Augmentative Plating in the Treatment of Femoral Nonunion after Intramedullary Nail Fixation.

Objective: Failure of bone healing after intramedullary nailing (IMN) of a femoral diaphyseal fracture is an uncommon condition, which can cause obvious pain symptoms and seriously affect the daily life of patients. Ununion of femoral fracture requires treatment to promote successful bone union. Augmentative plating (AP) has yielded good results in treating femoral nonunion after IMN. However, there are few large cohort studies and no technical standard for this treatment. To determine (1) the proportion of individuals with femoral nonunion after IMN who achieved radiographic signs of osseous union following the additional treatment of AP and autogenous bone grafting and (2) the factors associated with the failure of this treatment. Methods: Nonunion after IMN fixation is defined as an unhealed fracture with no radiographic signs of osseous union at least six months after IMN treatment. Osseous union as bridging bone on three of four cortices with the absence of a radiolucent line. Between January 2011 and January 2022, 83 individuals diagnosed with femoral nonunion after IMN fixation underwent AP and an autogenous bone graft. Results: Seventy-six of the 83 nonunion individuals attained osseous union by 12 months. Six of 36 (16.7%) subjects with mono-cortical plates had non-union. Conversely, one of 47 subjects (2%) with bi-cortical plates had non-union. There were 18 individuals whose AP had ≤6 cortices. Five of these 18 (38.5%) individuals had non-union. Two of 65 with an AP of >6 cortices had non-union. AP with ≤ 6 cortices was a major risk factor for the likelihood of unsuccessful procedures compared to AP with > 6 cortices. Three individuals experienced incision infection at the bone graft harvest site and were treated with local wound care. Conclusions: A high proportion of individuals with femoral nonunion after IMN fixation were salvaged by AP and an autogenous bone graft. Bi-cortical plate and screw intersection of more than six cortices may increase the treatment effectiveness. Limitations: There were limitations of this study. First, it was a retrospective study over a 10-year period, and the patients were treated by different orthopedic surgeons. Second, lack of functional evaluation is another limitation of the present work. Generalizability: The technique of bi-cortical plate and screw intersection of more than six cortices is not difficult for experienced orthopedic surgeons, and no special surgical tools is required. Closing Statement: Many literature has confirmed the good effect of APP technology in treating femoral nonunion after intramedullary nail fixation, but there are still cases of failure. Our study may enable this technology to achieve better therapeutic effects.

Individualized herbal prescriptions for delayed union: A case series.

Background Bone fractures are important clinical events for both patients and professionals. Active treatment options are limited for delayed unions and for nonunions; surgery is common but not entirely risk-free. This report describes three cases of delayed union successfully treated with herbal decoction. Participants Three patients had trapezoid and 3rd metacarpal bone fractures, 2nd, and 5th metatarsal bone fractures, respectively. All three patients were diagnosed with delayed union by an independent orthopedic surgeon based on computed tomography (CT) scan/radiographic imaging and fracture duration without a healing process. Patients took herbal decoction, Jeopgol-tang, with individually added herbs based on symptom manifestations, twice daily for 56, 85 and 91 days with no additional interventions except for a splint that they had been wearing since fracture diagnosis. Outcomes Improvement of delayed union was evaluated using radiographic imaging or CT during treatment with Jeopgol-tang. Results After taking herbal medicine, callus and bony bridging were confirmed on follow-up imagings and the patients described their experience with pain reduction at an interview after recovery. Conclusions This case series suggests that the herbal decoction Jeopgol-tang warrants further investigation to establish its role as a complementary and integrative medicine treatment option for delayed unions.

Carpal scaphoid non-union treatment: a retrospective trial comparing simple retrograde percutaneous screw fixation versus percutaneous screw fixation plus pulsed electromagnetic fields (Physiostim®).

BACKGROUND: The purpose of this retrospective comparative study was to assess whether a complementary treatment by pulsed electromagnetic field could increase the bone-healing rate of scaphoid non-union without SNAC (scaphoid non-union advanced collapse) treated by retrograde percutaneous screw fixation. CASE DESCRIPTION: Eighteen patients with scaphoid non-union were included in this retrospective study. The group 1 was made of nine cases (seven stage IIA and two stage IIB) of scaphoid non-union treated by retrograde percutaneous screw fixation and pulsed electromagnetic fields (Physiostim®). The group 2 was made of nine cases (six stage IIA and three stage IIB) treated by simple retrograde percutaneous screw fixation. RESULTS: With a 10-month follow-up in group 1 and a 9.5-month follow-up in group 2, there were three cases of non-union in group 1 and two cases in group 2. Regarding the type of non-union, there was one case among the stage IIB and four cases among the stage IIA. CLINICAL RELEVANCE: The results of the study did not show any interest in the use of pulsed electromagnetic field for the treatment of carpal scaphoid non-union. They should be dropped. LEVEL OF EVIDENCE: III.

