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A scoping review of operative and non-invasive management in the treatment of non-unions

Published:September 28, 2022DOI:https://doi.org/10.1016/j.injury.2022.09.021

      Abstract

      Introduction

      Non-union occurs when a fracture fails to adequately heal, and requires additional intervention to achieve union. The purpose of this scoping review is to provide a high-level overview of the existing non-union management literature. This review aims to highlight the current literature on non-union management, as well as identify key areas that require future research to provide a better understanding of potential non-union management strategies.

      Methods

      This study utilized the scoping review framework from Arksey and O'Malley All relevant literature on non-union management was systematically searched for within the OVID Medline, OVID Embase, and Web of Science databases. As a scoping review, this study aimed to identify the high-level trends in non-union literature. This was assessed through a visual and numerical summary of the general themes in non-union literature, as well as the timeline in which these trends have occurred.

      Results

      The literature search identified 8081 articles, of which 2210 articles were included. There is a large body of evidence for various surgical treatment options for non-union. The literature suggests healing rates between 80 and 100 percent for commonly utilized surgical procedures, such as plating with bone graft for long bones. Despite these beneficial healing rates, the requirement of a surgery creates a large socioeconomic burden. The possibility for bone growth stimulator (BGS) options to achieve non-union healing rates in a similar realm as surgical options suggests that the use of a BGS may be a beneficial option prior to surgical intervention, as this would potentially reduce the number of patients who would otherwise require surgery.

      Conclusion

      A large body of evidence exists on non-union management, which is largely comprised of case series and reports. The most commonly assessed non-unions include the tibia, wrist, and femur. Bone grafting, plating, and nailing are the most investigated treatment options. BGS are a non-operative treatment options for non-union that provide similar healing rates to surgical options in certain indications within initial observational data. BGS are a potential option for non-operative management of non-unions to reduce socioeconomic burdens of surgical intervention, with a need for further high-quality investigation in this therapeutic area.

