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Category: Midfoot/Forefoot Introduction/Purpose: Hallux interphalangeal joint (HIPJ) arthrodesis is an effective procedure to treat pain and provide stability, which is often performed for intrinsic pain to the HIPJ. Additionally, this procedure is typically employed in concert with the Jones tenosuspension. Despite that this is an accepted technique, the available literature is scant and questions remain regarding nonunion rates and contributory factors to poor healing. A systematic review of the literature was undertaken to determine the rate of nonunion for HIPJ arthrodesis. Methods: To acquire the highest quality and most relevant studies available, publications were eligible for inclusion only if they involved patients undergoing HIPJ arthrodesis. Studies additionally required mean follow-up of at least six weeks and inclusion of appropriate detail regarding complications, nonunion rates, and patient demographics. Ultimately, 7 studies involving 313 HIPJ arthrodeses met inclusion criteria. Results: A total of 291 patients with a weighted mean age of 48.9 were included. The nonunion rate was 28.3% at a weighted mean follow-up of 8.4 months. The overall complication rate was 33.0%. Conclusion: Considering the increased rate of complications and nonunions for this commonly employed procedure, additional prospective comparative analyses are needed to identify important patient demographics and to determine superior fixation constructs.

Category: Other Introduction/Purpose: When passively correctible, adult acquired flatfoot deformities (AAFD) are often treated with joint-sparing procedures. Questions remain, however, as to the efficacy of such flexible procedures when clinical deformities become more severe. In patients with increasingly severe deformities, a primary fusion may lead to more predictable outcomes, but also risks nonunion. The primary aim of this study was to compare the reoperation rates and complication rates following flexible reconstructions versus fusion procedures in the treatment of flexible AAFD. Methods: All patients, who were diagnosed and treated surgically for a flexible AAFD between January 1, 2001 and January 1, 2016, were identified. Exclusion criteria included incomplete medical records, rigid flatfoot deformities, and prior flatfoot surgery. Procedures defined as flexible reconstructions included medial calcaneal osteotomy (MCO), lateral calcaneal lengthening (LCL), double osteotomy, posterior tibial tendon (PTT) debridement, or PTT augmentation; procedures defined as fusions included subtalar (ST) arthrodesis, talonavicular (TN) arthrodesis, calcaneocuboid (CCJ) arthrodesis (alone or in combination with a LCL), double arthrodesis, or triple arthrodesis. Patient demographics, type of surgical procedure, postoperative complications, and reoperation rates were collected. Bivariate analysis was performed to compare patients who had a flexible reconstruction procedure versus a fusion procedure. Results: Two-hundred-thirty-nine patients (255 feet, mean follow up 62±50 months, range 15-104) were included. Two-hundred-eight (87%) patients underwent a flexible reconstruction, average age 55 (±12.0), while 31 (13%) patients underwent a fusion, average age 58 (±14.4) (p = 0.161). Age, BMI, diabetes and neuropathy rates were similar for both groups. Fifty-four patients (24%) underwent a flexible reconstruction and returned to the OR versus 11 (34%) in the fusion group (p = 0.217). Nonunion occurred more in the fusion group, with 5 (16%) versus 10 (4%) nonunions in the flexible reconstruction (p = 0.027). Symptomatic nonunion rates were similar. Rates of surgical revision for nonunion among patients returning to the OR were similar between flexible (7/54, 3%) and fusion (3/11, 9%) groups (p = 0.117). Conclusion: No significant difference in reoperation rates was found between flexible AAFD patients who were treated with flexible reconstructions versus fusions. As expected, the nonunion rate was significantly higher in the fusion group. Notably, rates of revision surgery for nonunion were similar between groups. Our findings suggest that nonunion should be less of a concern when considering a flexible versus fusion procedure for patients with a severe AAFD, and that other factors such as the degree of deformity should guide decision making.

