The devastating effects of humeral nonunion on health-related quality of life.

BACKGROUND: Humeral nonunion is estimated to occur at a rate of 1.1%-25% depending on the fracture location and pattern, mechanism of injury, patient compliance with the immobilization protocol and patient's nutritional status and medical comorbidities. Fracture nonunion can cause chronic pain and limited range of motion and may hinder normal function. There is very little data from the patients' perspective regarding their experience with a humeral nonunion. The aim of this study was to establish health-related quality of life (HRQoL) norms for patients diagnosed with a humeral nonunion. MATERIALS AND METHODS: We reviewed a prospectively collected database of 185 humeral nonunions seen and treated at our quaternary referral center. We recorded patient characteristics including sex, age, history of infection, previous surgery, associated nerve palsy, handedness, and the anatomic location of the nonunion. At initial clinical evaluation, all patients were asked to complete the 12-Item Short Form Health Survey (SF-12), Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, Brief Pain Inventory (BPI), and a time trade-off questionnaire. These scores were compared to other well-known chronic medical conditions' HRQoL scores. RESULTS: The cohort reported an average utility score of 0.55 ± 0.35, average SF-12 Physical Component Summary score of 30.2 ± 7.6, average SF-12 Mental Component Summary score of 42.5 ± 6.1, and average raw DASH score of 69 ± 21, which was worse than the general US population, patients with asthma, hypertension, stroke, type 2 diabetes, and AIDS. Patients with humeral nonunion are willing to trade 45% of their remaining life to obtain perfect health, and when stratified by handedness, we found that patients with a humeral nonunion of their dominant arm were willing to trade 49.7% compared with 39.7% in patients with a humeral nonunion of their nondominant arm (P = .04). DISCUSSION: The results of our study show that humeral nonunion is a chronic medical condition that has a debilitating effect on patients, both physically and mentally. It is important for orthopedic surgeons to acknowledge these conditions as physically and mentally debilitating to their patients. Our study highlights these physical and mental burdens and helps to quantify humeral nonunion in relation to more well-known chronic conditions, such as asthma, diabetes, AIDS, and stroke. CONCLUSIONS: Humeral nonunions have a devastating effect on a patient's physical and mental health with HRQoL measures lower than patients with other chronic conditions, such as asthma, diabetes, AIDS, and stroke. We found that our patients, on average, would trade approximately 45% of their remaining life span for perfect health.

Trauma fellowship impact on trends and complications of operatively treated clavicle fractures in recently trained orthopedic surgeons.

PURPOSE: The purpose of this study was to evaluate whether fellowship training affected trends and complications of operative clavicle fracture treatment in newly trained orthopedic surgeons. METHODS: The American Board of Orthopedic Surgery (ABOS) database was utilized to identify cases of open treatment of clavicle fractures submitted by ABOS Part-II Board Certification candidates. From 2005 to 2017, 3148 candidates performed at least one open clavicle fracture treatment. Overall, 6919 cases were included; 3516 of these had over 6 weeks of follow-up. Candidates were divided by fellowship type into 5 groups: Trauma, Sports Medicine, Hand and Upper Extremity or Shoulder, multiple, and other or no fellowship(s). Group differences were analyzed with ANOVA and Bonferroni post hoc analysis. Complications, reoperations, nonunion rates, and readmissions between groups were evaluated with Chi-squared test and logistic regression analyses. RESULTS: Case volume during the study period was significantly higher after 2007. Trauma candidates performed significantly more operations for clavicle fracture per candidate while candidates with other or no fellowship(s) performed significantly fewer operations per candidate. Patients treated by Trauma candidates were significantly older, had significantly fewer early surgical complications and significantly more early medical complications. Nonunion rates were not significantly different between groups. CONCLUSION: Candidates treated clavicle fractures surgically more often in 2007 and beyond. Trauma candidates treated older patients, had fewer early surgical complications, and had more medical complications. Reoperation, readmission and nonunion rates were not significantly different between groups.

