Aim

Although non-unions being one of the most common complication after long-bone fracture fixation, the definition of this entity remains controversial and varies widely among authors. A clear definition is crucial, not only for the evaluation of published research data but also for the establishment of uniform treatment concepts. The aim of this systematic review was to identify the definitions and different criteria used in the scientific literature to describe non-unions after long bone fractures.

Introduction

Non-unions often arise because of high strain environments at fracture sites. Revision fixation, bone grafting and biologic treatments to treat long bone fracture non-union can be expensive and invasive. Percutaneous strain reduction screws (PSRS) can be inserted as a day-case surgical procedure to supplement primary fixation at a fraction of the cost of traditional treatments. Screw insertion perpendicular to the plane of a non-union can resist shear forces and achieve union by modifying the strain environment. A multi-centre retrospective study was undertaken to confirm the results of the initial published case series, ascertain whether this technique can be adopted outside of the developing institution and assess the financial impact of this technique.

Bone non-union following fracture is a major cause of morbidity in combat casualties.

The various clinical treatments used to prevent or treat non-union remain of limited efficacy. Research therefore continues in pre-clinical animal models in an attempt to identify an effective clinical treatment. The aim of this study was to systematically evaluate emerging pre-clinical therapies in order to rationalise priorities for translational research.

The methodological protocol of this study was registered with the Collaborative Approach to Meta Analysis and Review of Animal Data from Experimental Studies (CAMARADES) and published.

The review identified 3251 animal studies, 851 of which fulfilled the criteria for inclusion as detailed in the protocol. Of these, 702 of the studies described therapies that had progressed to clinical trials and were therefore excluded. The remaining 149 papers described eighteen categories of therapy that represent novel therapies yet to translate to clinical trials. These studies used a range of animal models, with heterogeneity that precluded formal synthesis and meta-analysis.

This study provides a systematic evaluation of novel therapies with potential to prevent or treat non-union. It also represents a novel application of an emerging epidemiological technique to address a key priority in Combat Casualty Care research.

Septic complications of long bone fracture are still a significant clinical problem. Although inflammatory process after intramedullary nailing is a rare complication, its treatment is complex. The aim of this study is to analyze the effectiveness of the treatment of septic complications of the long bone union with use of Reamer–Irrigator–Aspirator (RIA) technique and intramedullary antibiotic-coated PMMA nailing.

An analysis of the effectiveness of treatment of 49 patients with septic non-union of long bones (12 femur, 37 tibia), in which the RIA method was applied with antibiotic cement impregnated intramedullary nailing. Treatment consisted of reaming of long bone canal using the RIA technique and the intramedullary cement coated nail with the targeted antibiotic. Treatment required second stage with nail exchange and PMMA removal after 6 weeks to prevent the resitant strains selection.

In a group of patients treated with use of above-mentioned method the remission of inflammatory process was achieved in all cases. 32 (67%) patients developed bone union, 24 patients with tibial and 8 patients with femoral septic bone union disorders. The average duration of bone union obtainment with intramedullary nailing was 37 weeks. The most common inconveniences that occurred during treatment was prolonged wound discharge and pain.

Inflammatory complications of fractures in our material involved extensive injuries, usually high-energetic.

Despite the increase of surgical procedures for extremities injuries and improvement of various fixation devices and surgical methods, the number of unsatisfactory osteosynthesis results reaches 2–7%. Chronic osteomyelitis after lower extremities long bones osteosynthesis occurs in 1.3–23% of cases, and the percentage of bone nonunion due to infections reaches 83%. We conducted a retrospective analysis of 237 patient treatment with chronic osteomyelitis following tibial and femoral bone osteosynthesis. Two groups were selected for the analysis: the first group contained 194 patients treated with sheets and the second one contained 43 patients treated with intramedullary locked nails. In cases of unconsolidated fractures and false joints, the necrectomy was performed with single-step or two-step replacement of internal fixation for external fixation. In this case segmental bone defects reached 20.9% in the first group and 3.6% in the second one. Here the treatment was performed using the Ilizarov method with the bone defect distraction replacement. Conclusions. 1. Chronic osteomyelitis following sheets usage, unlike the osteomyelitis following the intramedullary locked osteosynthesis, leads more often to the formation of edge and segmental bone defects, which significantly prolongs the treatment duration. 2. External fixation application for postoperative osteomyelitis treatment in case of the bone nonunion made it possible to eliminate the purulent process and restore the extremity support function. 3. The inflammatory process relapses reached 14.9% in the first group and 3.1% in the second one