      Keywords

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      References

        • Ekegren C.L.
        • Edwards E.R.
        • de Steiger R.
        • Gabbe B.J.
        Incidence, costs and predictors of non-union, delayed union and mal-union following long bone fracture.
        Int J Environ Res Public Health. 2018; 15https://doi.org/10.3390/ijerph15122845
        • Zura R.
        • Xiong Z.
        • Einhorn T.
        • et al.
        Epidemiology of fracture non-union in 18 human bones.
        JAMA Surg. 2016; 151e162775https://doi.org/10.1001/jamasurg.2016.2775
        • Bell A.
        • Templeman D.
        • Weinlein J.C.
        Non-union of the Femur and Tibia: an update.
        Orthop Clin N Am. 2016; 47: 365-375https://doi.org/10.1016/j.ocl.2015.09.010
        • Brinker M.R.
        • Trivedi A.
        • OʼConnor D.P.
        Debilitating effects of femoral non-union on health-related quality of life.
        J Orthop Trauma. 2017; 31: e37-e42https://doi.org/10.1097/BOT.0000000000000736
        • Chaudhary M.M.
        Infected non-union of tibia.
        Indian J Orthop. 2017; 51: 256-268https://doi.org/10.4103/ortho.IJOrtho_199_16
        • Mills L.
        • Tsang J.
        • Hopper G.
        • Keenan G.
        • Simpson A.H.R.W.
        The multifactorial aetiology of fracture non-union and the importance of searching for latent infection.
        Bone Jt Res. 2016; 5: 512-519https://doi.org/10.1302/2046-3758.510.BJR-2016-0138
        • Antonova E.
        • Le T.K.
        • Burge R.
        • Mershon J.
        Tibia shaft fractures: costly burden of non-unions.
        BMC Musculoskelet Disord. 2013; 14: 42https://doi.org/10.1186/1471-2474-14-42
        • Nolte P.A.
        • Klein-Nulend J.
        Normal and impaired fracture healing.
        Concepts and cases in non-union treatment. AO Trauma. Georg Thieme Verlag, 2011: 49-55
        • Padhye K.P.
        • Kulkarni V.S.
        • Kulkarni G.S.
        • et al.
        Plating, nailing, external fixation, and fibular strut grafting for non-union of humeral shaft fractures.
        J Orthop Surg Hong Kong. 2013; 21: 327-331https://doi.org/10.1177/230949901302100313
        • Simpson A.H.R.W.
        • Robiati L.
        • Jalal M.M.K.
        • Tsang S.T.J.
        Non-union: indications for external fixation.
        Injury. 2019; 50: S73-S78https://doi.org/10.1016/j.injury.2019.03.053
        • Baldwin P.
        • Li D.J.
        • Auston D.A.
        • Mir H.S.
        • Yoon R.S.
        • Koval K.J.
        Autograft, allograft, and bone graft substitutes: clinical evidence and indications for use in the setting of orthopaedic trauma surgery.
        J Orthop Trauma. 2019; 33: 203-213https://doi.org/10.1097/BOT.0000000000001420
        • Whitfield J.F.
        • Morley P.
        • Willick G.E.
        • Bone Growth Stimulators
        New tools for treating bone loss and mending fractures.
        Vitam Horm. 2002; 65: 1-80https://doi.org/10.1016/s0083-6729(02)65059-9
        • Leighton R.
        • Watson J.T.
        • Giannoudis P.
        • Papakostidis C.
        • Harrison A.
        • Steen R.G.
        Healing of fracture non-unions treated with low-intensity pulsed ultrasound (LIPUS): a systematic review and meta-analysis.
        Injury. 2017; 48: 1339-1347https://doi.org/10.1016/j.injury.2017.05.016
        • Griffin X.L.
        • Costa M.L.
        • Parsons N.
        • Smith N.
        Electromagnetic field stimulation for treating delayed union or non-union of long bone fractures in adults.
        Cochrane Database Syst Rev. 2011; CD008471https://doi.org/10.1002/14651858.CD008471.pub2
        • Palanisamy P.
        • Alam M.
        • Li S.
        • Chow S.K.H.
        • Zheng Y.P.
        Low-intensity pulsed ultrasound stimulation for bone fractures healing: a review.
        J Ultrasound Med Off J Am Inst Ultrasound Med. 2021; (Published online May 5)https://doi.org/10.1002/jum.15738
        • Higgins A.
        • Glover M.
        • Yang Y.
        • Bayliss S.
        • Meads C.
        • Lord J.
        EXOGEN ultrasound bone healing system for long bone fractures with non-union or delayed healing: a NICE medical technology guidance.
        Appl Health Econ Health Policy. 2014; 12: 477-484https://doi.org/10.1007/s40258-014-0117-6
      1. NICE. EXOGEN ultrasound bone healing system for long bone fractures with non-union or delayed healing. Published 2019. https://www.nice.org.uk/guidance/mtg12

