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Objectives: To determine (1) the rate of positive cultures in presumed aseptic nonunions, (2) the rate and microbial spectrum of positive cultures that represented occult infection, and (3) rates of nonunion healing., Design: Retrospective cohort study., Setting: Tertiary referral center., Patients Selection Criteria: Adult patients with a presumed aseptic nonunion treated with single-stage revision between 2002 and 2022., Outcome Measures and Comparisons: The rate of positive cultures compared for 2 protocols: old: 1-2 samples cultured 7 days versus new: 5 samples cultured 14 days. The rate of positive cultures meeting occult infection criteria with the new protocol (≥2 samples with phenotypically indistinguishable microorganisms, or ≥1 sample with a high virulent microorganism). Nonunion healing rates between protocols and between groups based on culture results with the new protocol., Results: One hundred seventy-nine patients were included. The rate of positive cultures was 14% (n = 15/105) with the old protocol and 51% (n = 38/74) with the new protocol (P < 0.001). With the new protocol, the rate of positive cultures meeting occult infection criteria was 19% (n = 14/74), and coagulase-negative staphylococci (48%) and Cutibacterium acnes (38%) were the most common microorganisms. Nonunion healing rates after the primary revision did not differ between protocols (old: 82% vs. new: 86%, P = 0.41) and groups based on culture result (sterile: 86% vs. occultly infected: 93%, P = 0.66). The final overall nonunion healing rate was 97%., Conclusions: Occult infections were identified in 1 in 5 presumed aseptic nonunions using a standardized protocol with 5 intraoperative samples cultured 14 days and were predominantly caused by slow growing, gram-positive microorganisms. The local spectrum and antimicrobial sensitivity of occult infections should be considered when developing empiric antimicrobial protocols. Patients with presumed aseptic nonunions can expect high healing rates, regardless of the culture result., Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Peter Kloen serves as Section Editor for the Journal of Orthopaedic Trauma. The remaining authors report no conflicts of interest., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objectives: To assess trends in Patient-Reported Outcome Measurement Information Systems (PROMIS) Physical Function (PF) and Pain Interference (PI) in surgically treated tibial shaft fracture patients progressing to union versus nonunion., Design: Retrospective cohort study., Setting: Level 1 trauma center., Patient Selection Criteria: Patients with operatively treated tibial shaft fractures (AO/OTA 42-A, B, C) using an intramedullary nail., Outcome Measures and Comparisons: PROMIS PF and PI were compared between patients progressing to union and patients requiring nonunion repair., Results: A total of 234 patients (196 union, 38 nonunion) were included consisting 144 men and 90 women. The mean age of included patients was 40.8 years. A significant difference in mean PROMIS PF between union and nonunion patients was observed at 1-3 months ( P = 0.005), 3-6 months ( P < 0.001), 6-9 months ( P = 0.003), and 6-12 months ( P = 0.018). The odds of developing nonunion for every unit decrease in PROMIS PF was significant at 3-6 months (OR 1.07, P = 0.028) and 6-9 months (OR 1.17, P = 0.015). A significant difference in mean PROMIS PI between union and nonunion patients was observed at 1-3 months ( P = 0.001), 3-6 months ( P = 0.005), and 6-9 months ( P = 0.005). The odds of developing nonunion for every unit increase in PROMIS PI was significant at 1-3 months (OR 1.11, P = 0.005), 3-6 months (OR 1.10, P = 0.011), and 6-9 months (OR 1.23, P = 0.011)., Conclusions: Poorly trending PROMIS PF and PI in the clinical setting is a factor that can be used to evaluate progression to nonunion following tibial shaft repair where imaging studies may lag behind., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: J. Haller, MD is a paid consultant for Stryker, Globus, Orthogrid, Osteocentric, and NewClip Technics. T. Higgins, MD is a consultant and collects royalties for Depuy-Synthes and owns stock in Imagen, Osteocentric, and NT nPhase. The remaining authors have no funding or conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To describe outcomes following humerus aseptic nonunion surgery in patients whose initial fracture was treated operatively and to identify risk factors for nonunion surgery failure in the same population., Design: Retrospective case series., Setting: Eight, academic, level 1 trauma centers., Patients Selection Criteria: Patients with aseptic humerus nonunion (OTA/AO 11 and 12) after the initial operative management between 1998 and 2019., Outcome Measures and Comparisons: Success rate of nonunion surgery., Results: Ninety patients were included (56% female; median age 50 years; mean follow-up 21.2 months). Of 90 aseptic humerus nonunions, 71 (78.9%) united following nonunion surgery. Thirty patients (33.3%) experienced 1 or more postoperative complications, including infection, failure of fixation, and readmission. Multivariate analysis found that not performing revision internal fixation during nonunion surgery (n = 8; P = 0.002) and postoperative de novo infection (n = 9; P = 0.005) were associated with an increased risk of recalcitrant nonunion. Patient smoking status and the use of bone graft were not associated with differences in the nonunion repair success rate., Conclusions: This series of previously operated aseptic humerus nonunions found that more than 1 in 5 patients failed nonunion repair. De novo postoperative infection and failure to perform revision internal fixation during nonunion surgery were associated with recalcitrant nonunion. Smoking and use of bone graft did not influence the success rate of nonunion surgery. These findings can be used to give patients a realistic expectation of results and complications following humerus nonunion surgery., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Dr. J.R. Hsu reports consultancy for Globus Medical and personal fees from Smith & Nephew speakers' bureau. The remaining authors report no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To apply the recently developed fracture-related infection criteria to patients presenting for repair of fracture nonunion and determine the incidence and associated organisms of occult infection in these patients., Design: Retrospective study., Setting: Tertiary referral trauma center., Patients and Participants: Patients presenting with fracture nonunion after operative intervention., Main Outcome Measurements: Demographic variables, injury characteristics, culture results, and physical examination and laboratory values at the time of presentation., Results: A total of 270 nonunion patients were identified. Sixty-eight percent (n = 184) had no clinical or laboratory signs of infection at presentation before nonunion repair. After operative intervention, 7% of these clinically negative patients (n = 12/184) had positive intraoperative cultures indicating occult infection. The most common organisms causing occult infection were low-virulence coagulase-negative Staphylococcu s (83%) and Cutibacterium acnes (17%). Thirty-two percent of patients (n = 86/270) presented with clinical and/or laboratory signs of infection at presentation before nonunion repair, with 19% of these patients (n = 16/86) having negative cultures. The most common organisms in this group of patients with positive clinical signs and intraoperative cultures were methicillin-resistant Staphylococcus Aureus (21%) and gram-negative rods (29%). Patients with nonunion of the tibia were significantly more likely to have high-virulence organism culture results ( P < 0.001)., Conclusions: Based on this analysis, occult infection occurs in 7% of patients presenting with nonunion and no clinical or laboratory signs of infection. We recommend that all patients should be carefully evaluated for infection with intraoperative cultures regardless of presentation. Organisms associated with occult infection at the time of nonunion repair were almost exclusively of low virulence ( CoNS and C. Acnes ) and were more likely to present in the upper extremity. Patients with nonunion of the tibia were more likely to have infection secondary to high-virulence organisms and demonstrate clinical or laboratory signs of infection at the time of presentation., Level of Evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To evaluate outcomes using an interlocking antibiotic cement-coated nail and culture-specific systematic antibiotics in the treatment of infected nonunion after intramedullary nailing., Design: Retrospective observational cohort study., Setting: Urban level I trauma center., Patients/participants: Forty-one nonconsecutive patients who presented to a level I trauma center who underwent interlocked antibiotic nailing for treatment of infected nonunion status after primary intramedullary nailing., Outcomes: Eradication of infection, radiographic union by 2-year follow-up., Results: Antibiotic nailing successfully eradicated infection and led to fracture healing in 35 patients (85.4%), while 6 patients (14.6%) had persistent infection and required further surgical treatment. Of the 6 patients who required further treatment, 5 eventually went on to heal with fracture union and eradication of their infection, while 1 required a salvage procedure. Of the 5 patients who eventually went on to heal, 4 of them healed with repeat antibiotic or intramedullary nails, while 1 required segmental resection and bone grafting before healing., Conclusions: This study suggests that the proposed interlocked antibiotic nailing technique is a viable therapeutic option to eradicate infected nonunion and support fracture healing., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Assessing external validity and clinical relevance of modified radiographic union score (mRUS) to predict delayed union in closed humeral shaft fractures initially