Olecranon Osteotomy is a common approach used in the management of intraarticular distal humerus fractures. Significant complication rates have been associated with this procedure, including non-union rates of 0–13% and implant removal rates between 12–86%. This study is a multicentre retrospective study involving the largest cohort of olecranon osteotomies in the literature, examining implant fixation types, removal rates and associated complications. Patients were identified between 2007 and 2017 (minimum one year follow-up) via Canadian Classification of Health Interventions (CCI) coding and ICD9/10 codes by our health region's data information service. CCI intervention codes were used to identify patients who underwent surgery for their fracture with an olecranon osteotomy. Reasons for implant removal were identified from a chart review. Our primary outcome was implant removal rates. Categorical data was assessed using Chi square test and Fischer's Exact test. Ninety-nine patients were identified to have undergone an olecranon osteotomy for treatment of a distal humerus fracture. Twenty patients had their osteotomy fixed with a plate and screws and 67 patients were fixed with a tension band wire. Eleven patients underwent “screw fixation”, consisting of a single screw with or without the addition of a wire. One patient had placement of a cable-pin system. Of patients who underwent olecranon osteotomy fixation, 34.3% required implant removal. Removal rates were: 28/67 for TBW (41.8%), 6/20 plates (30%), 0/1 cable-pin and 0/11 for osteotomies fixed with screw fixation. Screw fixation was removed less frequently than TBW p<.006. TBW were more commonly removed than all other fixation types p<.043. Screws were less commonly removed than all other fixation types p<.015. TBW were more likely to be removed for implant irritation than plates, p<.007, and all other implants p<.007. The average time to removal was 361 days (80–1503 days). A second surgeon was the surgeon responsible for the removal in 10/34 cases (29%). TBWs requiring removal were further off the olecranon tip than those not removed p=.006. TBWs were associated with an OR of 3.29 (CI 1.10–9.84) for implant removal if implanted further than 1mm off bone. Nonunion of the osteotomy occurred in three out of 99 patients (3%). K-wires through the anterior ulnar cortex did not result in decreased need for TBW removal. There was no relation between plate prominence and the need for implant removal. There was no association between age and implant removal. The implant removal rate was 34% overall. Single screw fixation was the best option for osteotomy fixation, as 0/11 required hardware removal, which was statistically less frequent than TBW at 28/67. Screw fixation was removed less frequently than TBW and screw fixation was less commonly removed than all other fixation types. Only 6/20 (30%) plates required removal, which is lower than previously published rates. Overall, TBW were more commonly removed than all other fixation types and this was also the case if hardware irritation was used as the indication for removal. Nonunion rates of olecranon osteotomy were 3%

Introduction. Polymicrobial infections are expected to complicate the treatment of bone and joint infections. Septic nonunions often occur after initial open fractures, which prophylactically receive broad-spectrum antibiotics. However, no data that describes frequencies of polymicrobial infections and pathogens evident in course of the treatment of septic nonunions is published. Therefore, this study aims at investigating the frequency and pathogen types in polymicrobial infections. Methods. Surgically treated Patients with long bone septic nonunion admitted between January 2010 and March 2018 were included in the study. Following parameters were examined: age, gender, American Society of Anesthesiologists (ASA) score, body mass index (BMI), and anatomical location of the infected nonunion. Microbiological culture data, polymerase-chain-reaction results of tissue samples, sonication, and joint fluid of the initial and follow-up revision surgeries were assessed. No exclusion criteria were determined. Results. The study encompassed 42 patients with a mean age of 53.9 ± 17.7 years (range, 23 – 93). Sixteen (38.1%) patients were female. In 46.3% of the patients open fractures led to septic nonunion. Twenty-six nonunions occurred at the tibia or fibula, 11 were localized at the femur, 2 at the humerus and 3 at the forearm. Only 2 patients were assessed as ASA type 1, while 26 were ASA type 2 and 12 patients ASA type 3. Mean number of performed surgeries was 6 ± 0.67 (range 2 – 21). In 6 patients (14.3%) polymicrobial infection were evident. A change of evidenced pathogens in course of the treatment occurred in 21 patients (50%). In 16 patients (38.1%) previously detected bacteria could be evidenced by microbial testing after further revision surgery. Staphylococcus aureus was most often evident (n=34, 30.6%), followed by Enterococcus species (n=25, 22.5%) and Staphylococcus epidermidis (n=18, 16.2%). Five Staphylococcus aureus were resistant to methicillin (MRSA). In patients without polymicrobial infection or further germ detection in course of the treatment 86.4% of the infections were due to Staphylococcus species. Patients with change of detected pathogens and polymicrobial infections suffered from more enterococci infections. Infections due to streptococci and gram-negative bacteria could only be evidenced in patients with polymicrobial infection and pathogen change in course of the treatment. Conclusion. The observed difference of microbiological patterns in septic nonunion may help to facilitate adjuvant local and systemic antibiotic treatment in septic nonunion patients. Reasons for the observed difference of microbiological patterns and its influence on patient outcome have still to be elucidated