Comparison of the rate of delayed/nonunion in fifth metatarsal fractures receiving anti-inflammatory medications

Purpose Controversy exists regarding the acute effect of non-steroidal anti-inflammatory drugs (NSAIDs) on early fracture healing. The purpose of this study was to analyze the rate of nonunion or delayed union in patients with fifth metatarsal (5th MT) fractures. We hypothesize that the use of NSAIDs would increase the rate of nonunion/delayed union in 5th MT fractures. Methods Using PearlDiver, a national insurance database was analyzed. ICD codes were used to identify patients diagnosed with 5th MT fracture from 2007-2018. Patients were grouped by initial management (nonoperative vs. open reduction and internal fixation (ORIF) or non/malunion repair within 60 days) and sub-grouped by whether they had been prescribed at least one pre-defined NSAID. Subsequent ORIF or nonunion/malunion repair operative intervention was used as a surrogate for fracture nonunion/delayed union. Results Of the 10,991 subjects with a diagnosis of 5th MT, 10,626 (96.7%) underwent initial nonoperative treatment, 1,409 of which (13.3%) received prescription NSAIDS within 60 days of diagnosis. 16/1,409 (1.14%) subjects who received anti-inflammatory prescriptions underwent ORIF or repair of non/malunion at least 60 days after diagnosis while 46/9,217 (0.50%; P=0.003483) subjects who did not receive anti-inflammatory prescriptions underwent ORIF or repair of non/malunion at least 60 days after diagnosis. In the 365 subjects who underwent early repair/ORIF (within 60 days), there was no significant difference in the rate of nonunion/delayed union. Conclusion The rate of nonunion/delayed union of 5th MT fractures was significantly higher in subjects receiving NSAIDs within 60 days of initial diagnosis in patients managed non-operatively. Level of evidence Level III

Screw Cutting Vertebrae After Short-Segment Fixation of Pedicle Screw Combined with Kyphoplasty for Kummell Disease ： A Case Report and Literature Review

Introduction: Kummell disease is also known as vertebral fracture nonunion, delayed vertebral collapse and vertebral ischemic necrosis. It often occurs in a delayed manner after spinal injury, and is a complex and rare spinal disease. This study, aimed to report a case of stage 3 Kummell disease, diagnosed using magnetic resonance imaging (MRI) of the lumbar spine.Methods: The subject underwent a short-segment fixation of the pedicle screw combined with kyphoplasty.Results: The patient was satisfied with the relief of back pain after the surgery, but the surgery was found to cause screw cutting vertebrae in the second lumbar vertebra (L2).Conclusion: Short-segment fixation of the pedicle screw combined with kyphoplasty can reconstruct spinal stability, maintain stability of bone cement mass in vertebrae, correct kyphosis deformity, and relieve pain. However, Kummell disease in elderly patients is always accompanied by severe osteoporosis. The common fixation of the pedicle screw is prone to cause screw cutting, loosening, and pulling out. Therefore, we advocate using cement-augmented pedicle screws.

Addition of Bone Marrow Aspirate Concentrate Resulted in High Rate of Healing and Good Functional Outcomes in the Treatment of Clavicle Fracture Nonunion: A Retrospective Case Series

Bone marrow aspirate concentrate (BMAC) is an autologous cell composition that is obtained through a needle aspiration from the iliac crest. The purpose of this study was to evaluate the outcomes of patients treated with open reduction and internal fixation with BMAC supplementation for clavicle fracture nonunion. This was a retrospective case series of 21 consecutive patients with clavicle fracture nonunion that were treated with ORIF and BMAC supplementation between 2013 and 2020. Patients were evaluated for fracture union, time to union, complications related to surgical and donor site, and functional outcome using the Quick Disability of the Arm Shoulder and Hand (QDASH), subjective shoulder value (SSV), and pain. The mean age was 41.8 years. The mean follow-up was 36 months. Twenty (95.2%) patients demonstrated fracture union, with a mean time to union of 4.5 months. Good functional scores were achieved: SSV, 74.3; QDASH, 23.3; pain level, 3.1. There were no complications or pain related to the iliac crest donor site. Supplementary BMAC to ORIF in the treatment of clavicle fracture nonunion is a safe method, resulting in high rates of fracture union and good functional outcomes with minimal complications and pain.

