femoral osteotomy for hip displacement. We also performed a literature review identifying common musculoskeletal presentations associated with the condition. Patients with Wolf-Hirschhorn Syndrome are at risk of hip displacement (subluxation), and we would advocate annual hip surveillance in this patient group.

Comparison of once-weekly teriparatide and alendronate against new osteoporotic vertebral fractures at week 12.

The objective of the present multicenter randomized study was to compare weekly teriparatide with alendronate in their inhibition of vertebral collapse, effects on delayed union, pain relief, and improvement of quality of life (QOL) in women with new osteoporotic vertebral fractures within 1 week after onset of the fracture. Patients were randomly allocated to the teriparatide and alendronate groups. Vertebral collapse, low back pain assessed by a visual analog scale, and QOL assessed by EuroQol 5 dimension at weeks 1, 2, 4, 8, and 12 after the start of the treatment were compared between the groups. Lumbar bone mineral density (BMD) at baseline and week 12 and the rate of delayed union at week 12 were also compared. Each group consisted of 48 subjects. Vertebral collapse progressed over time in both groups, with no significant difference between the groups. Pain on rising up from lying position, turning over in bed, and resting in the lying position improved over time in both groups, with no significant difference between the groups. There were no significant differences in increase in BMD and delayed union. QOL in the teriparatide group showed significant improvement in comparison with that in the alendronate group at week 12. The weekly formulation of teriparatide showed comparable inhibition of vertebral collapse, increase in BMD, promotion of bone union, and improvement of pain and significant improvement of QOL at week 12 in comparison with alendronate in patients with a new osteoporotic vertebral fracture within 1 week after onset of the fracture. The weekly formulation of teriparatide may have improved components of QOL other than pain at week 12.

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.

The effect of post-operative NSAID administration on bone healing after elective foot and ankle surgery.

BACKGROUND: Post-operative pain is a common concern following elective foot and ankle surgery. NSAIDs used for pain relief have led to bone-healing complications in animal models and in vitro studies. This retrospective study examined the rate of bone-healing complications in post-surgical patients using NSAIDs. METHODS: Participants underwent elective foot surgeries between January 2016 and May 2018. Radiographs were used to identify bony nonunion at osteotomy sites 12 weeks post-surgery. RESULTS: Two-hundred thirty-two patients were evaluated; 59 (25.43%) were prescribed ibuprofen, 62 (27%) ketorolac, 15 (6.47%) acetaminophen, and 92 (40%) hydrocodone-acetaminophen. Two-hundred and twelve (91.38%) patients exhibited radiographic evidence of osseous union at 12 weeks and 20 (8.62%) had radiographic evidence of non-union of the osteotomy sites. There was no significant relationship between NSAID use and osseous non-union (p<0.05). CONCLUSIONS: Short-term use of oral ibuprofen and ketorolac in the post-operative period was not associated with bony non-union.