Treatment of recalcitrant atrophic non-union of the humeral shaft with BMP-7, autologous bone graft and hydroxyapatite pellets.

Recalcitrant humeral non-union is a disabling condition that is extremely difficult to treat. The use of BMP-7 has been proposed to improve bone healing. This is a report of the results obtained in 12 patients with recalcitrant humeral non-union treated using stable fixation with a long locking compression plate and BMP-7, autologous bone graft and hydroxyapatite pellets applied at the non-union site. Patients had up to three surgical attempts at non-union healing prior to our treatment. The average time from the initial fracture to our surgery was 5.2 years. Average follow-up was 5.3 years. At follow-up, non-union had healed in all patients by an average of 7.3 months. All the patients were very satisfied with their final results, despite a restricted range of motion of the elbow and a moderate muscular atrophy, which was frequently observed. Our study shows that BMP-7 associated with autologous bone grafting and hydroxyapatite pellets after stable fixation is an effective adjuvant to stimulate bone healing in the treatment of recalcitrant humeral non-union.

Delayed Union of a Jones Fracture in a Patient With Rothmund-Thomson Syndrome: A Case Report and Review of the Literature.

Rothmund-Thomson syndrome is a rare autosomal recessive genodermatosis, characterized by poikiloderma, small stature, juvenile cataracts, sparse hair, skeletal abnormalities, and a predisposition to osteogenic sarcomas and skin cancers. Although numerous skeletal abnormalities have been described in patients with Rothmund-Thomson syndrome, to our knowledge, only 1 study has shown evidence of delayed fracture healing in a patient with Rothmund-Thomson syndrome. We present the case of a 13-year-old female diagnosed with Rothmund-Thomson syndrome who demonstrated delayed union of her fifth metatarsal after a Jones fracture. She was treated conservatively for 6 weeks with non-weightbearing cast immobilization and was then transitioned to a controlled ankle motion walker for an additional 4 weeks. Two months later, however, she continued to experience pain, and, on radiographic examination, the fracture remained unchanged. Therefore, with her guardian's consent, the patient elected to undergo open reduction and internal fixation of the fifth metatarsal fracture. At 8 weeks postoperatively, the patient reported a subsidence of symptoms and had returned to normal activity. With our report, we hope to increase practitioner awareness that delayed bone healing could be a possibility in patients with Rothmund-Thomson syndrome and encourage consideration of routine imaging and supplementation with calcium and vitamin D. Additionally, the present findings suggest that patients with Rothmund-Thomson syndrome could benefit from early surgical intervention, given their poor bone healing capacity and high likelihood of nonunion. Although the association between impaired bone healing and Rothmund-Thomson syndrome is rational, additional studies are needed to determine the prevalence of chronic nonunion in this patient population.

Early application of pulsed electromagnetic field in the treatment of postoperative delayed union of long-bone fractures: a prospective randomized controlled study.

BACKGROUND: Pulsed electromagnetic field (PEMF) is reported to be an effective adjunct for the management of nonunion long-bone fractures. Most studies implement PEMF treatment after 6 months or longer of delayed union or nonunion following fracture treatment. Despite these variations in treatment, the early application of PEMF following a diagnosis of a postoperative delayed union has not been specifically analyzed. In this study, the outcomes of postoperative delayed union of long-bone fractures treated with an early application of PEMF were evaluated as compared with a sham-treated control group. METHODS: In this prospective, randomized controlled study, a total of 58 long-bone fracture patients, who presented with delayed union of between 16 weeks and 6 months, were randomly split into two groups and subjected to an early application of PEMF or sham treatment. Clinical and radiological assessments were performed to evaluate the healing status. Treatment efficacy was assessed at three month intervals. RESULTS: Patients in the PEMF group showed a higher rate of union than those in the control group after the first three months of treatment, but this difference failed to achieve statistical significance. At the end of the study, PEMF treatment conducted for an average of 4.8 months led to a success rate of 77.4%. This was significantly higher than the control, which had an average duration of 4.4 months and a success rate of 48.1%. The total time from operation to the end of the study was a mean of 9.6 months for patients in the PEMF group. CONCLUSIONS: Fracture patients treated with an early application of PEMF achieved a significantly increased rate of union and an overall reduced suffering time compared with patients that receive PEMF after the 6 months or more of delayed union, as described by others.