Dynamic Hip Screw versus Cannulated Cancellous Screw in Pauwels Type II or Type III Femoral Neck Fracture: A Systematic Review and Meta-Analysis

Vertically oriented femoral neck fractures (FNFs) are known to be especially unstable FNFs, and they have a higher associated risk of failure. The dynamic hip screw (DHS) technique and the cannulated cancellous screw (CCS) technique are the two main fixation techniques used in the treatment of FNFs. However, no large clinical study has compared the DHS and CCS techniques in patients with high-shear-angle FNFs. MEDLINE, Embase, Cochrane Library, and Web of Science were systematically searched for studies that compared the DHS and CCS techniques for the treatment of Pauwels type II or type III FNF. Pooled analysis was performed to identify differences between the DHS and CCS techniques in Pauwels type II or type III FNF, with a focus on postoperative complications such as fracture nonunion and osteonecrosis of the femoral head (ONFH). We included five studies with a total of 252 patients. The DHS technique was used in 96 patients (DHS group), and the CCS technique was used in 156 patients (CCS group). The pooled analysis revealed that the nonunion rate in the CCS group was significantly higher than that in the DHS group (OR = 0.32; 95% CI, 0.11–0.96; p = 0.04, I2 = 0%), but there was no difference in the incidence of ONFH between the groups (OR = 0.98; 95% CI, 0.20–4.73; p = 0.98, I2 = 53%). For vertically oriented FNFs, the DHS technique is more favorable and has a lower risk of fracture nonunion than the CCS technique.

Analysis of Related Factors Influencing the Efficacy of Extracorporeal Shockwave in the Treatment of Fracture Nonunion: A Prospective Study in Shanghai, China

Background: Extracorporeal shockwave is recommended as the first choice for the treatment of fracture nonunion, However, some patients with fracture nonunion have poor response to extracorporeal shockwave therapy. The present study aimed to investigate related factors which may affect the clinical efficacy of extracorporeal shockwave on fracture nonunion. Methods: Ultrasound examination was applied to observe nonunion gap, local blood supply, hardness of callus and hematoma formation before and after extracorporeal shockwave therapy. The patient's condition was followed up for 12 months after extracorporeal shockwave therapy. Four correlations and regression analysis methods were applied to analyze the factors which were correlated the clinical efficacy of extracorporeal shockwave. Receiver-operating characteristic analysis revealed that the cut-off of the fracture nonunion gap was 4.200 mm and the cut-off of the hardness of callus/impulse energy was 2.555. Single factor linear correlation analysis, multi-factor linear regression analysis, single-factor logistic regression analysis were applied. Results: The four ultrasound signs were significantly correlated with extracorporeal shockwave therapy: nonunion gap (r = -0.723; OR = 3.074), local blood supply (r = 0.611; OR = 0.191), hardness of callus/impulse energy (r = -0.510; OR = 19.942), and hematoma formation (r = 0.722; OR = 0.015). Conclusions: Nonunion gap larger than 4.200 mm and hardness of callus/impulse energy larger than 2.555 are risk factors of extracorporeal shockwave therapy outcome, and good local blood supply and effective hematoma formation induced by extracorporeal shockwave therapy are protective factors. By analyzing the related factors of extracorporeal shockwave therapy on fracture nonunion, clinicians may screen out the patients with fracture nonunion who are not suitable for extracorporeal shockwave therapy, and reduce the risk of fracture nonunion.

Atlantoaxial wiring hardware failure resulting in intracranial hemorrhage and hydrocephalus: illustrative case

BACKGROUND Atlantoaxial sublaminar wiring has many known complications related to hardware failure, but intracranial hemorrhage is a rare complication. OBSERVATIONS A 61-year-old female patient with prior atlantoaxial sublaminar wiring for odontoid fracture nonunion experienced decreased level of consciousness due to a subarachnoid and subdural hemorrhage of the posterior fossa with intraventricular extension and hydrocephalus. Rupture of the sublaminar wire with intramedullary protrusion was the cause of the hemorrhage. The patient was treated with ventriculostomy for hydrocephalus and occipital cervical fusion for spinal instability, along with removal of the broken wire and drainage of a hematoma. LESSONS This uncommon cause of intracranial hemorrhage highlights an additional risk of atlantoaxial sublaminar wiring compared with other atlantoaxial fusion techniques. In addition, this case suggests cervical instrumentation failure as a differential diagnosis of subarachnoid and subdural hemorrhage of the posterior fossa when a history of prior instrumentation is known.