Efficacy of PRECICE Nail in Treatment of Adult Patients With Posttraumatic Femoral Leg Length Discrepancy.

SUMMARY: Posttraumatic, limb length discrepancy in adults is a challenge to treat, and multiple treatment protocols over the years have shown varying levels of success and complications. Before the introduction of the PRECICE nail in 2011, our preferred method of limb lengthening used an Ilizarov or Taylor Spatial frame. To assess the PRECICE nail, we evaluated the accuracy and complications during treatment in a series of skeletally mature patients with posttraumatic femoral limb length discrepancy. The surgical technique along with a case series of 8 patients are described in detail. On average, the target lengthening for the PRECICE nail was 44 mm, and all patients achieved lengthening within 2 mm and complete bony consolidation. The only observed complication in our series was a broken screw 1 year after the patient started weight-bearing. The PRECICE nail demonstrated promising results and was useful for bone regeneration and consolidation without the need for additional procedures. The rate of complications was low compared with previous methods, making this device an excellent treatment option.

Utility of Common Biomarkers for Diagnosing Infection in Nonunion.

OBJECTIVES: To evaluate the diagnostic utility of leukocyte count (WBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) for distinguishing between septic and aseptic nonunions. DESIGN: A single-gate (cohort) design was used, using 1 set of eligibility criteria applied to a consecutive sample of nonunions. SETTING: Private quaternary referral center. PATIENTS/PARTICIPANTS: Inclusion criteria were consecutive patients (≥18 years) with a nonunion requiring surgery that allowed for direct or medullary canal tissue sampling from the nonunion site. The cohort included 204 subjects with 211 nonunions. INTERVENTION: Blood samples were drawn for laboratory analysis of WBC, ESR, and CRP before surgery. MAIN OUTCOME MEASUREMENTS: The reference standard used to define infection was the fracture-related infection confirmatory criteria. Measures of diagnostic accuracy were calculated. To assess the additional diagnostic gain of each index lab test while simultaneously considering the others, logistic regression models were fit. RESULTS: The prevalence of infection was 19% (40 of 211 nonunion sites). The positive likelihood ratios (95% confidence interval) for WBC, ESR, and CRP were 1.07 (0.38-3.02), 1.27 (0.88-1.82) and 1.57 (0.94-2.60), respectively. Multivariable modeling adjusted for the effect of preoperative antibiotics showed that WBC (P = 0.42), ESR (P = 0.48), and CRP (P = 0.23) were not significant predictors of infection. CONCLUSIONS: In this consecutive sample of 211 nonunions in whom standard clinical practice would be to obtain index lab tests, our findings showed that WBC, ESR, and CRP were not significant predictors of infection. LEVEL OF EVIDENCE: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Treatment of Periprosthetic Nonunions of the Lower Extremity.

Multiple studies have reported nonunion rates of 3% to 17% following peri-prosthetic fractures. Determining management strategies based on the available literature is difficult because existing studies are small and involve heterogeneous treatments and multiple surgeons. The purpose of this study was to describe a consecutive series of patients who presented to the authors' clinic with a periprosthetic nonunion of the lower extremity and to report the methods used to achieve limb salvage and the associated complications. Patients were included if they were indicated for surgery for a nonunion of a periprosthetic fracture of the lower extremity that had previously undergone either closed or open intervention. A total of 26 patients were included in this study. Average follow-up was 58 months. Average age was 69 years, and 77% of the patients were female. Twenty-three patients had periprosthetic nonunions of the femur, with 6 being associated with total hip arthroplasty, 15 with total knee arthroplasty, and 2 with both a total hip arthroplasty and a total knee arthroplasty. Three patients had a periprosthetic nonunion of the tibia associated with a total knee arthroplasty. Limb salvage was successful in 25 of 26 cases. This was achieved by either healing of the nonunion using exuberant fixation with prosthesis revision when necessary (n=20) or resection of the nonunion with placement of a tumor prosthesis (n=5). Four of the 26 patients (15%) incurred at least 1 complication during treatment. Exuberant fixation of the nonunion (with prosthesis revision when necessary) or nonunion resection with placement of a tumor prosthesis was successful in 96% of cases. [Orthopedics. 2020;43(4):209-214.].