A complex injury of the distal ulnar physis: a case report and brief review of the literature.

Physeal fractures of the distal forearm are common injuries in children and adolescents. However, Salter-Harris type III and type IV fractures of the distal ulnar epiphysis are often high-energy injuries that require open reduction for restoration of anatomical alignment. These injuries are uncommon and there are few descriptions of them in the contemporary literature. Here we report the case of a 13-year-old boy with a type IV distal ulna fracture not diagnosed with standard radiography. After closed manipulation, an incompletely reduced physis was suspected on the basis of fluoroscopic imaging and comparison radiographs of the contralateral wrist. Computed tomography showed a large, displaced physeal fragment. The patient underwent open reduction and internal fixation. Thorough radiographic assessment should be conducted when there is a high suspicion for these fracture patterns. Appropriate diagnosis can lead to expedient reduction and expectant management of sequelae associated with these injuries.

Recognition, assessment, and treatment of non-union after surgical fixation of fractures: emphasis on 3D CT.

For the post-operative patient, conventional axial computed tomography (CT) imaging and 2D multiplanar reconstruction are of limited value because of the beam-hardening artifact. However, three-dimensional (3D) CT imaging is an effective means of detecting subtle fracture healing, or confirming non-union, and for evaluating the integrity of metal hardware. In this article we emphasize the advantages of 3D CT imaging in the assessment and preoperative planning of non-union for patients who have been surgically treated for fractures.

Pulsed electromagnetic field stimulation for acute tibial shaft fractures: a multicenter, double-blind, randomized trial.

BACKGROUND: Tibial shaft fractures are sometimes complicated by delayed union and nonunion, necessitating further surgical interventions. Pulsed electromagnetic field stimulation is an effective treatment for delayed unions and nonunions, but its efficacy in preventing healing complications in patients with acute fractures is largely untested. The purpose of this pragmatic trial was to determine whether adjuvant pulsed electromagnetic field therapy for acute tibial shaft fractures reduces the rate of surgical revision because of delayed union or nonunion. METHODS: In a double-blind randomized trial involving six metropolitan trauma hospitals, 259 participants with acute tibial shaft fractures (AO/OTA type 42) were randomized by means of external allocation to externally identical active and inactive pulsed electromagnetic field devices. Participants were instructed to wear the device for ten hours daily for twelve weeks. Management was otherwise unaltered. The primary outcome was the proportion of participants requiring a secondary surgical intervention because of delayed union or nonunion within twelve months after the injury. Secondary outcomes included surgical intervention for any reason, radiographic union at six months, and the Short Form-36 Physical Component Summary and Lower Extremity Functional Scales at twelve months. Main analyses were by intention to treat. RESULTS: Two hundred and eighteen participants (84%) completed the twelve-month follow-up. One hundred and six patients were allocated to the active device group, and 112 were allocated to the placebo group. Compliance was moderate, with 6.2 hours of average daily use. Overall, sixteen patients in the active group and fifteen in the inactive group experienced a primary outcome event (risk ratio, 1.02; 95% confidence interval, 0.95 to 1.14; p = 0.72). According to per-protocol analysis, there were six primary events (12.2%) in the active, compliant group and twenty-six primary events (15.1%) in the combined placebo and active, noncompliant group (risk ratio, 0.97; 95% confidence interval, 0.86 to 1.10; p = 0.61). No between-group differences were found with regard to surgical intervention for any reason, radiographic union, or functional measures. CONCLUSIONS: Adjuvant pulsed electromagnetic field stimulation does not prevent secondary surgical interventions for delayed union or nonunion and does not improve radiographic union or patient-reported functional outcomes in patients with acute tibial shaft fractures.

Do successful surgical results after operative treatment of long-bone nonunions correlate with outcomes?