treated with conservative management., Design: Retrospective cohort., Setting: Single urban academic level 1 trauma center., Patients: Patients undergoing initial nonoperative treatment of a humeral shaft fracture with a minimum of 3 months follow-up and at least one set of follow-up orthogonal x-rays within 12-weeks of injury., Main Outcome Measurements: Interobserver and intraobserver reliability of the (mRUS) system for humeral shaft fractures, and establishing an mRUS threshold at 6 and 12 weeks postinjury to predict surgery for delayed union., Results: mRUS demonstrated substantial interobserver agreement on all assessments. Intraobserver agreement was nearly perfect for all reviewers on repeat assessment. mRUS of ≤7 at 6 ± 1 weeks follow-up was associated with surgery for delayed union with an odds ratio of 4.88 (95% CI, 2.52-9.44, P < 0.01), sensitivity of 0.286, and specificity of 0.924. At 12 ± 1 weeks follow-up, the same threshold demonstrated a stronger association with an odds ratio of 14.7 (95% CI, 4.9-44.1, P < 0.01), sensitivity of 0.225, and specificity of 0.981., Conclusions: The mRUS for humeral shaft fractures is reliable and reproducible providing an objective way to track subtle changes in radiographs over time. An mRUS of ≤7 at 6 or 12 weeks postinjury is highly specific for delayed union. This can be helpful when counseling patients about the risk of nonunion and potential early surgical intervention., Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: (1) Evaluate whether initial results from percutaneous treatment of nonunion are reproducible (2) Estimate the relative cost of percutaneous treatment of nonunion versus traditional methods., Design: Retrospective multicentre case series., Setting: Four Level 1 trauma centers., Patients/participants: Fifty-one patients (34 men and 17 women) with a median age of 51 years (range 14-81) were treated for nonunion at a median of 10 months (range 4-212) from injury., Intervention: Percutaneous strain reduction screws (PSRS)., Main Outcome Measured: Union rates and time to union were compared for patients treated in the developing institution versus independent units as well as with previously published results., Results: Forty-five (88%) patients achieved union at a median time of 5.2 months (range 1.0-24.7) confirming the previously published results for this technique. Comparable results were seen between the developing institution and independent units. No patients experienced adverse events beyond failure to achieve union. PSRS seems to offer savings of between £3177 ($4416) to £11,352 ($15,780) per case compared with traditional methods of nonunion surgery., Conclusions: PSRS is a safe, efficacious treatment for long bone nonunion and may be more cost-effective than traditional nonunion treatment methods. The promising initial results of this technique have now been replicated outside of the developing institution., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Summary: We present the surgical technique for arthrodesis of the subtalar and calcaneocuboid joints of a Sanders type IV calcaneal fracture nonunion via a distraction bone block arthrodesis technique with tricortical iliac crest allograft combined with reamer/irrigator/aspirator autograft from the patient's femur. A lateral extensile approach to the calcaneus was used for the exposure, which allowed the surgeon to follow the stepwise complex surgical plan outlined here. Calcaneal nonunions are difficult to treat, but good outcomes can be achieved if proper technique with bone grafting is used., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To assess the outcomes of patients after rib nonunion reconstruction., Design: Retrospective case series., Setting: Level 1 trauma center., Patients/participants: Between January 2007 and August 2019, 25 consecutive patients with 51 nonunions with disabling pain or chronic instability were treated for nonunited rib fractures., Intervention: Rib nonunion reconstructions performed using plate and screw fixation, recannalizing the medullary canal and augmented with autogenous iliac crest bone graft., Main Outcome Measurements: Patient demographics, mechanism of injury, number of rib nonunions, and postoperative radiographs were assessed. Satisfaction, patient-reported complications, return to occupation and activity, and general health measures were captured using patient questionnaires., Results: In 25 patients, 51 painful rib nonunions were surgically treated. The average length from injury to surgical rib reconstruction was 25.1 months (range = 3-118 months; median = 12 months). Follow-up was obtained in 18 of 25 patients (72%) with a mean of 46.1 months (range = 13-139 months). All ribs achieved radiographic union at an average of 12.3 weeks (range = 8-24 weeks) after surgery. Sixteen of 18 patients (89%) reported satisfaction with surgery and 15 patients (83%) reported mild to no pain at final follow-up. Five patients had complications that all resolved after subsequent treatment., Conclusions: Successful treatment of symptomatic rib nonunion is possible using rib plates in conjunction with bone grafting and has high union rates, satisfactory results, and limited complications., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest. P. A. Cole is currently receiving institutional grant support from Stryker Inc., Depuy-Synthes, AOTrauma, AONA, COTA, OMeGA, honoraria from AOTrauma, and is a stockowner in Bonefoams, Inc. Funding sources did not play a role in this investigation. The remaining authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Fracture nonunion remains a devastating complication and may occur for several reasons, though the microbial contribution remains poorly estimated. Next-generation sequencing (NGS) techniques, including 16S rRNA gene profiling, are capable of rapid bacterial detection within clinical specimens. Nonunion cases may harbor microbes that escape detection by conventional culture methods that contribute to persistence. Our aim was to investigate the application of NGS pathogen detection to nonunion diagnosis., Methods: In this prospective multicenter study, samples were collected from 54 patients undergoing open surgical intervention for preexisting long-bone nonunion (n = 37) and control patients undergoing fixation of an acute fracture (n = 17). Intraoperative specimens were sent for dual culture and 16S rRNA gene-based microbial profiling. Patients were followed for evidence of fracture healing, whereas patients not healed at follow-up were considered persistent nonunion. Comparative analyses aimed to determine whether microbial NGS diagnostics could discriminate between nounions that healed during follow-up versus persistent nonunion., Results: Positive NGS detection was significantly correlated with persistent nonunion, positive in 77% more cases than traditional culture. Nonunion cases were observed to have significantly increased diversity and altered bacterial profiles from control cases., Discussion: NGS seems to be a useful adjunct in identification of organisms that may contribute to nonunion. Our findings suggest that the fracture-associated microbiome may be a significant risk factor for persistent nonunion. Ongoing work aims to determine the clinical implications of isolated organisms detected by sequencing and to identify robust microbial predictors of nonunion outcomes., Level of Evidence: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: J. Parvizi and C. Tipton are consultants for MicroGenDx. J. D. Conway is a consultant for Bonesupport, Orthofix, Smith + Nephew, and Zimmer Biomet; receives fellowship support from Biocomposites; is on the MicroGenDX advisory board; and her spouse receives royalties from the University of Florida. The following organizations supported the institution of J. D. Conway: Biocomposites, DePuy Synthes Companies, MHE Coalition, Orthofix, OrthoPediatrics, Pega Medical, Smith + Nephew, Stryker, and Zimmer Biomet. The remaining authors report no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To identify factors associated with the need for reoperations in patients treated surgically for fracture nonunion., Design: Retrospective cohort study., Setting: One urban Level 1 trauma center and an orthopaedic specialty hospital., Patients/participants: This study included 365 patients who did not and 95 patients who did undergo a reoperation after nonunion repair., Intervention: All patients who underwent fracture nonunion repair were identified. Baseline demographic, injury, and surgical information were collected. These factors were compared between patients who did and did not require an unplanned reoperation., Main Outcome Measurements: An unplanned reoperation after index fracture nonunion surgery., Results: When compared with patients who did not undergo a reoperation after their index fracture nonunion surgery, patients who underwent at least 1 reoperation had a greater proportion of those who sustained an open fracture, a high-energy injury, initial neurologic or vascular injuries, the need for a flap or soft tissue graft at initial treatment, and lower extremity injuries with univariate analysis. Unplanned reoperation was also associated with diagnosis of "infected" nonunion at initial nonunion surgery. Multivariate analysis confirmed initial nerve or vascular injuries and positive infection status were statistically significant predictors of a reoperation., Conclusions: Initial injury characteristics such as nerve or vascular injury at initial injury and positive infection status at the index nonunion surgery were associated with the need for a secondary surgery after nonunion repair. Appropriate care of these patients should be aimed at adjusting expectations of unplanned reoperation in the future and potentially enhanced treatment strategies., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: The goals of the study were (1) to document the healing rates of femoral nonunions stratified by those that healed as intended, healed after a subsequent intervention, and those that did not heal; (2) to report the