Immediate Soft-Tissue Reconstruction for Chronic Infected Tibia Nonunions Treated with an Ilizarov Frame.

There are multiple options available for the management of large tibial defects. The Ilizarov frame is one of the most widely used techniques due to the physiological bone growth and the symmetrical distribution of axial forces permitting adequate bone distribution. However, disadvantages still remain including obtaining additional soft-tissue access for defect coverage. We present our experience with soft-tissue reconstruction for chronic infected tibial nonunions using free tissue transfers simultaneously with Ilizarov device placement. A retrospective review was performed from 2014 to 2016 of patients presenting with a chronically infected tibia nonunion and treated by our senior orthopedic and plastic surgeons. Demographic data, comorbidities, intraoperative details and postoperative outcomes were collected. A total of 6 patients were identified with a mean age of 46.2 ± 11.6 years. Complete flap survival and resolved active infection were achieved in 5 of our patients, 4 demonstrated body union on imaging, and all of them reached complete ambulance. Flap revisions with allografting for partial flap loss were performed in 1 patient. Preoperative planning is critical for immediate lower extremity reconstruction in the setting of an Ilizarov frame. From our institutional experience, free tissue transfer can safely be placed after frame placement.

Principles of Nonunion Management: State of the Art.

A substantial proportion of fractures can present with nonunion, and the management of nonunion continues to present a challenge for orthopaedic surgeons. A variety of biological, mechanical, patient, and injury factors can contribute to the occurrence of nonunion, and often the cause of nonunion may be multifactorial. Successful management often requires assessment and treatment of more than one of these factors. This article reviews common factors that may contribute to nonunion including infection, impaired biology, and metabolic disorders. In addition, new and evolving strategies for diagnosing the cause and effectively treating nonunion including the diagnosis of infection, metabolic workup, bone grafting, cell-based therapies, and biological adjuvants are reviewed and discussed.

High Rate of Union for Aseptic Distal Tibial Nonunions in Adults Treated With Slow Gradual Compression via Circular External Fixation.

OBJECTIVE: To evaluate the healing rate of aseptic nonunions of the distal third of the tibia treated with Ilizarov slow gradual compression and deformity correction. DESIGN: Retrospective cohort study. SETTING: Tertiary referral center. PATIENTS/PARTICIPANTS: Ninety-four consecutive adult patients with 94 distal third tibial aseptic nonunions. INTERVENTION: Ilizarov external fixation and slow gradual compression; most patients also underwent bone grafting, deformity correction, or both before the initiation of compression. MAIN OUTCOME MEASUREMENTS: Rate of bony union. RESULTS: Eighty-seven of 94 cases (92.6%) healed after slow gradual compression across the nonunion site with a circular external fixator. Four of the 7 patients who failed treatment healed after additional operative treatment, and the remaining 3 refused further care. CONCLUSIONS: Circular external fixation with slow gradual compression was successful in treating aseptic nonunions of the distal third of the tibia in 92.6% of cases. Careful selection of patients for this treatment method can lead to a high success rate with a relatively low rate of major complications. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Subtubercle Osteotomy for Medial Compartment Osteoarthritis of the Knee Using Ilizarov Technique: Survival Analysis and Clinical Outcomes.