UNLABELLED: There has been increased emphasis on validated, patient-reported functional outcomes after orthopaedic interventions for various conditions. The few reports on these types of outcomes after treatment of fracture nonunions are limited to specific anatomic sites, limited by small numbers, and retrospective. To determine whether successful healing of established long-bone nonunions resulted in improved functional outcomes and reduction in patient-reported pain scores, we prospectively followed 80 patients. These patients had a mean of 1.4 surgical procedures before enrollment and a mean of 18 months had elapsed from previous surgery until enrollment. Baseline data and functional scores were obtained before intervention. Seventeen of the 80 patients (21%) had positive intraoperative cultures. At a mean of 18.7 months (range, 12-36 months), 72 (90%) nonunions had healed. Patients with healed nonunions scored better on the Short Musculoskeletal Functional Assessment. Pain scores among all patients improved compared with baseline, but to a greater degree in patients who achieved healing by final followup. Our data suggest improvement in pain scores is seen in all patients after surgery, whereas successful internal fixation leads to improved function. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Chiropractic care of a patient with low back pain associated with subluxations and a Malgaigne-type pelvic fracture.

OBJECTIVE: To describe the chiropractic care of a patient with a pelvic ring fracture and concomitant subluxations of multiple segments of the spinal column. CLINICAL FEATURES: A 23-year-old male, after falling down a flight of stairs, was initially hospitalized for fractures of the pelvis. Five weeks posthospitalization, the patient initiated chiropractic care with complaints of severe low back pain with lower extremity involvement. He also complained of neck pain and occipital headache. The patient had several positive low back orthopedic tests with bilaterally absent Achilles deep tendon reflexes. The anteroposterior radiographic view revealed ununited fractures at the left superior and inferior pubic ramus, noted as a type I Malgaigne fracture. Subluxations were detected at the left innominate (ie, fracture-subluxation) and at the patient's lumbar, thoracic, and cervical spine. INTERVENTION AND OUTCOME: The patient was cared for with contact-specific, high-velocity, low-amplitude adjustments to sites of vertebral and sacroiliac subluxations. The patient's response to care was positive, receiving great pain relief. Less than 3 months after initiating care, the patient returned to work on regular duty. CONCLUSION: There are indications that patients suffering from the injuries described above may derive benefits from chiropractic care. The practitioner must pay careful attention to issues of biomechanical and vascular stability and adjustment modifications in these types of patients.

Nonunion: general principles and experimental data.

Nonunions of long bone fractures can be treated successfully with one operative procedure in more than 90% of patients. In fact, 80% of patients can have good to excellent final restoration of mechanical axis alignment and proper length. Patients with infected nonunions may require more than one procedure to eliminate infection and heal the nonunion. Treatment must be tailored to the individual patient to address all components of the problem. We reviewed the main experimental data regarding the knowledge of nonunions and the basic methods that may be applied to the treatment of nonunions.

Treatment of nonunions with electric and electromagnetic fields.

Electric and electromagnetic fields are, collectively, one form of biophysical technique which regulate extracellular matrix (ECM) synthesis and may be useful in clinically stimulating repair of fractures and nonunions. Preclinical studies have shown that electric and electromagnetic fields regulate proteoglycan (PG) and collagen synthesis in models of endochondral ossification, and increase bone formation in vivo and in vitro. A substantial number of clinical studies have been done that suggest acceleration of bone formation and healing, particularly osteotomies and spine fusions, by electric and electromagnetic fields. Many of these studies have used randomized, placebo controlled designs. In osteotomy trials, greater bone density, trabecular maturation, and radiographic healing were observed in actively treated, compared with placebo-treated patients. In spine fusions, average union rates of 80% to 90% were observed in actively treated patients across numerous studies compared with 65% to 75% in placebo-treated patients. Uncontrolled, longitudinal cohort studies of delayed and nonunions report mean union rates of approximately 75% to 85% in fractures previously refractory to healing. The few randomized controlled studies in delayed and nonunions suggest improved results with electric and electromagnetic fields compared with placebo treatment, and equivalent to bone grafts.

Treatment of nonunions and osseous defects with bone graft and calcium sulfate.

