Edward K Rodriguez1, Christina Boulton2, Michael J Weaver3, Lindsay M Herder4, Jordan H Morgan5, Aron T Chacko4, Paul T Appleton4, David Zurakowski6, Mark S Vrahas5. 1. Beth Israel Deaconess Medical Center, Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA, USA. Electronic address: ekrodrig@bidmc.harvard.edu. 2. University of Maryland, Shock Trauma, Department of Orthopaedics, Baltimore, MD, USA. 3. Brigham and Women's Hospital, Department of Orthopedic Surgery, Harvard Medical School, Boston, MA, USA. 4. Beth Israel Deaconess Medical Center, Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA, USA. 5. Brigham and Women's Hospital, Department of Orthopedic Surgery, Harvard Medical School, Boston, MA, USA; Massachusetts General Hospital, Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA, USA. 6. Boston Children's Hospital, Departments of Anesthesia and Surgery, Harvard Medical School, Boston, MA, USA.
Abstract
INTRODUCTION: Reported initial success rates after lateral locked plating (LLP) of distal femur fractures have led to more concerning outcomes with reported nonunion rates now ranging from 0 to 21%. Reported factors associated with nonunion include comorbidities such as obesity, age and diabetes. In this study, our goal was to identify patient comorbidities, injury and construct characteristics that are independent predictors of nonunion risk in LLP of distal femur fractures; and to develop a predictive algorithm of nonunion risk, irrespective of institutional criteria for clinical intervention variability. PATIENTS AND METHODS: A retrospective review of 283 distal femoral fractures in 278 consecutive patients treated with LLP at three Level1 academic trauma centers. Nonunion was liberally defined as need for secondary procedure to manage poor healing based on unrestricted surgeon criteria. Patient demographics (age, gender), comorbidities (obesity, smoking, diabetes, chronic steroid use, dialysis), injury characteristics (AO type, periprosthetic fracture, open fracture, infection), and management factors (institution, reason for intervention, time to intervention, plate length, screw density, and plate material) were obtained for all participants. Multivariable analysis was performed using logistic regression to control for confounding in order to identify independent risk factors for nonunion. RESULTS: 28 of the 283 fractures were treated for nonunion, 13 were referred to us from other institutions. Obesity (BMI>30), open fracture, occurrence of infection, and use of stainless steel plate were significant independent risk factors (P<0.01). A predictive algorithm demonstrates that when none of these variables are present (titanium instead of stainless steel) the risk of nonunion requiring intervention is 4%, but increases to 96% with all factors present. When a stainless plate is used, obesity alone carries a risk of 44% while infection alone a risk of 66%. While Chi-square testing suggested no institutional differences in nonunion rates, the time to intervention for nonunion varied inversely with nonunion rates between institutions, indicating varying trends in management approach. DISCUSSION: Obesity, open fracture, occurrence of infection, and the use of stainless steel are prognostic risk factors of nonunion in distal femoral fractures treated with LLP independent of differing trends in how surgeons intervene in the management of nonunion.
INTRODUCTION: Reported initial success rates after lateral locked plating (LLP) of distal femur fractures have led to more concerning outcomes with reported nonunion rates now ranging from 0 to 21%. Reported factors associated with nonunion include comorbidities such as obesity, age and diabetes. In this study, our goal was to identify patient comorbidities, injury and construct characteristics that are independent predictors of nonunion risk in LLP of distal femur fractures; and to develop a predictive algorithm of nonunion risk, irrespective of institutional criteria for clinical intervention variability. PATIENTS AND METHODS: A retrospective review of 283 distal femoral fractures in 278 consecutive patients treated with LLP at three Level1 academic trauma centers. Nonunion was liberally defined as need for secondary procedure to manage poor healing based on unrestricted surgeon criteria. Patient demographics (age, gender), comorbidities (obesity, smoking, diabetes, chronic steroid use, dialysis), injury characteristics (AO type, periprosthetic fracture, open fracture, infection), and management factors (institution, reason for intervention, time to intervention, plate length, screw density, and plate material) were obtained for all participants. Multivariable analysis was performed using logistic regression to control for confounding in order to identify independent risk factors for nonunion. RESULTS: 28 of the 283 fractures were treated for nonunion, 13 were referred to us from other institutions. Obesity (BMI>30), open fracture, occurrence of infection, and use of stainless steel plate were significant independent risk factors (P<0.01). A predictive algorithm demonstrates that when none of these variables are present (titanium instead of stainless steel) the risk of nonunion requiring intervention is 4%, but increases to 96% with all factors present. When a stainless plate is used, obesity alone carries a risk of 44% while infection alone a risk of 66%. While Chi-square testing suggested no institutional differences in nonunion rates, the time to intervention for nonunion varied inversely with nonunion rates between institutions, indicating varying trends in management approach. DISCUSSION: Obesity, open fracture, occurrence of infection, and the use of stainless steel are prognostic risk factors of nonunion in distal femoral fractures treated with LLP independent of differing trends in how surgeons intervene in the management of nonunion.
Authors: Nabil A Ebraheim; Grant S Buchanan; Xiaochen Liu; Maxwell E Cooper; Nicholas Peters; Jacob A Hessey; Jiayong Liu Journal: Orthop Surg Date: 2016-08 Impact factor: 2.071
Authors: Masato Yuasa; Nicholas A Mignemi; Jeffry S Nyman; Craig L Duvall; Herbert S Schwartz; Atsushi Okawa; Toshitaka Yoshii; Gourab Bhattacharjee; Chenguang Zhao; Jesse E Bible; William T Obremskey; Matthew J Flick; Jay L Degen; Joey V Barnett; Justin M M Cates; Jonathan G Schoenecker Journal: J Clin Invest Date: 2015-07-27 Impact factor: 14.808