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Introduction: Nonsteroidal anti-inflammatory drugs (NSAIDs) may potentially delay or cause non-union of fractures by inhibiting prostaglandin synthesis. However, studies have shown conflicting results. This systematic review and meta-analysis aim to synthesize current evidence on the potential influence of NSAIDs on bone healing. Methods: We conducted a comprehensive search of PubMed, Embase, and Cochrane CENTRAL databases for studies published up to 25 July 2023. Specific keywords included "NSAID," "nonsteroidal anti-inflammatory drug," "cyclooxygenase-2 inhibitor," "bone healing," "non-union," "pseudoarthrosis," "delayed union," and "atrophic bone." Eligible studies included prospective, retrospective, and case-controlled studies assessing the correlation between NSAID use and bone healing outcomes. The leave-one-out approach was used to test the robustness of the meta-analysis results. Results: A total of 20 studies with 523,240 patients were included in the analysis. The mean patient age ranged from 6.7 to 77.0 years, with follow-up durations from 3 to 67 months. The meta-analysis revealed no significant difference in non-union or delayed union between NSAID users and non-users [pooled adjusted odds ratio (OR) = 1.11; 95% confidence interval (CI): 0.99-1.23]. Initial analysis identified a significant association between NSAID usage and an increased risk of reoperation, but this association became insignificant upon sensitivity analysis (crude OR = 1.42; 95% CI: 0.88-2.28). Discussion: NSAIDs may have a minimal impact on non-union or delayed union risks. However, caution is advised due to the limited number of studies and the absence of a specific focus on NSAID types and dosages. Further research is necessary to better understand the implications of NSAID use on bone healing. [ABSTRACT FROM AUTHOR]

Background: Fractures at the distal end of the radius, a prevalent orthopedic concern, challenge clinicians due to their complex nature and the diverse patient demographics they affect. Primary stability is key, especially in cases involving osteoporotic bones or younger patients. The Ellis plate with a locking screw mechanism offers a promising solution to achieve this stability, potentially preventing secondary displacement regardless of bone quality. Aims and Objectives: This study aims to rigorously assess the effectiveness of the Ellis volar locking compression plate in treating distal end radius fractures. It focuses on evaluating functional outcomes post-treatment, providing insights into the efficacy of this approach. Materials and Methods: This study evaluated the efficacy of the Ellis plate in managing distal radius fractures, under ethical approval number KMC/IEC/Ortho/2021-5. Twenty adult patients with unstable fractures were included based on specific criteria and provided informed consent. Exclusion criteria included unwillingness for surgery, medical unsuitability, osteoporosis, minors, and compound fractures with vascular injury. Surgical outcomes were assessed using the Gartland and Werley scoring system, with follow-up appointments scheduled over 1 year to monitor progress and adherence to physiotherapy plans. Results: The study encompassed 20 patients, with a gender distribution of 12 males and eight females and an average age of 43.3 years. Utilizing the Gartland and Werley demerit grading system, the study reported 45% superb outcomes, another 45% good outcomes, 10% fair outcomes, and no poor outcomes. This distribution highlights the potential of the Ellis plate technique in achieving positive results in fracture treatment. Conclusion: The study concludes that the Ellis plate technique is a viable and effective option for stabilizing distal end radius fractures. However, achieving the best possible outcomes depends on several factors, including strict adherence to AO principles, maintaining high standards of aseptic practice, following appropriate post-operative rehabilitation protocols, and ensuring comprehensive patient education. This multifaceted approach is crucial for the successful treatment of these fractures.

Surgical management of fractures has advanced with the incorporation of advanced technology, surgical techniques, and regenerative therapies, but delayed bone healing remains a clinical challenge and the prevalence of long bone nonunion ranges from 10 to 15% of surgically managed fractures. Delayed bone healing arises from a combination of mechanical, biological, and systemic factors acting on the site of tissue remodeling, and careful consideration of each case's injury-related, patient-dependent, surgical, and mechanical risk factors is key to successful bone union. In this review, we describe the biology and biomechanics of delayed bone healing, outline the known risk factors for nonunion development, and introduce modern preventative and corrective therapies targeting fracture nonunion. [ABSTRACT FROM AUTHOR]

challenge clinicians due to their complex nature and the diverse patient demographics they affect. Primary stability is key, especially in cases involving osteoporotic bones or younger patients. The Ellis plate with a locking screw mechanism offers a promising solution to achieve this stability, potentially preventing secondary displacement regardless of bone quality. Aims and Objectives: This study aims to rigorously assess the effectiveness of the Ellis volar locking compression plate in treating distal end radius fractures. It focuses on evaluating functional outcomes post-treatment, providing insights into the efficacy of this approach. Materials and Methods: This study evaluated the efficacy of the Ellis plate in managing distal radius fractures, under ethical approval number KMC/IEC/Ortho/2021-5. Twenty adult patients with unstable fractures were included based on specific criteria and provided informed consent. Exclusion criteria included unwillingness for surgery, medical unsuitability, osteoporosis, minors, and compound fractures with vascular injury. Surgical outcomes were assessed using the Gartland and Werley scoring system, with follow-up appointments scheduled over 1 year to monitor progress and adherence to physiotherapy plans. Results: The study encompassed 20 patients, with a gender distribution of 12 males and eight females and an average age of 43.3 years. Utilizing the Gartland and Werley demerit grading system, the study reported 45% superb outcomes, another 45% good outcomes, 10% fair outcomes, and no poor outcomes. This distribution highlights the potential of the Ellis plate technique in achieving positive results in fracture treatment. Conclusion: The study concludes that the Ellis plate technique is a viable and effective option for stabilizing distal end radius fractures. However, achieving the best possible outcomes depends on several factors, including strict adherence to AO principles, maintaining high standards of aseptic practice, following appropriate post-operative rehabilitation protocols, and ensuring comprehensive patient education. This multifaceted approach is crucial for the successful treatment of these fractures. [ABSTRACT FROM AUTHOR]