Background Although successful outcomes of platelet-rich plasma (PRP) in treating nonunion fractures have been reported, there are widespread confounding factors and biases in the studies. This study aims to assess the biological benefits of PRP-enhanced therapy while controlling for the two core factors of nonunion fractures—biomechanics and biology. Methods Retrospective analysis of medical records of patients with aseptic atrophic tibial diaphyseal fracture nonunion treated with a single locking plate in a tertiary trauma center. Patients were divided into the PRP group and the non-PRP group based on the use of PRP. The surgical procedure for the non-PRP group was a single locked plate fixation combined with autologous iliac bone grafting. For the PRP group, PRP-enhanced autologous iliac bone grafting and the creation of a bioactive chamber were added. The outcome measures included the union rate, average healing time, visual analog scale pain score, lower limb function score, and complications. Results A total of 90 patients were included, with 39 patients in the PRP group and 51 patients in the non-PRP group. The average follow-up was 16.15 ± 3.14 months in the PRP group and 15.86 ± 3.26 months in the non-PRP group. No significant differences were observed between the two groups in terms of demographic characteristics and disease parameters ( P  > 0.05). At 9 months post-revision surgery, the healing rate in the PRP group was higher than that in the non-PRP group (58.97% vs 33.33%, p  = 0.015,χ 2  = 5.885), but the final union rate did not differ significantly (92.31% vs 78.43%, p  = 0.072,χ 2  = 3.240). After excluding cases of persistent nonunion, the PRP group had a significantly shorter average healing time compared to the non-PRP group (8.88 ± 2.03 months vs 10.54 ± 2.59 months, p  = 0.002, t =  −3.103,95%CI: [ −2.74,  −0.60]) and a higher lower limb function score (67.72 ± 4.18 vs 64.55 ± 5.98, p  = 0.003, t = 2.700, 95%CI: [0.83, 5.52]). The PRP group had 4 (10.26%) complications, while the non-PRP group had 8 (15.69%) complications. Conclusion In the treatment of atrophic fracture nonunion, PRP enhanced autologous iliac bone grafting can shorten bone healing time and accelerate the healing process, thereby improving limb function more rapidly. This finding provides a superior treatment option clinically for patients in need of accelerated nonunion healing and early recovery of lower limb function.

In this article, we review controversies in assessing the risk of serious adverse effects caused by administration of nonsteroidal anti-inflammatory drugs (NSAIDs). Our focus is upon NSAIDs used in short courses for the management of acute postoperative pain. In our review of the literature, we found that the risks of short-term NSAID use may be overemphasized. Specifically, that the likelihood of renal dysfunction, bleeding, nonunion of bone, gastric complications, and finally, cardiac dysfunction do not appear to be significantly increased when NSAIDs are used appropriately after surgery. The importance of this finding is that in light of the opioid epidemic, it is crucial to be aware of alternative analgesic options that are safe for postoperative pain control.

BackgroundTibial nonunion remains a considerable burden for patients and the surgeons who treat them. In recent years, alternatives to autogenous grafts for the treatment of tibial nonunions have been sought. The purpose of this study was to evaluate the efficacy of autogenous iliac crest bone graft (ICBG) in the treatment of tibial shaft nonunions.Material and methodsSixty-nine patients were identified who underwent ICBG for repair of atrophic or oligotrophic tibial nonunion and had complete data with at least one year of follow-up (mean 27.9 months). Surgical treatments consisted of revision/supplemental fixation ± ICBG. Surgical approaches for graft placement were either posterolateral (PL), anterolateral (AL), or direct medial (DM). Healing status, time to union, postoperative pain, and functional outcomes were assessed.ResultsBony union was achieved by 97.1% (67/69) of patients at a mean time of 7.8 ± 3.2 months postoperatively. There was no significant difference in mean time to union between the three surgical approach groups: (PL (44.9%) = 7.3 months, AL (20.3%) = 9.2 months, DM (34.8%) = 7.6 months; p = 0.22). Intraoperative cultures obtained at the time of nonunion surgery were positive in 27.5% of patients (19/69). Positive cultures were associated with need for secondary surgery as 8/19 patients (42.1%) with positive cultures required re-operation. Two out of four patients that developed iliac donor site hematomas/infections requiring washout had positive intraoperative cultures as well. There was no difference in final SMFA among the three surgical approach groups.ConclusionsAutogenous ICBG remains the gold standard in the management of persistent tibial nonunions regardless of surgical approach. There is a small risk for complication at the iliac crest donor site. Given the high union rate, autogenous iliac crest bone grafting for tibial nonunion remains the gold standard for this difficult condition.Level of evidenceLevel III