prevalence of recalcitrant femoral nonunions and (3) to identify specific demographic, injury, and treatment-related risk factors for the development of a recalcitrant nonunion., Design: Longitudinal observational cohort study., Setting: Academic Level 1 trauma center., Patients/participants: One hundred twenty-two femoral nonunions treated with either a plate or intramedullary nail by a single surgeon between 1991 and 2018., Intervention: Bivariate and multivariate regression analysis were performed to identify specific demographic, injury, and treatment factors in patients who developed a recalcitrant nonunion., Results: Although 83.6% of the femoral nonunions eventually healed, only 66% "healed as intended" with 17.2% requiring 1 or more additional procedures to consolidate and 16.4% of nonunions failing to unite. There were no statistically significant differences in the recalcitrance rate when we compared treatment with conventional versus locked plates or primary versus exchange nailing. Risk factors for developing a recalcitrant nonunion were deep infection, current smokers, metabolic bone disease, and patients who had undergone 3 or more prior surgical procedures., Conclusions: The use of both intramedullary nails and modern plates were associated with a high rate of recalcitrance. Infection, current smokers, metabolic bone disease, and 3 or more prior surgical procedures were predictors for the development of a recalcitrant nonunion., Level of Evidence: Therapeutic Leve IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To compare and stratify the healing rates after our index nonunion surgery using contemporary methods of fixation, report the prevalence of recalcitrant non-union, and identify specific demographic, injury, and treatment-related risk factors for the development of a recalcitrant nonunion., Design: Retrospective analysis of a prospectively collected database., Setting: Academic Level 1 Trauma Center., Patients/participants: Two hundred twenty-two tibial nonunions treated with internal fixation by a single surgeon., Intervention: Bivariate and multivariate regression analysis were performed to compare healing rates by the type of fixation and graft augmentation and to identify specific demographic, injury, and treatment-related risk factors for the development of a recalcitrant nonunion., Results: Of the 222 patients, 162 (73%) healed as intended and 51 (23%) required 1 or more subsequent interventions to achieve union (96%). Nine fractures (4%) failed to unite. The 60 fractures (27%) that required a subsequent intervention(s) or failed to consolidate were defined as recalcitrant nonunions. There were no statistically significant differences in the recalcitrant rate when we compared plates versus nails or types of bone graft. Risk factors for developing a recalcitrant nonunion were multifactorial and included grade III open fractures, compartment syndrome, deep infection, and 2 or more prior surgical procedures., Conclusions: Internal fixation remains a successful method of treatment for most tibial nonunions. However, 27% of patients required a subsequent intervention because of failure to heal our index nonunion procedure. Factors that are associated with recalcitrant nonunions were a grade III open fracture, compartment syndrome, deep infection, and 2 or more or more prior surgical procedures., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Summary: A 58-year-old woman with a proximal 1/3 humeral shaft nonunion presented 2 years after initial injury. We present a technique for nonunion repair, including nonunion site preparation, direct compression of the fracture site using plate osteosynthesis, and iliac crest bone graft harvest and utilization. The purpose of this video is to review humeral shaft nonunion literature and describe our management technique., Competing Interests: K. A. Egol: Acumed, LLC: research support; Exactech, Inc: IP royalties; paid consultant; Orthopaedic Trauma Association: board or committee member; Polypid: unpaid consultant; SLACK Incorporated: publishing royalties and financial or material support; Smith & Nephew: paid presenter or peak; Synthes: research Support; Wolters Kluwer Health—Lippincott Williams & Wilkins: publishing royalties and financial or material support. The remaining authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To document union rate, complications and patient-reported outcomes after open reduction and internal fixation (ORIF), with and without bone grafting (BG), for humeral diaphyseal nonunion after failed nonoperative management., Design: Retrospective., Setting: University teaching hospital., Patients and Intervention: From 2008 to 2017, 86 consecutive patients [mean age 59 years (range 17-86), 71% (n = 61/86) women] underwent nonunion ORIF (plate and screws) at a mean of 7 months postinjury (range 3-21.5). Eleven (13%) underwent supplementary BG., Main Outcome Measurements: Union rate and complications for 83 patients (97%) at a mean of 10 months (3-61). Patient-reported outcomes (QuickDASH, EQ-5D, EQ-VAS, SF-12, satisfaction) for 53 living, cognitively-intact patients (78%) at a mean of 4.9 years (0.3-9.2)., Results: Ninety-three percent (n = 77/83) achieved union after nonunion ORIF. Complications included recalcitrant nonunion (7%, n = 6/83), iatrogenic radial nerve palsy (6%, n = 5/83), infection (superficial 7%, n = 6/83; deep 2%, n = 2/83), and iliac crest donor site morbidity (38%, n = 3/8). The union rate with BG was 78% (n = 7/9) and without was 95% (n = 70/74; P = 0.125), and was not associated with the nonunion type (atrophic 91%, n = 53/58; hypertrophic 96%, n = 24/25; P = 0.663). Median QuickDASH was 22.7 (0-95), EQ-5D 0.710 (-0.181-1), EQ-visual analog scale 80 (10-100), SF-12 physical component summary 41.9 (16-60.5), and mental component summary 52.6 (18.7-67.7). Nineteen percent (n = 10/53) were dissatisfied with their outcome., Conclusions: ORIF for humeral diaphyseal nonunion was associated with a high rate of union. Routine BG was not required and avoided the risk of donor site morbidity. One in 5 patients were dissatisfied despite the majority achieving union., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To determine the factors associated with successful union and eradication of infection in the setting of staged procedures to treat obviously infected nonunions of long bones. We hypothesize that patients with positive intraoperative cultures obtained at the time of definitive surgery for infected nonunions are more likely to have persistent nonunion than those with negative cultures., Design: Multicenter retrospective review., Setting: Eight academic Level 1 trauma centers., Patients/participants: Patients who underwent staged management for obviously infected nonunion of a long bone., Main Outcome Measurements: For each patient, initial fracture management, management of retained implants, number of debridements, grafting, bacteriology, antibiotic course, bone defect management, soft-tissue coverage, and definitive surgery performed were reviewed., Results: A total of 134 patients were treated with staged procedures for obviously infected nonunion of a long bone (mean age 49 years, 60% open fractures, and mean follow-up 22 months). During definitive procedures, 120 patients had intraoperative cultures taken with 43% having positive cultures. For culture-positive patients, 41 patients achieved eventual union and 10 had persistent nonunion. Of 69 culture-negative patients, 66 achieved eventual union and 3 had persistent nonunion. The number of patients with union versus persistent nonunion was statistically significant between culture-positive and culture-negative groups (P = 0.015)., Conclusions: Management of infected nonunion in long bones with staged treatments before definitive fixation are beneficial but ultimately less effective when performed in the setting of positive bacterial cultures at the time of definitive management., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To develop a tool that can be used preoperatively to identify patients at risk of poor functional outcome following operative repair of fracture nonunion., Design: Retrospective analysis of prospectively collected data., Setting: Academic medical center., Patients/participants: Three hundred twenty-eight patients who underwent operative repair of a fracture nonunion were prospectively followed for a minimum of 12 months post-operatively., Intervention: After randomization, 223 (68%) patients comprised an experimental cohort and 105 (32%) patients comprised a separate validation cohort. Within the experimental cohort, forward stepwise multivariate logistic regression was applied to 17 independent variables to generate a predictive model identifying patients at risk of having a poor functional outcome [Predicting Risk of Function in Trauma-Nonunion (PRoFiT-NU) Score]., Main Outcome Measurements: Functional outcomes were assessed using the Short Musculoskeletal Function Assessment (SMFA). Poor outcome was defined as an SMFA function index greater than 10 points above the mean at 12 months post-operatively., Results: Significant predictors of poor outcome were lower extremity nonunion [odds ratio (OR) = 3.082; P = 0.021], tobacco use (OR = 2.994; P = 0.009), worker's compensation insurance (OR = 3.986; P = 0.005), radiographic bone loss (OR = 2.397; P = 0.040), and preoperative SMFA function index (OR = 1.027; P = 0.001). The PRoFiT-NU model was significant and a good predictor of poor functional outcome (χ(5) = 51.98, P < 0.0005; area under the receiver operating curve = 0.79). Within the separate validation cohort, 16% of patients had a poor outcome at a PRoFiT-NU score below 25% (low risk), 39% of patients had a poor outcome at a PRoFiT-NU score between 25% and 50% (intermediate risk), and 63% of patients had a poor outcome at a PRoFiT-NU score above 50% (high risk)., Conclusions: The PRoFiT-NU score is an accurate predictor of poor functional outcome following fracture nonunion repair., Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence description of levels of evidence.