IntroductionNonsteroidal anti-inflammatory drugs (NSAIDs) may potentially delay or cause non-union of fractures by inhibiting prostaglandin synthesis. However, studies have shown conflicting results. This systematic review and meta-analysis aim to synthesize current evidence on the potential influence of NSAIDs on bone healing.MethodsWe conducted a comprehensive search of PubMed, Embase, and Cochrane CENTRAL databases for studies published up to 25 July 2023. Specific keywords included “NSAID,” “nonsteroidal anti-inflammatory drug,” “cyclooxygenase-2 inhibitor,” “bone healing,” “non-union,” “pseudoarthrosis,” “delayed union,” and “atrophic bone.” Eligible studies included prospective, retrospective, and case-controlled studies assessing the correlation between NSAID use and bone healing outcomes. The leave-one-out approach was used to test the robustness of the meta-analysis results.ResultsA total of 20 studies with 523,240 patients were included in the analysis. The mean patient age ranged from 6.7 to 77.0 years, with follow-up durations from 3 to 67 months. The meta-analysis revealed no significant difference in non-union or delayed union between NSAID users and non-users [pooled adjusted odds ratio (OR) = 1.11; 95% confidence interval (CI): 0.99–1.23]. Initial analysis identified a significant association between NSAID usage and an increased risk of reoperation, but this association became insignificant upon sensitivity analysis (crude OR = 1.42; 95% CI: 0.88–2.28).DiscussionNSAIDs may have a minimal impact on non-union or delayed union risks. However, caution is advised due to the limited number of studies and the absence of a specific focus on NSAID types and dosages. Further research is necessary to better understand the implications of NSAID use on bone healing.

Abstract Introduction Fractures with delayed healing can be a serious complication, especially for athletes depending on quick return to sports. To our knowledge, no cases of increased healing of delayed union fractures with autologous biomedical interventions have been reported. Case presentation A 33-year-old Swedish professional boxer with a fractured humerus with a delayed union and a partially torn supraspinatus tendon was treated with injections of liquid platelet-rich fibrin and heat-coagulated albumin gel. He recovered almost completely from both injuries in only 1 month and could return to professional boxing in 3 months. Conclusion This case raises the hypothesis that liquid platelet-rich fibrin and heat-coagulated albumin gel may be an effective, minimally invasive intervention in fractures with a delayed union. Further research is required to test this theory.

Background: Fracture healing is a very complex and well-orchestrated regenerative process involving many cell types and molecular pathways. Despite the high efficiency of this process, unsatisfying healing outcomes, such as non-union, occur for approximately 5–10% of long bone fractures. Although there is an obvious need to identify markers to monitor the healing process and to predict a potential failure in callus formation to heal the fracture, circulating bone turnover markers' (BTMs) utility as biomarkers in association with radiographic and clinical examination still lacks evidence so far. Methods: A systematic review on the association between BTMs changes and fracture healing in long bone non-union was performed following PRISMA guidelines. The research papers were identified via the PubMed, Cochrane, Cinahl, Web of Science, Scopus, and Embase databases. Studies in which the failure of fracture healing was associated with osteoporosis or genetic disorders were not included. Results: A total of 172 studies were collected and, given the inclusion criteria, 14 manuscripts were included in this review. Changes in circulating BTMs levels were detected during the healing process and across groups (healed vs. non-union patients and healthy vs. patients with non-union). However, we found high heterogeneity in patients' characteristics (fracture site, gender, and age) and in sample scheduling, which made it impossible to perform a meta-analysis. Conclusions: Clinical findings and radiographic features remain the two important components of non-union diagnosis so far. We suggest improving blood sample standardization and clinical data collection in future research to lay the foundations for the effective use of BTMs as tools for diagnosing non-union. [ABSTRACT FROM AUTHOR]

Addressing non-unions involves stabilizing the affected area through osteosynthesis and improving bone biology using bone grafts. However, there is no consensus on the optimal treatment method. This study aims to compare outcomes of non-union surgery using conventional treatment methods (metal hardware ± graft) versus osteosynthesis with the human allogeneic cortical bone screw (Shark Screw®) alone or in combination with a metallic plate. Thirty-four patients underwent conventional treatment, while twenty-eight cases received one or more Shark Screws®. Patient demographics, bone healing, time to bone healing, and complications were assessed. Results revealed a healing rate of 96.4% for the Shark Screw® group, compared to 82.3% for the conventionally treated group. The Shark Screw® group exhibited a tendency for faster bone healing (9.4 ± 3.2 vs. 12.9 ± 8.5 weeks, p = 0.05061). Hardware irritations led to six metal removals in the conventional group versus two in the Shark Screw® group. The Shark Screw® emerges as a promising option for personalized non-union treatment in the foot, ankle, and select lower leg cases, facilitating effective osteosynthesis and grafting within a single construct and promoting high union rates, low complications, and a rapid healing process. [ABSTRACT FROM AUTHOR]