UEBMI covers working and retired employees in cities (i.e., employers and employees from government agencies and institutions, state-owned enterprises, private businesses, social organizations, and other private entities), and URBMI covers citizens without employment in cities (i.e., children, students, elderly people, and unemployed residents). [...]indicators of osteoporosis such as bone density or imaging information are seldom available in the medical insurance databases. [...]consistent with previous publications on hip fracture incidence [8,9,11,16,29], in this study, hip-fracture-related indicators such as the incidence of hip fracture and associated costs in patients aged 55 years and above were used as surrogate indexes for determining the burden of osteoporosis or osteoporotic fractures. Additionally, we included specific symptoms and signs (hip pain, shorting and external rotation of the affected leg), special examination (hip X-ray), and particular treatments (open reduction and internal fixation of femoral neck fracture, open reduction and internal fixation of intertrochanteric fracture). Exclusion criteria for case identification were the following: (1) pathological fracture, (2) old hip fracture, (3) femoral shaft fracture, (4) distal femoral fracture, (5) subtrochanteric fracture, (6) complications and sequelae of hip fracture (non-union, delayed union, malunion, osteomyelitis, osteoarthritis, and anchylosis), (7) prosthesis complications, (8) osteonecrosis of the femoral head, (9) hip dislocation, and (10) removal of internal fixation devices.

Background Although intramedullary nailing has been established as the gold standard for treating femoral shaft fractures, nonunion following intramedullary nailing remains a major concern for clinicians, severely affecting patients’ walking ability and quality of life. Presently, there are certain controversies and deficiencies in nonunion classification and treatment. Herein, we propose a novel classification system for aseptic femoral shaft nonunion after intramedullary nailing based on X-ray-assessed nailing morphology and stability. Furthermore, we sought to explore the new classification’s clinical significance and management implications. Methods This retrospective study involved the analysis of clinical data collected from 82 patients with aseptic bone nonunion after intramedullary nailing of femoral shaft fractures between 2010 and 2022. The patients were classified into four groups based on intramedullary nailing stability and bone defect existence, as revealed in X-ray images. The four classifications were as follows: Type I (intramedullary nailing is stable without bone defect), Type II (intramedullary nailing is stable with bone defect), Type III (intramedullary nailing is not stable without bone defect), and Type IV (intramedullary nailing is not stable with bone defect). Based on the novel classifications, we introduced individualized treatment methods. Type I patients underwent dynamization, and Type II patients received bone grafting and plate fixation. Type III patients underwent larger intramedullary nail exchange or plate fixation, and Type IV patients received larger intramedullary nail exchange and plate fixation with bone graft or double plate fixation with bone graft. Data on relevant indicators were collected. Results All patients recovered well with no complications. The average surgery times for Types I-IV were 0.4 ± 0.1, 0.8 ± 0.2, 1.1 ± 0.4, and 1.6 ± 0.4 h, respectively. Furthermore, the mean blood loss volumes for Types I-IV were 23.4 ± 4.8, 53.3 ± 8.4, 56.3 ± 7.9, and 125.2 ± 10.8 ml, respectively. The average bone healing time of all 82 patients was 5.1 ± 1.5 months. On the other hand, the mean bone healing times for Types I-IV were 4.6 ± 1.1, 4.7 ± 1.1, 5.1 ± 1.5, and 5.7 ± 1.8 months, respectively. Furthermore, the LEFS scores for Types I-IV were 68.7 ± 3.5, 69.8 ± 3.1, 66.8 ± 3.8, and 68.6 ± 2.9 points, respectively. The mean surgery time and bleeding volume increased gradually from Types I to IV ( p  < 0.05) but with no significant difference between Types II and III. Moreover, there were no statistical differences in fracture healing times, LEFS scores, age, and nonunion durations across the four classifications. Conclusions The proposed novel classification system could achieve accurate diagnosis and guidance for clinical management of aseptic femoral shaft nonunion after intramedullary nailing. The corresponding individualized treatment approaches could improve prognostic outcomes and healing rates and alleviate postoperative complications. Clinical trial number Not applicable.