        • Mehta S.
        • Long K.
        • DeKoven M.
        • Smith E.
        • Steen R.G.
        Low-intensity pulsed ultrasound (LIPUS) can decrease the economic burden of fracture non-union.
        J Med Econ. 2015; 18: 542-549https://doi.org/10.3111/13696998.2015.1019887
        • Arksey H.
        • O'Malley L.
        Scoping studies: towards a methodological framework.
        Int J Soc Res Methodol. 2005; 8: 19-32https://doi.org/10.1080/1364557032000119616
        • Levac D.
        • Colquhoun H.
        • O'Brien K.K.
        Scoping studies: advancing the methodology.
        Implement Sci. 2010; 5: 69https://doi.org/10.1186/1748-5908-5-69
        • Liberati A.
        • Altman D.G.
        • Tetzlaff J.
        • et al.
        The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.
        PLoS Med. 2009; 6e1000100https://doi.org/10.1371/journal.pmed.1000100
        • Brinker M.R.
        • O'Connor D.P.
        Management of aseptic tibial and femoral diaphyseal non-unions without bony defects.
        Orthop Clin N Am. 2016; 47: 67-75https://doi.org/10.1016/j.ocl.2015.08.009
        • Ferguson D.O.
        • Shanbhag V.
        • Hedley H.
        • Reichert I.
        • Lipscombe S.
        • Davis T.R.C.
        Scaphoid fracture non-union: a systematic review of surgical treatment using bone graft.
        J Hand Surg Eur Vol. 2016; 41: 492-500https://doi.org/10.1177/1753193415604778
        • Jin Y.F.
        • Xu H.C.
        • Shen Z.H.
        • Pan X.K.
        • Xie H.
        Comparing augmentative plating and exchange nailing for the treatment of non-union of femoral shaft fracture after intramedullary nailing: a meta-analysis.
        Orthop Surg. 2020; 12: 50-57https://doi.org/10.1111/os.12580
        • Pinder R.M.
        • Brkljac M.
        • Rix L.
        • Muir L.
        • Brewster M.
        Treatment of scaphoid non-union: a systematic review of the existing evidence.
        J Hand Surg. 2015; 40 (e3): 1797-1805https://doi.org/10.1016/j.jhsa.2015.05.003
        • Munk B.
        • Larsen C.F.
        Bone grafting the scaphoid non-unionA systematic review of 147 publications including 5 246 cases of scaphoid non-union.
        Acta Orthop Scand. 2004; 75: 618-629https://doi.org/10.1080/00016470410001529
        • Leighton R.
        • Phillips M.
        • Bhandari M.
        • Zura R.
        Low intensity pulsed ultrasound (LIPUS) use for the management of instrumented, infected, and fragility non-unions: a systematic review and meta-analysis of healing proportions.
        BMC Musculoskelet Disord. 2021; 22: 532https://doi.org/10.1186/s12891-021-04322-5
        • Aleem I.S.
        • Aleem I.
        • Evaniew N.
        • et al.
        Efficacy of electrical stimulators for bone healing: a meta-analysis of randomized sham-controlled trials.
        Sci Rep. 2016; 6: 31724https://doi.org/10.1038/srep31724
        • Petrisor B.
        • Lisson S.
        • Sprague S.
        Extracorporeal shockwave therapy: a systematic review of its use in fracture management.
        Indian J Orthop. 2009; 43: 161-167https://doi.org/10.4103/0019-5413.50851
        • Willems A.
        • van der Jagt O.P.
        • Meuffels D.E.
        Extracorporeal shock wave treatment for delayed union and non-union fractures: a systematic review.
        J Orthop Trauma. 2019; 33: 97-103https://doi.org/10.1097/BOT.0000000000001361
        • Uchiyama Y.
        • Tateiwa T.
        • Nakajima D.
        • Takatori N.
        • Watanabe M.
        An examination of the factors related to a reduction in the use of low-intensity pulsed ultrasound (LIPUS).
        J Orthop Trauma. 2017; 31: S3https://doi.org/10.1097/01.bot.0000520892.54352.d4
        • Harrison A.
        • Alt V.
        Low-intensity pulsed ultrasound (LIPUS) for stimulation of bone healing - a narrative review.
        Injury. 2021; 52: S91-S96https://doi.org/10.1016/j.injury.2021.05.002
        • Griffin X.L.
        • Warner F.
        • Costa M.
        The role of electromagnetic stimulation in the management of established non-union of long bone fractures: what is the evidence?.
        Injury. 2008; 39: 419-429https://doi.org/10.1016/j.injury.2007.12.014
        • Burns P.B.
        • Rohrich R.J.
        • Chung K.C.
        The levels of evidence and their role in evidence-based medicine.
        Plast Reconstr Surg. 2011; 128: 305-310https://doi.org/10.1097/PRS.0b013e318219c171
        • Mack C.D.
        • Pavesio A.
        • Kelly K.
        • et al.
        Breaking barriers: studying fracture healing in the BONES program.
        J Orthop Trauma. 2021; 35: S22https://doi.org/10.1097/BOT.0000000000002035
        • Irwin D.E.
        • Kelly K.
        • Winer I.
        • Stürmer T.
        • Zura R.
        Methodologies for validation of diagnoses in real-world data: BONES-a case study.
        J Orthop Trauma. 2021; 35: S28https://doi.org/10.1097/BOT.0000000000002036