Elsevier

Injury

Volume 45, Supplement 2, June 2014, Pages S3-S7
Injury

Delayed union and nonunions: Epidemiology, clinical issues, and financial aspects

https://doi.org/10.1016/j.injury.2014.04.002Get rights and content

Abstract

Fracture healing is a critically important clinical event for fracture patients and for clinicians who take care of them. The clinical evaluation of fracture healing is based on both radiographic findings and clinical findings. Risk factors for delayed union and nonunion include patient dependent factors such as advanced age, medical comorbidities, smoking, non-steroidal anti-inflammatory use, various genetic disorders, metabolic disease and nutritional deficiency. Patient independent factors include fracture pattern, location, and displacement, severity of soft tissue injury, degree of bone loss, quality of surgical treatment and presence of infection. Established nonunions can be characterised in terms of biologic capacity, deformity, presence or absence of infection, and host status. Hypertrophic, oligotrophic and atrophic radiographic appearances allow the clinician to make inferences about the degree of fracture stability and the biologic viability of the fracture fragments while developing a treatment plan. Non-unions are difficult to treat and have a high financial impact. Indirect costs, such as productivity losses, are the key driver for the overall costs in fracture and non-union patients. Therefore, all strategies that help to reduce healing time with faster resumption of work and activities not only improve medical outcome for the patient, they also help reduce the financial burden in fracture and non-union patients.

Introduction

It has been estimated that 100,000 fractures go on to nonunion each year in the United States. [1]. The reported incidence and prevalence on nonunion vary significantly based on anatomic region and the criteria used to define nonunion. This variability reflects the overall complexity of understanding the epidemiology of nonunion. Risk factors for nonunion can be characterised as either patient dependent or patient independent. Established patient dependent risk factors include advanced age, various medical comorbidities, sex, smoking, non-steroidal anti-inflammatory use, various genetic disorders, metabolic disease and nutritional deficiency [2], [3], [4], [5]. Patient independent factors include fracture pattern, location, and displacement, severity of soft tissue injury, degree of bone loss, quality of surgical treatment and presence or absence of infection [6].

Section snippets

Assessment of nonunion

Assessing a patient with a suspected nonunion involves obtaining a clinical history and physical examination, imaging studies, as well as laboratory testing. Important elements of the patient history include pain with weight bearing and subjective fracture instability. Physical examination should focus on tenderness or motion at the fracture site, deformity, status of the soft tissue envelope, signs of infection, and range of motion at joints adjacent to the fracture site. Radiographic

“Doctor, is my fracture healed yet?”

Following a traumatic injury, patients most common question is whether their fracture is healed. The answer to this question has a very important impact for the patient because it may determine whether they can weight-bear, whether they can return to work, or whether additional surgery may be required. Not knowing whether their fracture is healing normally creates uncertainty as the patient plans their future. When the possibility of additional surgery is added to this uncertainty, significant

When is a fracture healed? Clinical perspective

The clinical evaluation of fracture healing is based on both radiographic findings and clinical findings. Plain radiographic findings that are used to define fracture union include the presence of bridging callus, the number of bridged cortices, and the disappearance of fracture lines. Depending on the fracture site, orientation, and the presence or absence of fixation it can be difficult to clearly evaluate these factors. Fractures that are rigidly fixed with interfragmentary compression may

Do we need a better assessment of fracture healing?

The answer to whether we need a better assessment of fracture healing is an unqualified yes. Fracture healing is a complex, dynamic process with both mechanical and biological components. There is tremendous variability in the characteristics of the patient, the fracture and the treatment all of which impact the time to healing and the chances of a successful repair. Although the end point is dichotomous (healed or not healed) the path to that endpoint may be long and varied, and predicting the

Markers of primary vs. secondary fracture healing

Fracture healing occurs by different mechanisms largely dependent on the mechanical environment at the fracture site [12], [13], [14], [15]. The fixation technique chosen by the surgeon defines the mechanical environment and determines how a fracture proceeds to consolidation. Two general mechanisms of bone healing are recognised in cortical bone. Primary bone healing occurs after surgical stabilization of a fracture with a rigid construct [16]. This type of fracture healing requires a perfect

Financial aspects

Health economics provide the theoretical background and practical tools to assess cost impact of different diseases and the “health economic value” of different treatment options. Many countries such as Australia, Canada and the United Kingdom additionally demand sound health economic data that show the “cost-effectiveness” of a new treatment strategy to justify the overall higher treatment costs [29]. Therefore, the need for health economic data has clearly gained importance, which is also

Financial aspects of prevention of non-unions after acute fracture

Two studies have looked at the health economic aspects of acute tibia fractures, with a focus on fracture healing time in order to assess financial impact of time to fracture consolidation and to avoid development of non-unions [32], [33].

In a retrospective study, Sprague and Bhandari compared medical and health economic results of patients with closed tibial shaft fractures who received early surgical treatment, defined as within 12 h of trauma (n = 16), with delayed treatment, defined as surgery

Costs of established non-unions

Regarding health economics of established non-unions, Beaver et al. determined the direct medical costs for the surgical and medical treatment of an established tibial diapyhseal non-union in 1997 to be US$11,333 for the US [35]. Patil and Montgomery calculated £29,204 for the direct costs of the Ilizarov frame technique in patients with aseptic and or septic tibial or femoral non-unions in the UK [36].

Dahabreh et al. showed that the use of BMP-7 reduces direct treatment costs in patients with

Financial summary

Non-unions are difficult to treat and have a high financial impact. Average direct costs of the treatment of an established long bone non-union have been reported as CN$11,800, US$11,333 and £29,204 [34], [35], [36]. It is obvious that comparison of those figures needs to take into consideration the different health care systems, base year rates, and currencies.

Indirect costs, such as productivity losses, are the key driver for the overall costs in fracture and non-union patients. It has been

Conflicts of interest

David J. Hak has received consultancy fees from RTI Biologics and Invibio.

Daniel Fitzpatrick has received licensing and consulting income from Zimmer and Synthes CMF.

Julius A. Bishop has received teaching honoraria from Synthes/Depuy, royalties from Innomed and research support from Covidien and Zimmer.

J. Lawrence Marsh has received royalties from Biomet Trauma and Oxford University Press.

Hamish Simpson has received institutional support from Stryker.

Volker Alt has acted as a consultant for

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