BackgroundSeptic and aseptic nonunion require different therapeutic strategies. However, differential diagnosis is challenging, as low-grade infections and biofilm-bound bacteria often remain undetected. Therefore, the examination of biofilm on implants by sonication and the evaluation of its value for differentiating between femoral or tibial shaft septic and aseptic nonunion in comparison to tissue culture and histopathology was the focus of this study.Materials and methodsOsteosynthesis material for sonication and tissue samples for long-term culture and histopathologic examination from 53 patients with aseptic nonunion, 42 with septic nonunion and 32 with regular healed fractures were obtained during surgery. Sonication fluid was concentrated by membrane filtration and colony-forming units (CFU) were quantified after aerobic and anaerobic incubation. CFU cut-off values for differentiating between septic and aseptic nonunion or regular healers were determined by receiver operating characteristic analysis. The performances of the different diagnostic methods were calculated using cross-tabulation.ResultsThe cut-off value for differentiating between septic and aseptic nonunion was ≥ 13.6 CFU/10 ml sonication fluid. With a sensitivity of 52% and a specificity of 93%, the diagnostic performance of membrane filtration was lower than that of tissue culture (69%, 96%) but higher than that of histopathology (14%, 87%). Considering two criteria for infection diagnosis, the sensitivity was similar for one tissue culture with the same pathogen in broth-cultured sonication fluid and two positive tissue cultures (55%). The combination of tissue culture and membrane-filtrated sonication fluid had a sensitivity of 50%, which increased up to 62% when using a lower CFU cut-off determined from regular healers. Furthermore, membrane filtration demonstrated a significantly higher polymicrobial detection rate compared to tissue culture and sonication fluid broth culture.ConclusionsOur findings support a multimodal approach for the differential diagnosis of nonunion, with sonication demonstrating substantial usefulness.Level of Evidence: Level 2Trial registration DRKS00014657 (date of registration: 2018/04/26)

PurposeAn osteoporotic vertebral fracture (OVF) is a common disease that causes disabilities in elderly patients. In particular, patients with nonunion following an OVF often experience severe back pain and require surgical intervention. However, nonunion diagnosis generally takes more than six months. Although several studies have advocated the use of magnetic resonance imaging (MRI) observations as predictive factors, they exhibit insufficient accuracy. The purpose of this study was to create a predictive model for OVF nonunion using machine learning (ML).MethodsWe used datasets from two prospective cohort studies for OVF nonunion prediction based on conservative treatment. Among 573 patients with acute OVFs exceeding 65 years in age enrolled in this study, 505 were analyzed. The demographic data, fracture type, and MRI observations of both studies were analyzed using ML. The ML architecture utilized in this study included a logistic regression model, decision tree, extreme gradient boosting (XGBoost), and random forest (RF). The datasets were processed using Python.ResultsThe two ML algorithms, XGBoost and RF, exhibited higher area under the receiver operating characteristic curves (AUCs) than the logistic regression and decision tree models (AUC = 0.860 and 0.845 for RF and XGBoost, respectively). The present study found that MRI findings, anterior height ratio, kyphotic angle, BMI, VAS, age, posterior wall injury, fracture level, and smoking habit ranked as important features in the ML algorithms.ConclusionML-based algorithms might be more effective than conventional methods for nonunion prediction following OVFs.