Mills L, Tsang J, Hopper G, Keenan G, Simpson A H R W
Royal Aberdeen Children's Hospital, Aberdeen, UK
Department of Orthopaedic Surgery, University of Edinburgh, Chancellor's building, 49 Little France Crescent, Edinburgh, EH16 4SB.
Bone Joint Res. 2016 Oct;5(10):512-519. doi: 10.1302/2046-3758.510.BJR-2016-0138.
A successful outcome following treatment of nonunion requires the correct identification of all of the underlying cause(s) and addressing them appropriately. The aim of this study was to assess the distribution and frequency of causative factors in a consecutive cohort of nonunion patients in order to optimise the management strategy for individual patients presenting with nonunion.
Causes of the nonunion were divided into four categories: mechanical; infection; dead bone with a gap; and host. Prospective and retrospective data of 100 consecutive patients who had undergone surgery for long bone fracture nonunion were analysed.
A total of 31% of patients had a single attributable cause, 55% had two causes, 14% had three causes and 1% had all four. Of those (31%) with only a single attributable cause, half were due to a mechanical factor and a quarter had dead bone with a gap. Mechanical causation was found in 59% of all patients, dead bone and a gap was present in 47%, host factors in 43% and infection was a causative factor in 38% of patients.In all, three of 58 patients (5%) thought to be aseptic and two of nine (22%) suspected of possible infection were found to be infected. A total of 100% of previously treated patients no longer considered to have ongoing infection, had multiple positive microbiology results.
Two thirds of patients had multiple contributing factors for their nonunion and 5% had entirely unexpected infection. This study highlights the importance of identifying all of the aetiological factors and routinely testing tissue for infection in treating nonunion. It raises key points regarding the inadequacy of a purely radiographic nonunion classification system and the variety of different definitions for atrophic nonunion in the current mainstream classifications used for nonunion.Cite this article: L. Mills, J. Tsang, G. Hopper, G. Keenan, A. H. R. W. Simpson. The multifactorial aetiology of fracture nonunion and the importance of searching for latent infection. Bone Joint Res 2016;5:512-519. DOI: 10.1302/2046-3758.510.BJR-2016-0138.
骨不连治疗取得成功的结果需要正确识别所有潜在病因并对其进行适当处理。本研究的目的是评估连续一组骨不连患者中致病因素的分布和频率，以便优化针对骨不连个体患者的治疗策略。
骨不连的病因分为四类：机械性；感染；有间隙的死骨；以及宿主因素。对100例连续接受长骨骨折不愈合手术患者的前瞻性和回顾性数据进行分析。
共有31%的患者有单一可归因病因，55%有两种病因，14%有三种病因，1%有所有四种病因。在那些仅有单一可归因病因的患者（31%）中，一半是由于机械性因素，四分之一有有间隙的死骨。在所有患者中，59%存在机械性病因，47%有死骨和间隙，43%有宿主因素，38%的患者感染是致病因素。总共58例被认为是无菌性的患者中有3例（5%）以及9例疑似可能感染的患者中有2例（22%）被发现存在感染。总共100%之前接受治疗且不再被认为有持续感染的患者有多项阳性微生物学结果。
三分之二的患者骨不连有多种促成因素，5%有完全意想不到的感染。本研究强调了在治疗骨不连时识别所有病因因素以及常规检测组织是否感染的重要性。它提出了关于单纯影像学骨不连分类系统的不足以及当前用于骨不连的主流分类中萎缩性骨不连的各种不同定义的关键点。引用本文：L. Mills, J. Tsang, G. Hopper, G. Keenan, A. H. R. W. Simpson. 骨折不愈合的多因素病因及寻找潜在感染的重要性。《骨与关节研究》2016；5：512 - 519。DOI: 10.1302/2046 - 3758.510.BJR - 2016 - 0138。