Patients presenting with femoral fractures and long-term use of bisphosphonate treatment are at risk of developing a delayed union and/or nonunion as a result of the atypical metabolic activity prevailing at the fracture edges of the affected extremity. The treatment of these nonunions poses a serious challenge to orthopaedic surgeons worldwide and necessitates specialized techniques and materials to design a construct that will last a long period (greater than 6 months), while still allowing weight-bearing in this elderly population. Treatment options, timing of intervention, selection of implant, and the option of bone grafting are discussed to assist the clinician to make the right decisions in these complex clinical cases.

Objective: To determine whether intramedullary nail (IMN) diameter, antegrade versus retrograde insertion, or the difference between the canal and IMN diameter affect femoral shaft fracture healing., Design: Retrospective analysis of a prospective database., Setting: Level One Regional Trauma Center., Patients/participants: Seven hundred thirty-three femoral shaft fractures (OTA/AO 32) treated with an IMN between 1999 and 2017. After exclusion criteria, 484 fractures remained in the final analysis., Intervention: Closed section, cannulated, interlocked, titanium alloy IMN using a reamed insertion technique., Main Outcome Measurements: Nonunion, IMN size (10, 11.5, and 13 mm), antegrade versus retrograde insertion, Δ canal-nail diameter (ΔD) after reaming (<1, 1-2, or >2 mm)., Results: IMN diameters used were as follows: 314/10 mm (64%), 137/11.5 mm (28%), and 33/13 mm (8%). Forty-five percent were placed in antegrade versus 55% retrograde. Four hundred fifty-six fractures (94.2%) healed uneventfully. There were no IMN failures. 10/484 IMNs (2%) had broken interlocking screws; only 4 were associated with a NU. Average time to union was 23 weeks (12-119). Twenty-eight (5.8%) developed NU. There was no statistical correlation between (1) the NU rate and IMN diameter: 10 mm, 6.3%; 11.5 mm, 5.1%; 13 mm, 3% (P = 0.8, power = 0.85), (2) the NU rate and ΔD: 7.1% <1 mm, 5.6% 1-2 mm, 20% >2 mm (P = 0.36), (3) the NU rate and fracture location: Prox = 11%, Mid = 5%, Dist = 3% (P = 0.13), or (4) the NU rate and antegrade (7.2%) versus retrograde (4.2%) insertion (P = 0.24)., Conclusion: Similar healing rates occurred regardless of IMN diameter, Δ canal-nail diameter after reaming, or insertion site. This indicates that a closed section, cannulated, interlocked, titanium alloy IMN with a diameter of 10 mm can be considered the standard diameter for the treatment of acute femoral shaft fractures, regardless of entry point. This should be associated with less reaming and therefore shorter operative times, and possibly less hospital implant inventories as well. Larger diameter IMN should be reserved for revision surgery., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objective: To compare 2 distraction osteogenesis techniques in post-traumatic tibial nonunion patients with composite bone and soft-tissue defects., Design: Nonrandomized prospective, case series, single-center study., Setting: Department of Orthopaedics and Traumatology, Limb Reconstruction Unit, El-Helal hospital, Cairo, Egypt., Participants: Fifty post-traumatic tibial nonunion patients with composite bone and soft-tissue defects., Intervention: Twenty-five patients were treated using bone transport (BT) technique, and 25 patients were treated using acute shortening (AS) and distraction technique., Outcome Measurements: The external fixation index (EFI); functional and bone results; and complication rates., Results: All patients were followed for a minimum of 18 months after removal of their Ilizarov frame. AS and BT groups were followed up for a mean of 19.7 and 20.3 months, respectively. The mean bone gap after resection and debridement was 4 cm in AS group and 5.9 cm in BT group (P = 0.06). The mean EFI was statistically significant and lower in the AS group compared with BT group (P = 0.03). There were no other statistically significant differences between either intervention groups., Conclusions: Both techniques achieved comparable good to excellent results, and the differences in number of complications and ASAMI scores for bone or function were not statistically significant. Yet, it appears that the AS technique may be superior because it has a significantly lower EFI. This may not be feasible in all cases, however, because the AS technique is limited by the defect size and the condition of the surrounding soft tissues., Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Femoral neck nonunions in young adults is among the most challenging problems to treat. This is due to their inherent problems, such as neck resorption, increase in fracture gap, sclerosis of fracture margins, and avascular necrosis. Hip salvage in these cases, although challenging, is recommended in the Asian subcontinent where social and religious activities require squatting and sitting cross-legged. Muscle pedicle grafts and other vascularized bone grafting techniques are preferred treatment options, but they are technically demanding and require advanced microsurgical skills. Valgus osteotomy, although successful in certain cases, has a high failure rate in patients with poor bone stock. We present a simple technique of valgus subtrochanteric osteotomy, impaction bone grafting, and stabilization with a sliding hip screw. Here, we describe in detail about the surgical technique and present the clinical outcomes in 44 patients, with a mean follow-up of 3.4 years and a union rate of 95.5%.