BACKGROUND: High tibial osteotomy with acute correction and internal fixation can be used to correct malalignment and malorientation and reduce symptoms in patients with medial compartment osteoarthritis of the knee. To address the inadequacies of this technique, we performed a series of subtubercle tibial osteotomy (STO) procedures using circular ring fixation to correct knee varus malalignment and joint malorientation. The purpose of this study was to analyze the ability of this technique to delay subsequent knee arthroplasty and decrease symptoms. METHODS: Sixty-one patients had a total of 72 STO procedures using the Ilizarov technique to correct a varus deformity of the proximal part of the tibia. Radiographic measurements were performed at the time of presentation and after osseous union and frame removal. Clinical and radiographic variables were compared from presentation to the time of the latest follow-up. We performed a survival analysis, and our primary outcome was the time to conversion to knee arthroplasty. RESULTS: Radiographic measurements, including mechanical axis deviation, medial proximal tibial angle, and joint line congruence angle, significantly improved after deformity correction (p < 0.001 for all). In patients with a preoperative flexion contracture, the proximal posterior tibial angle significantly increased toward normal values (mean, 77.8° pretreatment versus 82.4° posttreatment; p = 0.007). Survival analysis demonstrated a rate of native knee-joint survival without conversion to arthroplasty of 94.2% (95% confidence interval [CI], 83% to 98%) at 5 years, 84.0% (95% CI, 69% to 92%) at 10 years, and 51.3% (95% CI, 28% to 71%) at 15 years. In addition, time-trade-off and Brief Pain Inventory outcomes significantly improved (p < 0.001). The complication rate was 8%. CONCLUSIONS: STO procedures using the Ilizarov technique for symptomatic varus knee deformity, performed over the course of 18 years, resulted in high knee survival rates without arthroplasty and significant improvement in clinical status. The STO technique provides several advantages over acute correction with internal fixation through a conventional high tibial osteotomy, including maintenance of the patellofemoral relationship, no retained implants, and accurate coronal and sagittal plane corrections. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Socio-demographic factors impact time to discharge following total knee arthroplasty.

AIM: To determine social, logistical and demographic factors that influence time to discharge in a short stay pathway (SSP) by following total knee arthroplasty (TKA). METHODS: The study included primary TKA's performed in a high-volume arthroplasty center from January 2016 through December 2016. Potential variables associated with increased hospital length of stay (LOS) were obtained from patient medical records. These included age, gender, race, zip code, body mass index (BMI), number of pre-operative medications used, number of narcotic medications used, number of patient reported allergies (PRA), simultaneous bilateral surgery, tobacco use, marital status, living arrangements, distance traveled for surgery, employment history, surgical day of the week, procedure end time and whether the surgery was performed during a major holiday week. Multivariate step-wise regression determined the impact of social, logistical and demographic factors on LOS. RESULTS: Eight hundred and six consecutive primary SSP TKA's were included in this study. Patients were discharged at a median of 49 h (post-operative day two). The following factors increased LOS: Simultaneous bilateral TKA [46.1 h longer (P < 0.001)], female gender [4.3 h longer (P = 0.012)], age [3.5 h longer per ten-year increase in age (P < 0.001)], patient-reported allergies [1.1 h longer per allergy reported (P = 0.005)], later procedure end-times [0.8 h longer per hour increase in end-time (P = 0.004)] and Black or African American patients [6.1 h longer (P = 0.047)]. Decreased LOS was found in married patients [4.8 h shorter (P = 0.011)] and TKA's performed during holiday weeks [9.4 h shorter (P = 0.011)]. Non-significant factors included: BMI, median income, patient's living arrangement, smoking status, number of medications taken, use of pre-operative pain medications, distance traveled to hospital, and the day of surgery. CONCLUSION: The cost of TKA is dependent upon LOS, which is affected by multiple factors. The clinical care team should acknowledge socio-demographic factors to optimize LOS.

Precise Measurement of the Outer Diameters of Antibiotic-Laden Cement Nails Produced by Various Sized Thoracostomy Catheter Molds.