Introduction: Fractures with delayed healing can be a serious complication, especially for athletes depending on quick return to sports. To our knowledge, no cases of increased healing of delayed union fractures with autologous biomedical interventions have been reported. Case presentation: A 33-year-old Swedish professional boxer with a fractured humerus with a delayed union and a partially torn supraspinatus tendon was treated with injections of liquid platelet-rich fibrin and heat-coagulated albumin gel. He recovered almost completely from both injuries in only 1 month and could return to professional boxing in 3 months. Conclusion: This case raises the hypothesis that liquid platelet-rich fibrin and heat-coagulated albumin gel may be an effective, minimally invasive intervention in fractures with a delayed union. Further research is required to test this theory. [ABSTRACT FROM AUTHOR]

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

The bone fracture cases have been increasing yearly, accompanied by the increased number of patients experiencing non-union or delayed union after their bone fracture. Although clinical materials facilitate fracture healing (e.g., metallic and composite materials), they cannot fulfill the requirements due to the slow degradation rate, limited osteogenic activity, inadequate osseointegration ability, and suboptimal mechanical properties. Since early 2000, nanomaterials successfully mimic the nanoscale features of bones and offer unique properties, receiving extensive attention. This paper reviews the achievements of nanomaterials in treating bone fracture (e.g., the intrinsic properties of nanomaterials, nanomaterials for bone defect filling, and nanoscale drug delivery systems in treating fracture delayed union). Furthermore, we discuss the perspectives on the challenges and future directions of developing nanomaterials to accelerate fracture healing.

Background: Delayed union in long bone fractures poses a significant clinical challenge, necessitating effective treatment solutions. The urgency for novel and effective treatment modalities is ever-increasing, especially considering the prevalence and complications associated with delayed union. Aims and Objectives: This retrospective analysis aims to assess the safety and efficacy of autologous bone marrow injections in treating delayed union in a diverse cohort of individuals with long bone fractures. Materials and Methods: The study includes 100 individuals aged 21–69 with varying fracture types. Fracture classifications comprised 40% closed fractures (n=40) and 60% open fractures (n=60). Notably, the femur had a higher prevalence of open fractures (n=30) than closed fractures (n=20). Tibia fractures demonstrated a similar propensity, with 25 open and 15 closed cases. Humerus fractures manifested an even distribution between open and closed categories (n=5 each), indicating their relative resilience to open fractures. Results: Union was attained in 82 cases, with a mean union time of 7.4 weeks post-the-third bone marrow injection. The timeframe for the union varied widely, ranging from 4 to 17 weeks. In eight instances where bone marrow injections failed to achieve union, alternative treatment via bone grafting was necessary. No significant complications were reported; however, minor discomfort was experienced by 13% of the patients and was effectively managed with over-the-counter analgesics. Conclusion: This retrospective analysis demonstrates the high efficacy and safety of autologous bone marrow injections in treating delayed union in long bones, making them a promising alternative treatment strategy with minimal complications.

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

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Background: Delayed union in long bone fractures poses a significant clinical challenge, necessitating effective treatment solutions. The urgency for novel and effective treatment modalities is ever-increasing, especially considering the prevalence and complications associated with delayed union. Aims and Objectives: This retrospective analysis aims to assess the safety and efficacy of autologous bone marrow injections in treating delayed union in a diverse cohort of individuals with long bone fractures. Materials and Methods: The study includes 100 individuals aged 21-69 with varying fracture types. Fracture classifications comprised 40% closed fractures (n=40) and 60% open fractures (n=60). Notably, the femur had a higher prevalence of open fractures (n=30) than closed fractures (n=20). Tibia fractures demonstrated a similar propensity, with 25 open and 15 closed cases. Humerus fractures manifested an even distribution between open and closed categories (n=5 each), indicating their relative resilience to open fractures. Results: Union was attained in 82 cases, with a mean union time of 7.4 weeks post-the-third bone marrow injection. The timeframe for the union varied widely, ranging from 4 to 17 weeks. In eight instances where bone marrow injections failed to achieve union, alternative treatment via bone grafting was necessary. No significant complications were reported; however, minor discomfort was experienced by 13% of the patients and was effectively managed with over-the-counter analgesics. Conclusion: This retrospective analysis demonstrates the high efficacy and safety of autologous bone marrow injections in treating delayed union in long bones, making them a promising alternative treatment strategy with minimal complications. [ABSTRACT FROM AUTHOR]