The treatment of long bone nonunions and fractures with osseous defects is challenging. The results of 26 patients with either a persistent long bone nonunion or an osseous defect after an open fracture were reviewed. Each patient was treated with debridement of devitalized tissue, open reduction and internal fixation, and bone grafting using a mixture of autogenous iliac crest bone graft and medical grade calcium sulfate. The current study evaluated the union rate and associated complications for treatment of these injuries using this protocol. Each nonunion was confirmed intraoperatively, and healing was determined clinically by the patients' return to full activities without pain and radiographically by the presence of bridging trabeculae. Complications included persistent nonunion (four patients), wound drainage (five patients), wound drainage and cellulitis (one patient) and cellulitis alone (one patient). Using this treatment protocol, 22 patients (85%) achieved healing after one surgery and an additional two patients (92%) achieved healing after a second surgery. Medical grade calcium sulfate increases the volume of graft material, facilitates bone formation, and is safe in the treatment of nonunions and fractures with osseous defects.

The complications seen from the treatment by traditional bonesetters.

Traditional bone setters are rampant in the West African subregion but the atrocities committed by them have never been reported hence the need for this article that deals with the menace caused by them. All patients referred to the University College Hospital between 1996 and 2001 were included in this study. Only a few number of the patients have been selected just to illustrate the menace caused by the traditional bonesetters in so many African societies. The deformities, financial loss and amputations resulting from the management by traditional bonesetters have been highlighted. Suggestions are made on how to improve awareness in the way of adequate communications through televisions, radio and the press. Much need to be done in the society as it was found in the study that poverty or lack of education alone is not the major cause of the society seeking the help of the traditional healers, but probably the culture and traditional beliefs of the society.

Pulsed electromagnetic fields for the treatment of bone fractures.

The effectiveness of electrical stimulation and Pulsed Electro Magnetic Field (PEMF) stimulation for enhancement of bone healing has been reported by many workers. The mechanism of osteogenesis is not clear, therefore, studies look for empirical evidence. The present study involved a clinical trial using low amplitude PEMF on 19 patients with non-union or delayed union of the long bones. The pulse system used was similar in shape to Bassett's single pulse system where the electric voltage pulse was 0.3 mSec wide repeating every 12 mSec making a frequency of about 80 Hz. The peak magnetic fields were of the order of 0.01 to 0.1 m Tesla, hundred to thousand times smaller than that of Bassett. Among the 13 who completed this treatment schedule the history of non-union was an average of 41.3 weeks. Within an average treatment period of 14 weeks, 11 of the 13 patients had successful bone healing. The two unsuccessful cases had bone gaps greater than 1 cm following removal of dead bone after infection. However, use of such a low field negates Bassett's claim for a narrow window for shape and amplitude of wave form, and justifies further experimental study and an attempt to understand the underlying mechanism.

Electrical stimulation of bone nonunion with the presence of a gap.

A total of 22 established nonunions was treated with a capacitively-coupled electrical signal. A gap of 0.5 cm or more between the fragments was present in all of these nonunions. After an average of 26 weeks of treatment with capacitive coupling, radiographic assessment showed solid bone union in 72.7% of the cases. The results were better when the fracture site was metaphyseal. When the site was diaphyseal, bone healing was mainly achieved by bone trabeculae invading the gap. When the site was metaphyseal, healing occurred by the formation of a peripheral callus. The results were not affected by the presence of infection. In 8 of the cases osteomyelitis occurred, but all healed.

Capacitively coupled electrical field in the treatment of a leg fracture after total knee replacement.

Electrical stimulation has been used as treatment for nonunions of fractures since the early 1950s, with a reported success rate of 80-85%. We report a case of nonunion of a tibial fracture below a revised total knee prosthesis treated with a capacitively coupled electrical field. After 3 months of treatment, consolidation of this difficult fracture was evident with abundant callus formation.

A ten-year review of treatment of delayed union and nonunion with an implanted bone growth stimulator.

A ten-year clinical and roentgenographic review was conducted on the patients in the original Australian multicenter trial that evaluated use of an implantable bone growth stimulator for delayed union and nonunion. Of the original 81 patients, 38 patients were located, seven patients had died from unrelated causes, and 36 were unlocatable. Of the 38 patients located, 37 patients (representing 38 fractures) participated in a detailed clinical review and had a roentgenographic assessment. All fractures had remained united, and normal bone remodeling had occurred. There were no adverse effects of the generator or cathode wire. Six patients initially reported as failures had healed after further surgical intervention. Thus, normal osteogenesis occurs in association with electrical stimulation using an implantable bone growth stimulator. This ten-year review supports the long-term safety and effectiveness of this technique in treating nonuniting fractures.