Introduction: Periprosthetic fracture nonunions represent a rare problem in orthopaedic practice, although their incidence has increased with the increased frequency of joint replacement surgery. This video demonstrates the use of a linked nail-plate construct to repair a distal femoral periprosthetic fracture nonunion., Methods: The patient is a 93-year-old woman who is 1-year status-post a left distal femoral periprosthetic fracture with known delayed healing. She presents with a low energy trauma and hardware failure. The patient was indicated for operative fixation using a linked nail-plate construct given the patient's previous hardware failure, advanced age, and poor bone quality., Results: This video demonstrates the linked nail-plate technique for the repair of a distal femoral periprosthetic fracture nonunion. Anatomical reduction and stable fixation with bone graft was performed with excellent results. There were no intraoperative or postoperative complications and no issues related to metallurgy., Conclusions: In this video, we present the case of an atrophic distal femoral periprosthetic nonunion treated with a linked nail-plate construct with autologous bone graft. Although femoral periprosthetic fracture nonunions are a rare occurrence, they can be successfully treated with operative intervention aimed at compression plating with supplemental bone grafting.

Objectives: To evaluate the clinical and functional outcomes after operative repair of nonunited lower extremity fractures initially repaired outside the developed Western world., Design: Retrospective analysis of prospectively collected data., Setting: Academic medical center., Patients/participants: From September 2004 through February 2017, 227 patients who underwent operative repair of a lower extremity fracture nonunion were prospectively enrolled in a research registry. All patients underwent previous fracture surgery and had at least 12 months of postoperative follow-up., Intervention: Repair of lower extremity fracture nonunion., Main Outcome Measurements: Postoperative complications, reoperation rate, time to union, and functional outcomes were assessed using the Short Musculoskeletal Function Assessment and Visual Analog Scale pain scores. Univariate and multivariate analyses were performed to evaluate the differences in patients who underwent initial fracture repair outside the developed Western world as opposed to within the United States., Results: Twenty-one patients (9.3%) underwent initial fracture repair outside the developed Western world. These patients had a greater incidence of infected nonunions (47.6% vs. 23.3%; P = 0.015) and failure of a previous implant at the time of presentation (52.4% vs. 22.8%; P = 0.003) than those initially managed within the United States. This cohort also experienced a greater rate of postoperative complications after nonunion repair (23.8% vs. 6.3%; P = 0.016). The geographic location of initial fracture repair was not associated with postoperative Short Musculoskeletal Function Assessment scores or Visual Analog Scale pain scores after controlling for possible confounding variables., Conclusions: Patients who present with a nonunited lower extremity fracture initially repaired outside the developed Western world experience a high rate of postoperative complications after fracture nonunion repair but can expect good short- and long-term functional outcomes., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Valgus intertrochanteric osteotomy is an effective method of treating femoral neck nonunion by reducing shear forces at the fracture and correcting the neck-shaft angle. Good outcomes have been reported in the literature. Through careful preoperative planning and a precise operative technique, reliable healing of both the osteotomy and nonunion can be achieved.

This article describes percutaneous strain reduction screws, a technical trick, to provide effective stability in a simple manner and at low cost. Percutaneous strain reduction screws are an option when a surgeon has decided that further intervention is indicated for a fracture that has not united.

In physiologically young patients with displaced femoral neck fractures, surgical treatment is aimed at achieving fracture union while preserving native hip anatomy and biomechanics. The intracapsular environment, tenuous vascular supply, and unfavorable hip biomechanics contribute to the high complication rates seen after osteosynthesis of these fractures. Conventional fixation methods for osteosynthesis of femoral neck fractures include multiple cancellous screws, fixed-angle dynamic implants, and fixed-angle length-stable constructs. Despite several biomechanical and clinical studies evaluating various surgical options, the optimal fixation construct to allow healing and prevent nonunion of displaced femoral neck fractures is not known. This article will review the clinical data regarding conventional fixation constructs and describe the technique and rationale behind 2 novel alternative treatment options for these challenging fractures. The surgical technique and clinical examples for constructs involving multiple cannulated screws/Pauwels screw augmented with a fibular strut graft, as well as a novel fixed-angle locking plate with controlled dynamic compression, are presented.

Young femoral neck fractures remain challenging fractures to treat. Reduction has repeatedly been shown to be the single most important determinant of patient outcome, and treating surgeons should do all they can to achieve anatomic reduction because this is an outcome variable within the surgeon's control. Whether an open or closed reduction is performed, we hope to provide the reader with reduction strategies when faced with this difficult fracture pattern. In addition, we hope to review indications and techniques for using the various treatment implants/modalities that are currently available as they pertain to reduction and fixation.

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

Objectives: To analyze the clinical and radiological outcomes of a series of patients treated with a pedicled vascularized bone graft (VBG) of the distal radius for the treatment of recalcitrant atrophic nonunions of the distal humerus., Design: Retrospective clinical study., Setting: University-affiliated teaching hospital., Patients: Fifteen patients with supracondylar humeral atrophic nonunions with at least 3 previous failed surgical interventions were included., Intervention: Debridement of the distal humerus nonunion through a posterior elbow approach with provisional fixation was performed. Then, a pedicled VBG was harvested from the distal radius and tunneled back into the humeral bone defect. Iliac crest was used as needed, both for the nonunion and to stabilize the radius. Finally, definitive fixation with 2 locked plates was performed., Main Outcome Measurements: Radiological results, complications, elbow range of motion, Mayo elbow performance score, and subjective pain were evaluated., Results: There were 4 male and 11 female patients, with a mean age of 51 (range, 28-73) years. The mean follow-up period was 46 (range, 37-72) months with a minimum of 3 years. Radiological consolidation was achieved in all patients. Elbow range of motion was >100 degrees in 11 patients and between 50 and 100 degrees in 4 patients. Preoperative Mayo scores were poor in all patients. At final follow-up, Mayo scores were excellent in 3, good in 9, and fair in 3 patients. The mean postoperative visual analog scale score was 1.2 (range 0-3)., Conclusions: Pedicled VBG of the distal radius was shown to be a reliable and effective alternative for the treatment of recalcitrant atrophic nonunions of the distal humerus, when other methods have failed., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Surgical management of lower extremity malunions and acute fractures in the setting of lower extremity deformities presents a unique challenge for orthopaedic surgeons. The objective of this study was to evaluate the outcomes of using the clamshell osteotomy in patients with acute fractures involving a malunion or deformity. A retrospective review of the cases performed by various orthopaedic traumatologists at 4 different trauma centers was performed to identify cases using the clamshell osteotomy from January 2012 to January 2016. Nine clamshell osteotomy cases were identified, 4 presenting fractures in the setting of previous malunions. All osteotomies healed within 15 months (average 6.8 ± 4.4 SD). In this multicenter case series, we demonstrate that using clamshell osteotomies can result in excellent outcomes for permitting intramedullary nailing of acute fractures in patients with lower extremity deformity.