Subtrochanteric femoral (ST) fractures are associated with high rates of delayed and non-union. The aim of this study was to analyse the risk factors associated with delayed/non-union in ST fractures. All patients with surgical stabilisation of ST fractures during the period 2014 to 2019 were identified in an electronic patient records database in two trauma centres. Exclusion criteria were incomplete clinical/radiological data, pathological fractures and loss to follow-up. Radiographs at about 6 months post-surgery were assessed for fracture union using Radiographic Union Score for Hip (RUSH). Fracture was deemed to be un-united if RUSH score was <18. CCD (caput-collum-diaphyseal) angle of operated and uninjured hip, residual displacement at fracture site and 3-point relationship was calculated on operative or immediate post-operative images in both groups. Student's t-test was used to compare CCD angle difference between operated and uninjured sides and the residual fracture displacement between delayed union and united fractures group. Chi-square test was used for 3-point relationship. Observational analysis was performed on implant failure rates including distal screw breakage. During the study period, there were total of 278 patients. 193 with inadequate data and 22 with pathological fractures were excluded. Advanced age and female sex had significantly higher rate of delayed union (p value of 0.043 and 0.003 respectively). Delayed union group (26) had a mean RUSH score of 14.1 and united group (37) had a mean RUSH score of 26.3 (p = 0.019). The mean CCD angle difference between operated and uninjured sides was −5.77° for delayed union and −2.33° for united fractures (p = 0.03). Residual displacement at fracture site showed statistically significant difference between delayed union and united fractures on anteroposterior and lateral views (p = 0.001 each). There was no statistical difference in 3-point relationship of implant in two groups (p = 0.775). 10 revision procedures were performed for implant failures. Distal screw failure (3 cases) was not a precursor for non-union in this study. This study confirms varus alignment of hip and residual fracture displacement after fracture fixation of subtrochanteric fracture are surgeon associated significant risk factors for delayed union at 6 months. Fracture contact and alignment are key to reduce failures in these group of fractures. Among patient factors, advancing age and female sex predisposes to higher rate of delayed union. [ABSTRACT FROM AUTHOR]

Abstract The optimal balance between mechanical environment and biological factors is crucial for successful bone healing, as they synergistically affect bone development. Any imbalance between these factors can lead to impaired bone healing, resulting in delayed union or non-union. To address this bone healing disorder, clinicians have adopted a technique known as "dynamization" which involves modifying the stiffness properties of the fixator. This technique facilitates the establishment of a favorable mechanical and biological environment by changing a rigid fixator to a more flexible one that promotes bone healing. However, the dynamization of fixators is selective for certain types of non-union and can result in complications or failure to heal if applied to inappropriate non-unions. This review aims to summarize the indications for dynamization, as well as introduce a novel dynamic locking plate and various techniques for dynamization of fixators (intramedullary nails, steel plates, external fixators) in femur and tibial fractures. Additionally, Factors associated with the effectiveness of dynamization are explored in response to the variation in dynamization success rates seen in clinical studies.

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

Background: Nonunion remains the most common major complication of ankle arthrodesis. Although previous studies have reported delayed union or nonunion rates, few have elaborated on the clinical course of patients experiencing delayed union. In this retrospective cohort study, we sought to understand the trajectory of patients with delayed union by determining the rate of clinical success and failure and whether the extent of fusion on computed tomography scan (CT) was associated with outcomes. Methods: Delayed union was defined as incomplete (<75%) fusion on CT between 2 and 6 months postoperatively. Thirty-six patients met the inclusion criterion: isolated tibiotalar arthrodesis with delayed union. Patient-reported outcomes were obtained including patient satisfaction with their fusion. Success was defined as patients who were not revised and reported satisfaction. Failure was defined as patients who required revision or reported being not satisfied. Fusion was assessed by measuring the percentage of osseous bridging across the joint on CT. The extent of fusion was categorized as absent (0%-24%), minimal (25%-49%), or moderate (50%-74%). Results: We determined the clinical outcome of 28 (78%) patients with mean follow-up of 5.6 years (range, 1.3-10.2). The majority (71%) of patients failed. On average, CT scans were obtained 4 months after attempted ankle fusion. Patients with minimal or moderate fusion were more likely to succeed clinically than those with "absent" fusion (P =.040). Of those with absent fusion, 11 of 12 (92%) failed. In patients with minimal or moderate fusion, 9 of 16 (56%) failed. Conclusion: We found that 71% of patients with a delayed union at roughly 4 months after ankle fusion required revision or were not satisfied. Patients with less than 25% fusion on CT had an even lower rate of clinical success. These findings may help surgeons in counseling and managing patients experiencing a delayed union after ankle fusion. Level of Evidence: Level IV, retrospective cohort study. [ABSTRACT FROM AUTHOR]

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

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

Surgical management of fractures has advanced with the incorporation of advanced technology, surgical techniques, and regenerative therapies, but delayed bone healing remains a clinical challenge and the prevalence of long bone nonunion ranges from 10 to 15% of surgically managed fractures. Delayed bone healing arises from a combination of mechanical, biological, and systemic factors acting on the site of tissue remodeling, and careful consideration of each case’s injury-related, patient-dependent, surgical, and mechanical risk factors is key to successful bone union. In this review, we describe the biology and biomechanics of delayed bone healing, outline the known risk factors for nonunion development, and introduce modern preventative and corrective therapies targeting fracture nonunion.

