Joshua A Shapiro1, Matthew R Stillwagon, Paul Tornetta, Thomas M Seaver, Mark Gage, Jeffrey O'Donnell, Keith Whitlock, Seth R Yarboro, Kyle J Jeray, William T Obremskey, Andres Rodriguez-Buitrago, Paul Matuszewski, Feng-Chang Lin, Robert F Ostrum. 1. From the Department of Orthopaedics, University of North Carolina, Chapel Hill, NC (Shapiro, Stillwagon, Lin, and Ostrum), the Department of Orthopaedic Surgery, Boston University, Boston, MA (Tornett and Seaver), the Department of Orthopaedic Surgery, Duke University, Durham, NC (Gage, O'Donnell, and Whitlock), the Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA (Yarboro), the Department of Orthopaedic Surgery, Greenville Health System, Greenville, SC (Jeray), the Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University, Nashville, TN (Obremskey and Rodriguez-Buitrago), and the Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY (Matuszewski).
Abstract
INTRODUCTION: This multicenter cohort study investigated the association of serology and comorbid conditions with septic and aseptic nonunion. METHODS: From January 1, 2011, to December 31, 2017, consecutive individuals surgically treated for nonunion were identified from seven centers. Nonunion-type, comorbid conditions and serology were assessed. RESULTS: A total of 640 individuals were included. 57% were male with a mean age of 49 years. Nonunion sites included tibia (35.2%), femur (25.6%), humerus (20.3%), and other less frequent bones (18.9%). The type of nonunion included septic (17.7%) and aseptic (82.3%). Within aseptic, nonvascular (86.5%) and vascular (13.5%) nonunion were seen. Rates of smoking, alcohol abuse, and diabetes mellitus were higher in our nonunion cohort compared with population norms. Coronary artery disease and tobacco use were associated with septic nonunion (P < 0.05). Diphosphonates were associated with vascular nonunion (P < 0.05). Serologically, increased erythrocyte sedimentation rate, C-reactive protein, parathyroid hormone, red cell distribution width, mean platelet volume (MPV), and platelets and decreased absolute lymphocyte count, hemoglobin, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, and albumin were associated with septic nonunion while lower calcium was associated with nonvascular nonunion (P < 0.05). The presence of four or more of increased erythrocyte sedimentation rate, C-reactive protein, or red cell distribution width; decreased albumin; and age younger than 65 years carried an 89% positive predictive value for infection. Hypovitaminosis D was seen less frequently than reported in the general population, whereas anemia was more common. However, aside from hematologic and inflammatory indices, no other serology was abnormal more than 25% of the time. DISCUSSION: Abnormal serology and comorbid conditions, including smoking, alcohol abuse, and diabetes mellitus, are seen in nonunion; however, serologic abnormalities may be less common than previously thought. Septic nonunion is associated with inflammation, younger age, and malnourishment. Based on the observed frequency of abnormality, routine laboratory work is not recommended for nonunion assessment; however, specific focused serology may help determine the presence of septic nonunion.
INTRODUCTION: This multicenter cohort study investigated the association of serology and comorbid conditions with septic and aseptic nonunion. METHODS: From January 1, 2011, to December 31, 2017, consecutive individuals surgically treated for nonunion were identified from seven centers. Nonunion-type, comorbid conditions and serology were assessed. RESULTS: A total of 640 individuals were included. 57% were male with a mean age of 49 years. Nonunion sites included tibia (35.2%), femur (25.6%), humerus (20.3%), and other less frequent bones (18.9%). The type of nonunion included septic (17.7%) and aseptic (82.3%). Within aseptic, nonvascular (86.5%) and vascular (13.5%) nonunion were seen. Rates of smoking, alcohol abuse, and diabetes mellitus were higher in our nonunion cohort compared with population norms. Coronary artery disease and tobacco use were associated with septic nonunion (P < 0.05). Diphosphonates were associated with vascular nonunion (P < 0.05). Serologically, increased erythrocyte sedimentation rate, C-reactive protein, parathyroid hormone, red cell distribution width, mean platelet volume (MPV), and platelets and decreased absolute lymphocyte count, hemoglobin, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, and albumin were associated with septic nonunion while lower calcium was associated with nonvascular nonunion (P < 0.05). The presence of four or more of increased erythrocyte sedimentation rate, C-reactive protein, or red cell distribution width; decreased albumin; and age younger than 65 years carried an 89% positive predictive value for infection. Hypovitaminosis D was seen less frequently than reported in the general population, whereas anemia was more common. However, aside from hematologic and inflammatory indices, no other serology was abnormal more than 25% of the time. DISCUSSION: Abnormal serology and comorbid conditions, including smoking, alcohol abuse, and diabetes mellitus, are seen in nonunion; however, serologic abnormalities may be less common than previously thought. Septic nonunion is associated with inflammation, younger age, and malnourishment. Based on the observed frequency of abnormality, routine laboratory work is not recommended for nonunion assessment; however, specific focused serology may help determine the presence of septic nonunion.
Authors: J van den Kieboom; P Bosch; J D J Plate; F F A IJpma; R Kuehl; M A McNally; W-J Metsemakers; G A M Govaert Journal: Bone Joint J Date: 2018-12 Impact factor: 5.082
Authors: Salim S Virani; Alvaro Alonso; Hugo J Aparicio; Emelia J Benjamin; Marcio S Bittencourt; Clifton W Callaway; April P Carson; Alanna M Chamberlain; Susan Cheng; Francesca N Delling; Mitchell S V Elkind; Kelly R Evenson; Jane F Ferguson; Deepak K Gupta; Sadiya S Khan; Brett M Kissela; Kristen L Knutson; Chong D Lee; Tené T Lewis; Junxiu Liu; Matthew Shane Loop; Pamela L Lutsey; Jun Ma; Jason Mackey; Seth S Martin; David B Matchar; Michael E Mussolino; Sankar D Navaneethan; Amanda Marma Perak; Gregory A Roth; Zainab Samad; Gary M Satou; Emily B Schroeder; Svati H Shah; Christina M Shay; Andrew Stokes; Lisa B VanWagner; Nae-Yuh Wang; Connie W Tsao Journal: Circulation Date: 2021-01-27 Impact factor: 29.690