OBJECTIVES: At our institution, custom-made antibiotic-laden cement nails (ACNs) fabricated during surgery using a thoracostomy catheter as a mold are commonly used to treat long-bone infection. As the outer diameter of the nails produced has not previously been described, we designed a study to measure the outer diameter of ACNs fashioned using commercially available and commonly utilized thoracostomy catheters of various sizes. METHODS: Six thoracostomy catheters from 2 different manufactures (Argyle PVC Thoracic Catheters; Covidien Ltd and Atrium PVC Thoracic Catheters; Atrium Medical Corporation), ranging from 20 French to 40 French, were utilized in this study. Each catheter was filled with antibiotic-laden cement, and the most proximal segment (largest outer diameter) and most distal segment (smallest outer diameter) were detached for study. Once the cement was cured, the thoracostomy catheters were cut away and the segments were measured using a calibrated digital caliper (Mitutoyo Corp, Aurora, IL). Because the ACNs produced using the technique taper from proximal to distal according to the shape of the thoracostomy catheter design, data were recorded as a maximum and minimum outer diameter for each ACN produced by each of the 6 thoracostomy catheter sizes studied. All measurements were in millimeters and were rounded to the nearest one-tenth of a millimeter. RESULTS: The ACNs produced using the various sized thoracostomy catheters had segments with outer diameters ranging from 4.2 mm to 11.2 mm. Both brands of catheters produced nails with similar distal diameters. Specifically, the mean distal diameter measurements were 4.2 mm for a 20 French catheter, 5.5 mm for a 24 French catheter, 6.6 mm for a 28 French catheter, 7.7 mm for a 32 French catheter, 8.4 mm for a 36 French catheter, and 9.9 mm for a 40 French catheter. The Argyle brand catheters produced nails with proximal diameters that increased with the catheter's size, from 7.1 mm for a 20 French catheter to 11.2 mm for a 40 French catheter. The Atrium brand catheters produced nails with a much tighter range of proximal diameters ranging from 9.4 mm to 11.1 mm. CONCLUSIONS: Thoracostomy catheters are commonly utilized to produce ACNs. The results of our study confirm that the fabricated nails taper in diameter from proximal to distal. Knowledge of the specific dimensions of the ACN produced by each size thoracostomy catheter will aid the orthopaedic surgeon in selecting the right size based on the diameter of the medullary canal being treated.

Debilitating Effects of Femoral Nonunion on Health-Related Quality of Life.

OBJECTIVE: The purpose of this study was to report the extent of the effects of femoral nonunion on health-related quality of life. DESIGN: Retrospective cohort. SETTING: Tertiary referral center. PATIENTS/PARTICIPANTS: One hundred eighty-seven consecutive patients (85 women, age 55.9 ± 16.9 years; 102 men, age 42.8 ± 16.1 years) with 188 nonunions of the femur, excluding those involving the hip or knee articular surfaces. INTERVENTION: Average nonunion duration was 28.5 months. 5.7% of the nonunions were infected, and the distal third was the most frequently involved segment. MAIN OUTCOME MEASUREMENTS: SF-12 Mental Component Summary (MCS) and Physical Component Summary (PCS) scores, Brief Pain Inventory (BPI), American Academy of Orthopaedic Surgeons Lower Limb Core Scale (LLCS), and Time Trade-Off (TTO) reported at the time of initial clinical evaluation at our center. RESULTS: The MCS scores averaged 43 ± 6.5, and the PCS scores averaged 26.3 ± 6.5, indicating the large adverse impact of femoral nonunion on mental and physical health, respectively. The BPI average intensity score averaged 5.1 ± 2.5, indicating moderate to severe pain. The LLCS averaged 53.9 ± 20.0, indicating substantial lower extremity-specific disability. The TTO questionnaire responses indicated that these patients were willing to trade an average of 38.3% of their remaining years of life to regain health. CONCLUSIONS: The impact of femoral shaft nonunion on physical health was comparable to end-stage hip arthrosis and tibial nonunion and worse than many other medical conditions. Femoral shaft nonunion is a debilitating chronic medical condition with substantial negative effects on health. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Biological Basis for Nonunions.

Fracture nonunion is a failure of the biological processes of fracture-healing. Critical cellular events in fracture-healing include the inflammatory response, differentiation and proliferation of progenitor cells, formation of fibrocartilage callus, angiogenesis and subsequent mineralization of the callus, vascular union (restoration of normal medullary circulation), and conversion of woven bone to lamellar bone. All critical events are closely regulated and coordinated by numerous cytokines and growth factors, which are expressed in complex spatial and temporal patterns throughout the repair process. At all phases of fracture-healing, poor cellular and metabolic capacity (e.g., chronic disease), excessive instability, and poor vascularity inhibit cellular responses and healing. Many biological treatments to prevent or treat nonunions are emerging in clinical use, including stem-cell and bone-marrow-aspirate preparations, various progenitor cells and growth factors (e.g., recombinant human bone morphogenetic proteins), and gene therapy.