The optimal balance between mechanical environment and biological factors is crucial for successful bone healing, as they synergistically affect bone development. Any imbalance between these factors can lead to impaired bone healing, resulting in delayed union or non-union. To address this bone healing disorder, clinicians have adopted a technique known as "dynamization" which involves modifying the stiffness properties of the fixator. This technique facilitates the establishment of a favorable mechanical and biological environment by changing a rigid fixator to a more flexible one that promotes bone healing. However, the dynamization of fixators is selective for certain types of non-union and can result in complications or failure to heal if applied to inappropriate non-unions. This review aims to summarize the indications for dynamization, as well as introduce a novel dynamic locking plate and various techniques for dynamization of fixators (intramedullary nails, steel plates, external fixators) in femur and tibial fractures. Additionally, Factors associated with the effectiveness of dynamization are explored in response to the variation in dynamization success rates seen in clinical studies. [ABSTRACT FROM AUTHOR]

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

High tibial osteotomy (HTO) is used as an alternative to total knee arthroplasty in young patients with knee osteoarthritis. In the conventional HTO, if the distraction distance is large, the osteotomy section will be significantly separated, forming a large bone defect gap, which may lead to delayed healing or even nonunion. We treated a series of 10 patients with medial knee osteoarthritis by a novel M-shaped high tibial osteotomy. This helped to improve greater contact of cortical sections and rapid healing of the osteotomy break. Over a mean follow-up period of 8.5 months (range, 6.0–12.0 months), all patients achieved bone union. None of the patients showed complications such as nonunion or infection. The novel M-shaped HTO procedure can reduce the probability of delayed union/nonunion and avoid the complications associated with bone grafting. Hence, this technique may be an effective alternative for the HTO. [ABSTRACT FROM AUTHOR]

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

Abstract Purpose Soft tissue injury and soft tissue injury as risk factors for nonunion following trochanteric femur fractures (TFF) are marginally investigated. The aim of this study was to identify risk factors for impaired fracture healing in geriatric trauma patients with TFF following surgical treatment with a femoral nail. Methods This retrospective cohort study included geriatric trauma patients (aged > 70 years) with TFF who were treated with femoral nailing. Fractures were classified according to AO/OTA. Nonunion was defined as lack of callus-formation after 6 months, material breakage, and requirement of revision surgery. Risk factors for nonunion included variables of clinical interest (injury pattern, demographics, comorbidities), as well as type of approach (open versus closed) and were assessed with uni- and multivariate regression analyses. Results This study included 225 geriatric trauma patients. Nonunion was significantly more frequently following AO/OTA 31A3 fractures (N = 10, 23.3%) compared with AO/OTA type 31A2 (N = 6, 6.9%) or AO/OTA 31A1 (N = 3, 3.2%, p

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

As non-unions are still common, a predictive assessment of healing complications could enable immediate intervention before negative impacts for the patient occur. The aim of this pilot study was to predict consolidation with the help of a numerical simulation model. A total of 32 simulations of patients with closed diaphyseal femoral shaft fractures treated by intramedullary nailing (PFNA long, FRN, LFN, and DePuy Synthes) were performed by creating 3D volume models based on biplanar postoperative radiographs. An established fracture healing model, which describes the changes in tissue distribution at the fracture site, was used to predict the individual healing process based on the surgical treatment performed and full weight bearing. The assumed consolidation as well as the bridging dates were retrospectively correlated with the clinical and radiological healing processes. The simulation correctly predicted 23 uncomplicated healing fractures. Three patients showed healing potential according to the simulation, but clinically turned out to be non-unions. Four out of six non-unions were correctly detected as non-unions by the simulation, and two simulations were wrongfully diagnosed as non-unions. Further adjustments of the simulation algorithm for human fracture healing and a larger cohort are necessary. However, these first results show a promising approach towards an individualized prognosis of fracture healing based on biomechanical factors. [ABSTRACT FROM AUTHOR]

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

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

Abstract Background The outcome of non-surgical treatment is generally good, but the treatment course can be long and painful with approximately a quarter of the patients acquiring a nonunion. Both surgical and non-surgical treatment can have disabling consequences such as nerve injury, infection, and nonunion. The purpose of the study is to compare patient-reported outcomes after surgical and non-surgical treatment for humeral shaft fractures. Methods A pragmatic randomized controlled trial (RCT) is planned with two study groups (SHAFT-Young and SHAFT-Elderly). A total of 287 eligible acute humeral shaft fractures are scheduled to be recruited and randomly allocated to surgical or non-surgical treatment with the option of early crossover due to delayed union. The surgical method within the allocation is decided by the surgeon. The primary outcome is the Disability of Arm, Shoulder, and Hand (DASH) score at 52 weeks, and is assessor blinded. The secondary outcomes are DASH score, EQ-5D-5L, pain assessed by visual analog score, Constant-Murley score including elbow range of motion, and anchor questions collected at all timepoints throughout the trial. All complications will be reported including; infection, nerve or vascular injury, surgical revisions (implant malpositioning, hardware failure, aseptic loosening, and peri-implant fracture), major adverse cardiovascular events, and mortality. Discussion The SHAFT trial is a pragmatic multicenter RCT, that will compare the effectiveness of the main strategies in humeral shaft fracture treatment. This will include a variety of fracture morphologies, while taking the dilemmas within the population into account by splitting the population by age and providing the orthopedic society with an interval for early crossover surgery. Trial registration Clinicaltrials.gov NCT04574336 . Registered on 5 October 2020.