Objective: To determine factors associated with nonunion of adult tibial fractures., Design: Retrospective review with data collection for logistic regression and survival analysis., Setting: Scottish Level I trauma center, 1985-2007., Patients: During this period, 1590 adult tibial fractures were treated by reamed nailing and 1003 fractures met all inclusion criteria for the chosen analysis., Intervention: Reamed intramedullary nailing., Main Outcome Measures: Record of nonunion diagnosis and final union time with characteristics, including age, gender, closed or open injury, OTA/AO classification, Gustilo classification, fasciotomy, infection, polytrauma, smoking, and injury severity score., Results: The overall nonunion rate was 12%, and median time to healing was 18 weeks. Age significantly influenced nonunion, with middle-aged patients at highest risk. Both fracture type (closed/open) and morphology (OTA/AO classification) significantly influenced nonunion risk and time to union. Among closed injuries, the highest nonunion rate was for OTA/AO type B fractures (15%). Among open injuries, the highest nonunion rate was for OTA/AO type C (61%). Both compartment syndrome and smoking did not significantly influence nonunion risk but did significantly extend time to union., Conclusions: Injury characteristics including fracture morphology and severity of soft tissue injury were strong predictors of compromised fracture healing. Age also influenced nonunion risk in an unexpected way, with highest rates in the middle decades of adulthood. Future studies should consider the possibility of similar age-related effects and clinical studies should seek to identify explanations for why this may arise, including both physiological and socio-behavioral factors., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

With an aging population, treatment of interprosthetic femur fractures continues to pose a challenge to the orthopaedic surgeon. Retrograde intramedullary nailing combined with open reduction internal fixation using a tissue-preserving plating technique was used in our series of 9 patients with noncomminuted, distal femur fractures. No interfragmentary screws, cables, cerclage wires, or supplemental bone grafts of any type were used. Each patient initiated weight-bearing as tolerated after operative intervention. Every fracture healed at an average of 20 weeks (range 18-24 weeks). Use of a lateral locking plate combined with a retrograde intramedullary nailing enables immediate postoperative weight-bearing and stable fixation for patients with interprosthetic femur fractures.

Objectives: To evaluate patient-independent risk factors for aseptic femoral hypertrophic nonunion requiring exchange nailing, with particular reference to the fit of the nail at the isthmus within the canal., Design: Retrospective case control study., Setting: Level 1 trauma center., Main Outcome Measurements: Between 2008 and 2012, 211 patients without any patient-dependent risk factors for nonunion were treated with a locked reamed intramedullary nail for a femoral shaft fracture. Twenty-three cases went on to hypertrophic nonunion requiring exchange nailing (treatment group) and 188 cases went on to union (control group). Patient-independent risk factors for exchange nailing were documented., Results: Patient-independent risk factors for exchange nailing were poor fracture reduction [Odds ratio (OR): 11.5, 95% confidence interval (CI), 4.0-33.4, P < 0.001], open fracture (OR: 7.6, 95% CI, 3.0-19.6, P = 0.004), Winquist classification of 4 (OR: 4.4, 95% CI, 1.9-6.7, P = 0.016), and poor nail fit (OR: 10.3, 95% CI, 5.1-28.4, P < 0.001). Multivariate analysis revealed nail fit as an independent predictor of femoral nonunion requiring exchange nailing (OR: 11.4, 95% CI, 6.9-15.2, P < 0.001). Moreover, we found a direct relationship between increasingly poor nail fit and increased risk of exchange nailing, with the criterion occurring at a nail fit ratio <70%., Conclusion: When proceeding to femoral fracture reamed intramedullary nailing, we recommend a minimum nail fit of 70% at the isthmus and ideally 90% or more, to avoid surgical reintervention., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Despite improvements in surgical technique and overall patient care, failed treatment of fractures of the femoral neck persists. For the physiologically young patient, joint preservation is the preferred method of treatment. Unfortunately, the best treatment option, proximal femoral osteotomy, is fast becoming a lost art. Preoperative planning is critical in this regard. The described preoperative planning work flow is a reliable method for obtaining the desired deformity correction for a variety of proximal femoral malunions and nonunion. Revisiting the classic Pauwels osteotomy for femoral neck nonunion is an appropriate vehicle to supply the first link in resurrecting this treatment modality by providing a standardized preoperative planning protocol.

Background: Morbid obesity and segmental fracture/bone loss are challenging problems in the treatment of fractures and nonunions of the distal femur. The use of an intramedullary rod as an endosteal substitute for a deficient medial cortex along with a lateral locked plate is 1-tool to combat these problems. This article describes the technique used and its results at a single Level 1 trauma center., Methods: Retrospective chart and radiographic review of all patients treated for acute fractures and nonunions of the distal femur using endosteal substitution with an intramedullary nail and a lateral locked plate. Fixation construct was determined at the surgeon's discretion and was strongly influenced by bone loss and patient body habitus., Results: Seven of 8 acute fractures and 8 of 8 nonunions healed without an unplanned reoperation. There were no cases of secondary displacement after fixation, and only 1 unplanned reoperation in the study group., Conclusion: Endosteal substitution with an intramedullary rod and the use of a lateral locked plate provides the stability needed to allow bone healing under prolonged or supraphysiologic loads seen in morbid obesity or segmental bone loss., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Three typical cases demonstrate the achievement of precision in the reconstruction of ununited fractures of the tibia by preliminary planning with the aid of tracings on roentgenograms, templates, and goniometer measurements.