Treatment of Infected Forearm Nonunions With Large Complete Segmental Defects Using Bulk Allograft and Intramedullary Fixation.

PURPOSE: The purpose of this study is to report the results of a series of infected forearm nonunions treated from 1998 to 2012 using a staged reconstruction technique. METHODS: At a median of 42 months follow-up, 7 patients who had an average segmental defect of 4.9 cm (range, 2.3-10.4 cm) were available for clinical and radiographic evaluation. Treatment consisted of serial debridement, implantation of an antibiotic cement spacer, and staged reconstruction using a bulk radius or ulna allograft with intramedullary fixation. RESULTS: All 7 patients ultimately achieved solid bone union, although 4 patients (57%) required additional surgery, consisting of autologous bone grafting and plating, to achieve healing at 1 of the allograft-host junction sites. No patient had recurrence of infection, and all reported substantial improvement with increased function and decreased pain. CONCLUSIONS: Our approach ultimately resulted in a 100% union rate without recurrence of infection, although many patients may require additional surgery to attain healing at both allograft-junction sites. Using bulk allograft provides the ability to span a large defect while reconstituting the forearm anatomy. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Addition of a Medial Locking Plate to an In Situ Lateral Locking Plate Results in Healing of Distal Femoral Nonunions.

BACKGROUND: Nonunion of the distal femur after lateral plating is associated with axial malalignment, chronic pain, loss of ambulatory function, and decreased knee ROM. The addition of a medial locking plate with autogenous bone grafting can provide greater stability to allow bone healing and may be used to achieve union in these challenging cases. QUESTIONS/PURPOSES: We wished to determine (1) the proportion of patients who achieve radiographic signs of osseous union for distal femoral nonunions with an in situ lateral plate after treatment with addition of a medial locking plate and autogenous bone grafting, and (2) the frequency and types of complications associated with this treatment. METHODS: Between 2007 and 2013, we treated 22 patients for 23 distal femoral nonunions, defined as an unhealed fracture with no radiographic signs of osseous union at a mean of 16 months (SD, 13 months) after injury. During that time, we used a treatment algorithm consisting of treatment in one or two stages. The single-stage procedure performed in 16 aseptic nonunions with a stable lateral plate involved addition of a medial locking plate and autogenous bone graft. A two-stage treatment performed in seven nonunions with lateral plate failure involved placement of a new lateral locking plate followed by addition of a medial locking plate with autogenous bone graft at least 2 months after the first procedure. Of the 22 patients treated, 20 had a median followup of 18 months (SD, 6-94 months). We defined osseous union by bridging bone on three of four cortices with absence of a radiolucent line or more than 25% cross-sectional area of bridging bone via CT. RESULTS: Twenty of the 21 nonunions attained radiographic signs of osseous union by 12 months. Six of the 20 patients experienced complications: one patient had a persistent nonunion; four patients underwent removal of symptomatic hardware; and one patient experienced skin breakdown at the bone graft harvest site. CONCLUSIONS: A very high proportion of patients achieve union when using medial locking plates to treat distal femoral nonunions after lateral plating of the original injury. Addition of bone graft, staged reconstruction, and revision of the initial lateral plate is indicated when the nonunion is associated with fatigue failure of the initial lateral plate. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Management of Aseptic Tibial and Femoral Diaphyseal Nonunions Without Bony Defects.

An evidence-based description of aseptic tibial and femoral diaphyseal nonunions without segmental defects is based on a systematic search of MEDLINE. Aseptic nonunion of the femoral or tibial diaphysis without segmental defects and with an in situ nail, treated with reamed exchange nailing or augmentative plating and bone grafting, has consistently high union rates. Aseptic nonunion without segmental defects and with in situ plate and screw fixation is best managed with revision plate and screw fixation and autogenous bone graft. Various techniques and methods of biological stimulation have relatively high union rates.