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

Fractures of long bones unite without any complication except for 2%–10% which may lead to delayed or non-union of the fracture. Management of delayed union of fractures poses a great challenge for orthopaedic surgeons. Platelet-rich plasma (PRP) is an autologous blood-derived biological agent, which delivers growth factors, cytokines, and bio-micro molecules at supraphysiologic concentrations at the site of tissue injury, thus potentiating the body's healing efforts. Various studies and research have proved the osteogenic activity of PRP. The growth factors present in the PRP induce the locally available resilient progenitor or stem cells and convert the atrophic environment into a trophic environment. We investigated the safety and efficacy of autologous PRP injection in the delayed union of long bone fractures. A total of 25 cases of delayed union of long bone fractures were augmented with 3 doses of autologous PRP at 3 weekly intervals and were followed up for 12 months. All the cases were documented with pre-and post-procedural and 12th -month visual analog score (VAS) and Warden's score. Out of 25 cases, 21 (84.00%) cases showed good union of fracture with adequate callus formation by 10–12 weeks with 3 doses of autologous PRP injections. The mean pre-procedural VAS and Warden's score at the final follow-up showed statistically significant results (p < 0.05). No other complications were noted due to autologous PRP application among the study participants during the study period except for 3 cases (2 cases of non-union, and 1 case of implant failure). Results of the current study suggest that autologous injection of PRP might be a safe and effective therapeutic tool for the management of delayed union of long bone fractures. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to assess the fracture union with percutaneous autologous bone marrow injection in delayed union and non-union of long bone fractures. Methods: Patients who were admitted in department of orthopaedics in Katuri medical college and hospital, Chinnakondrupadu, Guntur, with delayed union and non-union of long bone fractures, were included in this prospective study. Study span is about 2 years and sample size of 34 patients. Preoperatively patients were examined clinically and radiologically. Post operatively patients were followed up through serial post operative x-rays. Results: This study included 34 patients, out of which one case was lost in follow up. 24 out of 33 cases good bone union was achieved (72.7%). Radiographically the healing was seen on an average of 14 weeks. Conclusion: Percutaneous bone marrow injection is a minimally invasive procedure. It is a simple, quick, safe procedure providing cellular reactivation of osteogenesis with no related complications that may occur with bone grafting. [ABSTRACT FROM AUTHOR]

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

Background: Femoral shaft fractures constitute only 1.6% of all paediatric fractures but at the same time they are the most common fractures which require hospitalization in children. The present study was conducted to assess outcome of submuscular plating in paediatric femoral shaft fractures. Materials & Methods: 56 paediatric femoral shaft fractures patients of both genders were selected and fracture characteristics, intra-operative and post-operative findings, radiological findings, intraoperative or post complication was recorded. Preoperative anteroposterior and lateral view x ray of femur were taken to see the type of fracture. Results: Out of 56 patients, males were 30 and females were 26. The mean duration of hospital stays was 10.2 days, fluoroscopy time per surgery was 65.2 minutes, average time of callous formation was 3.2 in weeks and average time of fracture union was 8.1 weeks. Mechanism of injury was RTA in 32, fall in 20 and others in 4. Fracture pattern was oblique in 10, spiral in 14, transverse in 8 and comminuted in 24. Fracture site was proximal 1/3 in 12, middle 1/3 in 30 and distal 1/3 in 14. The difference was significant (P< 0.05). Common complications reported were delayed union in 2, non-union in 3, refracture in 1 and superficial infection in 2 patients. The difference was non-significant (P> 0.05). Conclusion: Sub-muscular plating is a surgical method with learning curve and is a very effective method of fixation for paediatric femur fractures. [ABSTRACT FROM AUTHOR]

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

• Fracture nonunion is a growing research field. • 1997 publications were found in Web of Science from 2004 to 2023. • Only 3.55 % were highly-cited papers. • USA, China and UK, were the most productive countries. • PV Giannoudis (Leeds, UK) was the most productive author. Nonunion of fractures continue to be the most challenging complication. The increased interest in this area has been anecdotally recognized through published research. The study aimed to conduct a comprehensive bibliometric analysis of global research on nonunion and delayed union of fractures to identify key trends, hotspots, and potential areas for future research development. Using a pre-defined search strategy, articles related to "Nonunion and Delayed Union of Fractures" that were published from January 1st, 2004 to December 31st, 2023, were retrieved from the Web of Science Core Collection for scientometric analysis. The bibliometrics method was used to analyze the publication dates, countries, institutions, journals, authors, highly cited literature and research hotspots. A total of 1997 publications were identified, which registered an average of 21.42 citations per paper (CPP). The 30.39 % and 3.55 % of the 1997 global publications have received external funding support and were highly-cited papers, respectively. The USA, China and UK, were the most productive countries, while Canada, Scotland, and Belgium registered the highest citation impact. University Leeds, Shanghai Jiao Tong University and Kobe University were the most productive organizations, while Vanderbilt University, University of Edinburgh and University Leeds registered the highest citation impact. Giannoudis PV, Egol KA, and Konda SR were the most productive authors, while Bhandari M, Mehta S, and Schemitsch EH registered the highest citation impact. Injury, Journal of Orthopaedic Trauma and Archives of Orthopaedic and Trauma Surgery contributed the most papers, while Journal of Bone and Joint Surgery-American, Injury and Clinical Orthopaedics and Related Research registered the highest citation impact per paper. The present bibliometric analysis shows the characteristics and trends of non-union fracture research and illuminates the current research situation and developmental trends. [Display omitted] [ABSTRACT FROM AUTHOR]