Objectives: To delineate the contributing factors of diaphyseal fracture nonunion in children and to determine suggested treatment based on the cohort examined., Design: Retrospective review., Patients: 16 children who underwent operative treatment for diaphyseal nonunion from January 1995 to December 2009., Intervention: Stabilization by internal or external fixators with or without bone grafting., Main Outcome Measure: Clinical reviews were evaluated by the side of the injury, mechanism of injury, time interval between injury and surgery, operation time, initial treatment type, and nonunion treatment type, and demographic date including age, sex, the presence or absence of pediatric diabetes, and follow-up duration. Radiographic evaluations were obtained to confirm the fracture site and the classification of the fracture pattern preoperatively, and they were used to postoperatively detect the type of nonunion, the time interval between the treatment of nonunion to bony union, and the residual deformity., Results: The youngest patient was 6 years with the average age being 11.1 years. Only one of the patients was younger than 8 years, so the distribution was a closed interval beginning at this age. Regardless of age, 16 of the patients were likely to experience nonunion if high-energy traumas and iatrogenic soft tissue injuries caused by the open-reduction procedure were abundant at the time of the fractures., Conclusions: The frequency of occurrence was affected by the age of the patient, and it increased when there was extensive iatrogenic soft tissue or insufficient fixation at the time of fracture. Close attention should be paid when dealing with nonunion so that iatrogenic damage is not caused, and sufficient fixation should be performed with adequate tools. Also, it should be noted that it is not unusual for deformities to occur and correction for such deformities should also be considered at the time of surgery., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objectives: To investigate what factors are associated with continued long-term pain after fracture nonunion surgery., Design: Prospective cohort study., Setting: Single Academic Institution., Patients/participants: Three hundred forty-one patients surgically treated for fracture nonunion were prospectively followed. Demographics, radiographic evaluations, VAS pain scores, and short musculoskeletal functional assessment (SMFA) scores were collected at routine intervals. Only patients who had a minimum of 1-year follow-up and complete healing were included this analysis. Patients were divided into a high-pain and low-pain cohort for comparison. Inclusion criteria for the high-pain cohort were defined as any patient who reported a pain score greater than one standard deviation above the mean., Main Outcome Measures: Long-term VAS pain scores and factors contributing to increased patient-reported long-term VAS pain scores., Results: Two hundred seventy patients met criteria and were included in this analysis, with 223 patients (82.6%) in the low-pain cohort and 47 patients (17.4%) in the high-pain cohort. The mean long-term pain score was 7.47 ± 1.2 in the high-pain group and 1.78 ± 1.9 in the low-pain group. Within the high-pain cohort, 55.6% of patients reported a net increase in pain from baseline to long-term follow-up compared with 10.5% in the low-pain cohort (P < 0.0005). High baseline pain score (P = 0.003), increased Charlson comorbidity index (CCI) (P = 0.008), lower income level (P = 0.014), and current smoking status (P = 0.033) were found to be significantly more prevalent in the high-pain cohort., Conclusions: Patients with higher baseline pain scores, elevated Charlson comorbidity index, lower income level or history of smoking are at an increased risk of reporting significant and potentially debilitating long-term pain after nonunion surgery. Although patients may expect complete relieve of pain, orthopaedic surgeons must inform patients of the possibility of experiencing pain 1 year or more postoperatively., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objective: To evaluate the outcomes of a single-stage surgical protocol to treat a presumed aseptic long-bone nonunion with positive intraoperative cultures obtained at the time of surgery., Design: Retrospective comparative series., Setting: Orthopaedic specialty hospital., Patients and Methods: We retrospectively identified 77 patients with long-bone nonunions thought to be aseptic preoperatively, which grew bacteria from cultures obtained at the time of index nonunion surgery., Intervention: Fifty (65%) patients underwent open debridement of the nonunion site followed by surgical stabilization through plates and screws. Twenty-seven (35%) patients underwent exchange nailing with canal reamings used for cultures., Main Outcome Measurement: Rate of radiographic union, time to clinical and radiographic union, nonunion rate after index nonunion surgery, and final union rate after revision procedures., Results: Osseous union after the index nonunion surgery was achieved in 84% of the patients (65 of 77). Time to clinical union was 6.3 months (range, 1-24 months), and time to radiographic union was 7.4 months (range, 2-24 months). Eighteen percent (14 of 77 patients) did not heal after the index nonunion surgery and required additional surgeries. The final union rate after revision surgery was 99% (76 of 77 patients)., Conclusions: Eighty-four percent of presumed aseptic nonunions of long-bone fractures with positive intraoperative cultures fully healed after a single-stage surgical protocol and long-term antibiotic when appropriate. When patients are diagnosed with a subclinical infected nonunion, they should be counseled about the higher likelihood of reoperation, but in most cases can expect excellent union rates after 1 additional surgery., Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objectives: To analyze long-term functional outcomes in patients with posttraumatic infected tibial nonunions having undergone bone transport with hexapod external fixator., Design: Retrospective cohort study., Setting: Level 1 trauma center., Patients/participants: Thirty-eight patients with infected nonunions of the tibia., Intervention: Resection of nonunion with application of stacked hexapod external fixator for bone transport., Main Outcome Measurements: Functional outcome was measured using the short Musculoskeletal Functional Assessment (sMFA). Parameters measured included age, sex, presence of diabetes, smoking, use of a free flap, bone defect size, length in frame, external fixation index, and direction of lengthening., Results: The mean sMFA score for the entire group was 27.1. Average patient age was 46.8 ± 12.7 years, 74% patients were male, 8% were diabetic, and 29% were smokers. Seventeen patients had soft-tissue defects that required a free flap. Smokers had higher degrees of disability compared with nonsmokers (39 ± 16 vs. 22 ± 14, P = 0.011). Patients requiring adjunctive stabilization had worse functional scores compared with those who did not receive adjunctive stabilization (33 ± 17 vs. 22 ± 15, P = 0.049). Sixteen patients returned 2 sMFA surveys at different time points after completion of bone transport. Initial average sMFA score was 26.5 at a mean of 25.3 months; subsequent sMFA scores averaged 19.4 at a mean of 98.8 months., Conclusions: Stacked hexapod external fixator bone transport is a reliable technique for infected nonunion of the tibia with bone loss. Improved sMFA scores can be expected from 2 to 8 years, suggesting full recovery takes longer than previously anticipated. Limb salvage with hexapod bone transport is justified over time., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Nonunions are uncommon sequelae of tibial pilon fractures, but they can present a challenging problem to the treating surgeon. Treatment strategies can range from isolated bone grafting to revision plating depending on the type of nonunion and patient factors. Here, we present our technique and clinical results for intramedullary nailing of tibial pilon nonunions.

Objectives: We present a treatment algorithm comprising 4 Ilizarov methods in managing infected tibial nonunion, using nonunion mobility and segmental defect size to govern treatment choice., Design: Decision protocol analysis study., Setting: A university-affiliated teaching hospital., Patients/participants: Seventy-nine patients were treated with 1 of 4 Ilizarov protocols. All patients had undergone at least one previous operation, 38 had associated limb deformity, and 49 had nonviable nonunions. Twenty-six had a new muscle flap at the time of Ilizarov surgery, and 25 had preexisting flaps reused., Intervention: Twenty-six cases were treated with monofocal distraction, 19 with monofocal compression, 16 with bifocal compression/distraction, and 18 with bone transport., Main Outcome Measurements: The primary outcome measure was the absence of recurrent infection. Secondary outcomes included bone union, complications, the Association for the Advancement of Methods of Ilizarov (ASAMI) bone and functional classification scores, and any need for further unplanned surgery., Results: Infection was eradicated in 76 cases (96.2%) with a mean follow-up duration of 40.8 months (range 6-131). All 3 infection recurrences occurred in the monofocal compression group. Following the initial Ilizarov method alone, union was achieved in 68 cases (86.1%) and was highest among the monofocal distraction (96.2%) and bifocal compression/distraction groups (93.8%). Monofocal compression achieved the lowest union rate (73.7%), significantly lower ASAMI scores, and a refracture rate of 31.6%. Bone transport secured union in 77.8% with a 44.4% unplanned reoperation rate. However, infection-free union was 100% after further treatment., Conclusions: Monofocal compression is not recommended for treating infected, mobile nonunions. Distraction (monofocal or bifocal) was effective and achieved higher rates of union and infection clearance., Level of Evidence: Level III.