Time Trade-Off as a Measure of Health-Related Quality of Life: Long Bone Nonunions Have a Devastating Impact.

BACKGROUND: Long bone nonunions have an important impact on a patient's quality of life. The purpose of this study was to compare long bone nonunions with use of the Time Trade-Off direct measure to compute utility scores and to determine which nonunion anatomic location had the lowest health-related quality of life. The Time Trade-Off assesses the percentage of a patient's remaining life that the patient would be willing to trade for perfect health. METHODS: Eight hundred and thirty-two consecutive long bone nonunions with Time Trade-Off data were identified and were retrospectively studied from a prospectively collected patient database. Nonunions with infections and those involving the articular portion of the bone were recorded. Time Trade-Off utility scores were obtained for all nonunion cases upon their initial clinical evaluation by a single surgeon specializing in reconstructive trauma. RESULTS: The mean utility score of our nonunion cohort was 0.68 and it differed significantly by long bone (p = 0.037). Nonunions of the forearm had the lowest utility score (0.54), followed by the clavicle (0.59), femur (0.68), tibia or fibula (0.68), and humerus (0.71). Post hoc tests showed that patients with nonunions of the forearm had significantly lower utility scores (p = 0.031) compared with all other bones. CONCLUSIONS: Patients diagnosed with a long bone nonunion have a very low health-related quality of life. We found that this single cohort's mean utility score was 0.68. This result is well below that of illnesses such as type-I diabetes mellitus (0.88), stroke (0.81), and acquired immunodeficiency syndrome (0.79). We found that patients with forearm nonunions had the lowest utility scores. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Results of a systematic approach to exchange nailing for the treatment of aseptic femoral nonunions.

OBJECTIVES: To evaluate the radiographic and clinical outcomes of a systematic approach to exchange nailing for the treatment of aseptic femoral nonunions previously treated with an intramedullary nail. DESIGN: Retrospective cohort. SETTING: Tertiary referral center. PATIENTS: Fifty aseptic femoral nonunions in 49 patients who presented with an intramedullary nail in situ an average of 25 months after the initial fracture nailing were evaluated. INTERVENTION: Our systematic approach includes inserting an exchange nail at least 2 mm larger in diameter than the in situ nail, using a different manufacturer's nail, static interlocking, correction of any metabolic and endocrine abnormalities, and secondary nail dynamization in cases showing slow progression toward healing. MAIN OUTCOMES MEASUREMENTS: The outcome measures were radiographic and clinical evidence of nonunion healing and time to union. RESULTS: All 50 femoral nonunions (100%) healed after this systematic approach to exchange nailing. The average time to achieve union was 7 months (range, 3-26 months). CONCLUSIONS: Utilization of this systematic approach of exchange nailing for the treatment of aseptic femoral nonunions resulted in a 100% healing rate. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Results of a systematic approach to exchange nailing for the treatment of aseptic tibial nonunions.

OBJECTIVES: The purpose of this study was to evaluate the effectiveness of a systematic approach to exchange nailing for the treatment of aseptic tibial nonunion. DESIGN: Retrospective cohort. SETTING: Tertiary referral center. PATIENTS: Forty-six aseptic tibial nonunion sites in 40 patients (2 bilateral and 4 segmental) who presented with an intramedullary nail on an average of 16 months after the initial treatment were presented in this study. INTERVENTION: Insertion of an exchange nail of at least >2-mm diameter than the prior nail using a different manufacturer's nail, static interlocking, partial fibulectomy in a select group of patients, and correction of underlying metabolic and endocrine abnormalities. MAIN OUTCOME MEASUREMENTS: Union rate, time to union. RESULTS: Forty-five of 46 tibial nonunion sites (98%) healed at an average of 4.8 months. CONCLUSIONS: Patient selection criteria and a systematic approach to exchange nailing for tibial nonunion is highly successful. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.