While several complications are described after intramedullary fixation using Titanium Elastic Nails (TEN) for pediatric forearm fractures, delayed union rates are reported to be around 4%. A 12-year-old patient, who underwent TEN after a forearm fracture, was recommended to have a secondary surgery due to nonunion at the ulna after 16 weeks of follow-up. Unfortunately, the existing callus formation was lost after the patient received a second blow during the preoperative preparation process. Moreover, the family refused the operation because of the fear of the COVID-19 pandemic. The patient’s family gave consent after 35 weeks, and the patient was taken under the operation. The complete union was achieved with a full range of motion after 6 months of follow-up. In conclusion, in pediatric forearm fractures, one should be careful about the delayed union, carry out close follow-up and thorough evaluation, and secondary surgery should not be avoided when necessary.

BackgroundThe incidence of periprosthetic fractures after total knee arthroplasty (TKA) increases in parallel with the number of procedures. Comminuted fractures along the primary fracture line extending to the edge of the prosthesis are challenging, and bilateral fractures are rarely reported, especially with open injuries.Case presentationA 65-year-old female had undergone bilateral TKA in our hospital 5 years before admission. She was admitted with a traumatic bilateral Rorabeck type II B distal femur periprosthetic fracture (closed right, open left, Gustilo II) and was treated with bilateral staged open reduction and internal fixation (ORIF) with double-locking plates. The patient experienced a prolonged delayed fracture union and finally healed around 21 months postoperatively. The function was satisfactory after 4 years of follow-up.ConclusionORIF with double-locking plates can be used to treat Rorabeck II B periprosthetic fracture where the primary fracture line extends beyond the edge of the prosthesis; however, there may be delayed healing or nonunion. Patients need to undergo long-term rehabilitation and endure long disability times and require good rehabilitation nursing care. Once they achieve bone healing, the treatment achieves bone preservation and substantial prosthesis survival.

Introduction: Low-intensity pulsed ultrasound (LIPUS) is a non-invasive treatment modality for delayed union or non-union of acute fractures. We aimed to assess the current use of LIPUS at a national level in the United Kingdom, why and how clinicians use it, what treatment protocols are followed, and what the current perceptions are on this technology.Methodology: Using a detailed online survey compromised of 20 questions delivered to known LIPUS users, we were able to collect qualitative data on indication of use, type of machine used, personal views on the technology, frequency of usage, and treatment protocols. Each question was peer-reviewed to exclude bias.Results: A total of 70 respondents completed the survey. LIPUS was used by most clinicians for cases of non-union (N = 55, 78.5%) and delayed union (N = 51, 72.8%). The majority of respondents personally used a LIPUS device between 1 and 5 times in 12 months (N = 38, 54.3%). Most considered LIPUS a failure after three to six months of treatment without clinical improvement (N = 39, 55.7%). A total of 32 respondents (45.7%) mentioned the need for funding approval before accessing LIPUS technology. Poor revision surgery candidates (N = 48, 68.6%) and atrophic non-union (N = 46, 65.7%) were the most frequently cited reasons for using LIPUS technology as treatment. Most participants (N = 48, 68.6%) considered LIPUS to be cost-effective. Despite most clinicians being comfortable with the use of LIPUS, some respondents did not understand the basic science underpinning the technology nor could explain the need for LIPUS to patients comfortably.Conclusion: LIPUS technology may have a significant role to play in the treatment of orthopaedic fracture related pathology. Regular users perceived the technology to be cost-effective and efficacious. Further research should standardize treatment protocols and aim to establish a national LIPUS registry. [ABSTRACT FROM AUTHOR]

Background As serious fracture complications, delayed union and non-union are parts of complications from fracture healing. Growth factors such as BMP-2, VEGF, proinflammatory cytokines including IL-6 and bone formation BALP, N-Mid-OC are important regulators of the fracture healing process. Red yeast rice (RYR), produced by fermenting Monascus purpureus rice, monacolin K, which is the main ingredient in RYR, was found to play a major role in the anti-inflammatory process and increasing the proliferation of osteoblast in osteoporosis cases. This study aims to examine the effect of RYR in the fracture healing process in delayed union rats through molecular studies of levels of IL-6, BMP- 2, VEGF, BALP, and N-Mid-OC. Methods This study was experimental research that used male rats ( Rattus novergicus) which were divided into a control and 3 treatment groups using a random sampling method. Group 1 was given orally 25 mg/kg, Group 2 was 50 mg/kg, Group 3 was 100 mg/kg, and the control group was given a placebo. The rats were then subjected to a delayed union fracture model. Observations were made for two periods on the 14th and 28th days. Results There were no significant differences in serology examination between days 0 and 14 between groups. However, there were significant differences between groups on day 28. IL-6, BMP-2, VEGF, BALP, and N-Mid-OC on day 28 between groups (p Conclusion A red yeast rice dose of 100 mg/KgBW significantly reduced IL-6, increased BMP-2, VEGF, BALP, N-Mid-OC, and RUST Score so as to improve the fracture healing process in delayed union rats.