Objective: To develop a clinically useful prediction model of success at the time of surgery to promote bone healing for established tibial nonunion or traumatic bone defects., Design: Retrospective case controlled., Setting: Level 1 trauma center., Patients: Adult patients treated with surgery for established tibia fracture nonunion or traumatic bone defects from 2007 to 2016. Two hundred three patients met the inclusion criteria and were available for final analysis., Intervention: Surgery to promote bone healing of established tibia fracture nonunion or segmental defect with plate and screw construct, intramedullary nail fixation, or multiplanar external fixation., Main Outcome Measures: Failure of the surgery to promote bone healing that was defined as unplanned revision surgery for lack of bone healing or deep infection. No patients were excluded who had a primary outcome event., Results: Multivariate logistic modeling identified 5 significant (P < 0.05) risk factors for failure of the surgery to promote bone healing: (1) mechanism of injury, (2) Increasing body mass index, (3) cortical defect size (mm), (4) flap size (cm), and (5) insurance status. A prediction model was created based on these factors and awarded 0 points for fall, 17 points for high energy blunt trauma (OR = 17; 95% CI, 1-286, P = 0.05), 22 points for industrial/other (OR = 22; 95% CI, 1-4, P = 0.04), and 28 points for ballistic injuries (OR = 28; 95% CI, 1-605, P = 0.04). One point is given for every 10 cm of flap size (OR = 1; 95% CI, 1-1.1, P < 0.001), 10 mm of mean cortical gap distance (OR = 1; 95% CI, 1-2, P = 0.004), and 10 units BMI, respectively (OR = 1.5; 95% CI, 1-3, P = 0.16). Two points are awarded for Medicaid or no insurance (OR = 2; 95% CI, 1-5, P = 0.035) and 3 points for Medicare (3; 95% CI, 1-9, P = 0.033). Each 1-point increase in risk score was associated with a 6% increased chance of requiring at least 1 revision surgery (P < 0.001)., Conclusions: This study presents a clinical score that predicts the likelihood of success after surgery for tibia fracture nonunions or traumatic bone defects and may help clinicians better determine which patients are likely to fail these procedures and require further surgery.

Segmental transport is an effective method of treatment for segmental defects, but the need for external fixation during the transport phase is a disadvantage. To avoid external fixation, we have developed a Cylinder-Kombi-Tube Segmental Transport (CKTST) module for combination with a commercially available motorized lengthening nail. This CKTST module allows for an all-internal segmental bone transport and also allows for optional lengthening if needed. The concept and surgical technique of CKTST are described and illustrated with a clinical case.

In this study, we sought to retrospectively evaluate union and infection rates after treatment of distal femur nonunions using a combined nail/plate construct with autogenous bone grafting obtained from the ipsilateral femur using a reamer irrigator aspirator system. Ten (10) patients treated at a Level I trauma center for nonunion of a femoral fracture using a combined nail/plate construct from 2004 to 2014 were included in the study. Union rate and postoperative infection rates were recorded. Mean interval from index surgery to nonunion repair was 12 months (range 4-36 months). Follow-up at 24 months indicated that the entire cohort of 10 patients achieved clinical union and radiographic union based on radiograph union score in tibias (RUST) criteria. Treatment of distal femur nonunions with a combined nail/plate construct and autogenous bone grafting results in a high rate of union with a low complication rate.

Purpose: Fracture nonunion is a common problem for today's orthopaedic surgeon. However, many techniques are currently available for the treatment of long-bone nonunion. This video demonstrates the use of iliac crest bone graft and plate stabilization in the setting of a hypertrophic femoral nonunion., Methods: Treatment of femoral nonunion after intramedullary nail fixation using compression plating and bone grafting is a reliable technique for reducing pain, improving function, and achieving radiographic union. Furthermore, the use of autologous bone graft, in particular iliac crest bone graft, has provided reliable clinical results., Results: In this video, we present the case of a hypertrophic femoral nonunion treated with supplemental bone grafting in addition to plate and screw fixation., Conclusions: Although femoral nonunions are a relatively rare occurrence, they can be reasonably treated using stabilization and supplemental bone grafting. Iliac crest bone graft provides for excellent results when used for treatment of a fracture nonunion.

Objectives: To analyze the radiographic outcomes of intertrochanteric osteotomy for the treatment of femoral neck nonunion with "undercorrection" of the Pauwels angle and relative preservation of the proximal femoral anatomy., Design: Retrospective cohort study., Setting: Level-1 trauma center., Patients: Thirty-two patients with established femoral neck nonunions that had been treated with intertrochanteric osteotomy were retrospectively identified through Current Procedural Terminology codes. Seven patients were treated with 30 degree closing wedge osteotomy and 25 with a 20 degree or smaller osteotomy., Intervention: Valgus-producing intertrochanteric osteotomy with a blade plate., Main Outcome Measurements: Femoral neck and intertrochanteric osteotomy osseous union., Results: Thirty-one of 32 patients (97%) went on to osseous union of the femoral neck and all intertrochanteric osteotomies healed. There was no significant difference in the rate of union of the femoral neck between those patients treated with 30 versus 20 degree or less osteotomies. After osteotomy, the mean Pauwels angle decreased from 71 degrees (range 52-95 degrees) to 47 degrees (range 23-67 degrees) and the mean proximal femoral offset decreased by 11 mm (range 0-23 mm). Seven patients developed radiographic signs of avascular necrosis after osteotomy (22%). Three patients of these patients were converted to total hip arthroplasty (9%). Patients treated with a 30 degree osteotomy were more likely to develop avascular necrosis (67% vs. 12%, P-value = 0.014)., Conclusions: Valgus-producing intertrochanteric osteotomy with a smaller degree of correction than has been traditionally described leads to an excellent rate of radiographic union while preserving more of the native proximal femoral anatomy., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Purpose: Rib fractures are a common chest injury that can typically be treated nonoperatively. However, a percentage of these will go on to nonunion, either because of unique characteristics of the fracture itself or because of a variety of poor healing factors of the host. If a patient has continued symptomology beyond 3 months, surgeons may consider operative management., Methods: Although isolated resection of fibrous scar tissue from the nonunion site may be sufficient in some cases, it may also be necessary to provide additional structural integrity to the rib depending on the extent of the fracture pattern and resection. This goal can be achieved operatively with rib plating and bone grafting to promote healing., Results: This video demonstrates the use of plating in the treatment of rib nonunion. It begins with relevant background information on rib fractures and nonunions, then details the approach, open reduction and internal fixation of 3 ribs using plates and bone graft aspirate. Pearls and pitfalls are included during the surgical technique aspect of the video to both help guide surgeons new to the procedure and provide potentially advantageous technical details to more experienced surgeons.

Introduction: This video demonstrates the technique of posterolateral bone grafting with iliac crest bone graft for a distal tibial nonunion., Methods: The patient is a 42-year-old man who is 6 months status post an open distal tibia-fibula fracture treated surgically, and presents complaints of persistent right ankle pain. The fracture site was tender to palpation, and 3 consecutive plain radiographs spaced 6 weeks apart demonstrated no evidence of callus formation., Results: This patient was indicated for posterolateral bone grafting of his tibia and fibula nonunion with autogenous iliac crest bone graft. The plan was to create a synostosis between the fibula and tibia. Atrophic and oligotrophic nonunions have poor biology at the fracture site to promote bone growth and would therefore benefit from autogenous iliac bone graft, as this technique is osteoinductive, osteoconductive, and osteogenic stem cells. Indications for posterolateral bone grafting of the tibia include atrophic or oligotrophic nonunions, an ipsilateral same level tibia and fibula nonunion, or a tibial nonunion with a large anteromedial soft-tissue injury., Conclusion: The technique of posterolateral bone grafting with iliac crest bone graft for distal third tibia and fibula atrophic nonunion provides a reliable method for achieving union. If patients with injuries at high risk of nonunion are followed closely and intervention is performed in a timely manner, additional fixation or revision of fixation is not necessary if the addition of appropriate osteoinductive, osteoconductive, and osteogenic material to the nonunion is performed.