Background: Discontinuity at the site of osteotomy is a complication after periacetabular osteotomy. The objectives of this study were to assess whether discontinuity is owed to delayed union or non-union and to clarify the risk factors associated with discontinuity >1 year after periacetabular osteotomy., Methods: We performed a retrospective review of 104 hips in 95 consecutive patients who underwent periacetabular osteotomy between 2017 and 2021. Pre- and post-periacetabular osteotomy radiographs of 97 hips in 89 patients were finally evaluated. Radiographic evaluations included the occurrence of stress fractures in the inferior pubic ramus and posterior column, incidence of discontinuity at osteotomy sites and stress-fractured bones, centre-edge angle, acetabular roof obliquity, and Tönnis grade. Clinical evaluations included the age at surgery, body mass index, and Harris hip score., Results: The incidence of discontinuity at the pubic osteotomy site and stress-fractured posterior column improved from 16.5 % to 2.1 % at 1 year postoperatively to 5.2 % and 0 % at the final follow-up, respectively. Multivariate analysis revealed that postoperative stress fracture in the inferior pubic ramus was significantly more common in patients with discontinuity of the stress-fractured inferior pubic ramus at the final follow-up., Conclusions: The present study demonstrated that even if discontinuity is present at the osteotomy site or stress-fractured inferior pubic ramus and posterior column 1 year post-periacetabular osteotomy, continuity can subsequently occur at these sites. The findings suggest that discontinuity 1 year postoperatively should be defined as delayed union rather than non-union. We also identified postoperative stress fracture in the inferior pubic ramus as a risk factor for discontinuity at the pubic osteotomy site at a mean time of 3.2 years after periacetabular osteotomy., Competing Interests: Declaration of competing interest The authors declare that there is no conflict of interest., (Copyright © 2024 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Introduction: Nonsteroidal anti-inflammatory drugs (NSAIDs) may potentially delay or cause non-union of fractures by inhibiting prostaglandin synthesis. However, studies have shown conflicting results. This systematic review and meta-analysis aim to synthesize current evidence on the potential influence of NSAIDs on bone healing., Methods: We conducted a comprehensive search of PubMed, Embase, and Cochrane CENTRAL databases for studies published up to 25 July 2023. Specific keywords included "NSAID," "nonsteroidal anti-inflammatory drug," "cyclooxygenase-2 inhibitor," "bone healing," "non-union," "pseudoarthrosis," "delayed union," and "atrophic bone." Eligible studies included prospective, retrospective, and case-controlled studies assessing the correlation between NSAID use and bone healing outcomes. The leave-one-out approach was used to test the robustness of the meta-analysis results., Results: A total of 20 studies with 523,240 patients were included in the analysis. The mean patient age ranged from 6.7 to 77.0 years, with follow-up durations from 3 to 67 months. The meta-analysis revealed no significant difference in non-union or delayed union between NSAID users and non-users [pooled adjusted odds ratio (OR) = 1.11; 95% confidence interval (CI): 0.99-1.23]. Initial analysis identified a significant association between NSAID usage and an increased risk of reoperation, but this association became insignificant upon sensitivity analysis (crude OR = 1.42; 95% CI: 0.88-2.28)., Discussion: NSAIDs may have a minimal impact on non-union or delayed union risks. However, caution is advised due to the limited number of studies and the absence of a specific focus on NSAID types and dosages. Further research is necessary to better understand the implications of NSAID use on bone healing., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Chuang, Yang, Tsai and Huang.)

Background: Subacute proximal pole scaphoid fractures (1 month to 6 months) have a higher risk of non-union. The aim of the present retrospective analysis is to evaluate the efficacy of gelled platelet-rich plasma (GPRP) as additional treatment to antegrade headless screw fixation of proximal pole scaphoid fractures. Methods: Forty-one patients were divided into two groups based on surgical treatment received: screw fixation alone (group A) and screw fixation and GPRP application at the fracture site (group B). A short cast was maintained for 4 weeks after surgery. Outcome measures included time to union, need for additional procedures, time to return to work, disabilities of the arm, shoulder, and hand (DASH) questionnaire, Michigan Hand Questionnaire (MHQ) and Mayo wrist score (MWS).Time to union was determined by monthly radiographs and confirmed by a computerized tomographic (CT) scan done at 4 months. Results: Union was achieved in 85.7% of patients in group A and in 100% of patients in group B. Patients in group B showed a faster time to healing (2.3 ± 0.4 months vs 3.1 ± 0.7 months, p = 0.0001) and earlier return to work (10.4 ± 2.2 vs 15.1 ± 2.9, p = 0.0001). There were no significant differences in patient-rated outcomes scores between the two groups at final follow-up. Conclusions: Internal fixation alone is effective in treating subacute proximal pole scaphoid fractures. GPRP application improves bone healing and functional recovery. Level of Evidence: Level III (Therapeutic) [ABSTRACT FROM AUTHOR]