Infection is a common cause of impaired fracture healing. In the clinical setting, definitive fracture treatment and infection are often treated separately and sequentially, by different clinical specialties. The ability to treat infection while promoting fracture healing will greatly reduce the cost, number of procedures, and patient morbidity associated with infected fractures. In order to develop new therapies, scientists and engineers must understand the clinical need, current standards of care, pathologic effects of infection on fractures, available preclinical models, and novel technologies. One of the main causes of poor fracture healing is infection; unfortunately, bone regeneration and infection research are typically approached independently and viewed as two separate disciplines. Here, we aim to bring these two groups together in an educational workshop to promote research into the basic and translational science that will address the clinical challenge of delayed fracture healing due to infection. Statement of clinical significance: Infection and nonunion are each feared outcomes in fracture care, and infection is a significant driver of nonunion. The impact of nonunions on patie[Q2]nt well-being is substantial. Outcome data suggests a long bone nonunion is as impactful on health-related quality of life measures as a diagnosis of type 1 diabetes and fracture-related infection has been shown to significantly l[Q3]ower a patient's quality of life for over 4 years.  Although they frequently are associated with one another, the treatment approaches for infections and nonunions are not always complimentary and cannot be performed simultaneously without accepting tradeoffs. Furthermore, different clinical specialties are often required to address the problem, the orthopedic surgeon treating the fracture and an infectious disease specialist addressing the sources of infection. A sequential approach that optimizes treatment parameters requires more time, more surgeries, and thus confers increased morbidity to the patient. The ability to solve fracture healing and infection clearance simultaneously in a contaminated defect would benefit both the patient and the health care system.

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. 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. Bone marrow aspirate concentrate (BMAC) is an autologous cell composition containing nucleated cells found in bone marrow, which is obtained through a needle aspiration from the iliac crest. Autologous bone graft provides both osteo-inductive and osteoconductive qualities. Thus, ICBG is considered the gold standard in the treatment of fracture nonunions. However, in the setting of clavicle fracture nonunion, when bone loss and/or shortening are minimal and structural bone graft is often not required, BMAC can provide osteo-inductive qualities and requires less time to obtain, with lower morbidity and pain in the donor site [ 20 ]. In a systematic review of the clinical applications of BMAC done by Gianakos et al. [ 21 ], they reviewed eight studies on the use of BMAC in nonunion and delayed union and found that it shortens time to union and decreases complications with a comparable to better union rate when compared to the use of ICBG. None of the studies reviewed examined the effect on clavicle fractures nonunion [ 21 ]. This study focuses on the proposition that treating clavicle fracture nonunion with open reduction and internal fixation with supplementation of BMAC will result in high rates of union, satisfactory functional and pain scores, and minimal donor site pain and/or complications. Union was defined as a completely bridging bone in two radiographs (i.e., two healed cortices), with obliteration of the fracture gap; this method was described in previous studies [ 22 , 23 , 24 ]. All radiographs were evaluated independently by two senior authors (D.B. and O.C.). Functional outcomes were evaluated using the subjective shoulder value SSV and the Quick Disabilities of the Arm, Shoulder, and Hand (QDASH). Pain level was measured using the visual analogue scale (VAS) for both shoulder and iliac crest donor site; questions were asked regarding complications at the iliac crest donor site. 2.3. Group Surg consisted of seven patients who were treated with ORIF initially for their acute injury, and the course of their management was considerably more heterogenic compared to group Con. The mean patient age was 35 years (range 30–45); there were five males and two, females and three were smokers. Two patients had suffered polytrauma, two were refractures, one was a distal clavicle NEER type 2 fracture, one was treated with a structural fibular allograft due to substantial bone deficit and shortening, and one patient was treated with BMAC after two previously failed ORIF operations without a bone graft. The mean QDASH scores were 23.3 (range 0–63.6) for the entire cohort, 25.2 (range 0–63.6) in group Con, and 19.9 (range 2.3–54.6) in group Surg ( Table 3 ). 4. Discussion The aim of this study was to evaluate the outcome of ORIF supplemented with BMAC for the treatment of clavicle fracture nonunion. A series of 21 patients were included in this study with the main results being a 95.2% union rate with no complications at the donor site. Clavicle fracture nonunion is an infrequent complication to a frequent injury. Previous studies regarding surgical treatment for clavicle fracture nonunion are retrospective in nature and describe small cohorts similar in size to this study. One of the largest studies was published in 2015 by Schnetzke et al., [ 30 ] in which they retrospectively compared treatment of clavicle fracture nonunion treated by ORIF with or without BG in 58 patients. Their long-term follow-up of 8.9 years showed an advantage in the BG group, with 93% union rates compared to only 73% in the non-BG group. In 2017, Rollo et al. [ 31 ] published their series of 57 patients achieving a union rate of 98% and concluded there was a necessity of autogenous or allogeneic bone grafting for patients with an atrophic nonunion. In 2014, Faraud et al. [ 22 ]. achieved a 90.5% union rate in a series of 21 cases and concluded that union is achieved with stable fixation with bone grafting from the site itself or the iliac crest. Other studies with smaller cohorts showed similar results with union rates of 94–100% with the use of BG [ 32 , 33 , 34 , 35 ]. In 2011, Singh et al. Nonunion after Conservative Treatment ( n = 14) Nonunion after Surgical Treatment ( n = 7) Total ( n = 21) Age (years) (SD) 1 45 (14) 35 (5.4) 41.8 (12.7) Gender, Male (%) 10 (71) 5 (71) 15 (71) Smoking (%) 6 (43) 3 (43) 9 (43) Distal clavicle fracture (%) 2 (14) 1 (14) 3 (14) Follow-up (months) (SD) 1 34.4 (15.5) 39.4 (26.3) 36.1

Aims Several previously identified patient-, injury-, and treatment-related factors are associated with the development of nonunion in distal femur fractures. However, the predictive value of these factors is not well defined. We aimed to assess the predictive ability of previously identified risk factors in the development of nonunion leading to secondary surgery in distal femur fractures. Methods We conducted a retrospective cohort study of adult patients with traumatic distal femur fracture treated with lateral locking plate between 2009 and 2018. The patients who underwent secondary surgery due to fracture healing problem or plate failure were considered having nonunion. Background knowledge of risk factors of distal femur fracture nonunion based on previous literature was used to form an initial set of variables. A logistic regression model was used with previously identified patient- and injury-related variables (age, sex, BMI, diabetes, smoking, periprosthetic fracture, open fracture, trauma energy, fracture zone length, fracture comminution, medial side comminution) in the first analysis and with treatment-related variables (different surgeon-controlled factors, e.g. plate length, screw placement, and proximal fixation) in the second analysis to predict the nonunion leading to secondary surgery in distal femur fractures. Results We were able to include 299 fractures in 291 patients. Altogether, 31/299 fractures (10%) developed nonunion. In the first analysis, pseudo-R2 was 0.27 and area under the receiver operating characteristic curve (AUC) was 0.81. BMI was the most important variable in the prediction. In the second analysis, pseudo-R2 was 0.06 and AUC was 0.67. Plate length was the most important variable in the prediction. Conclusion The model including patient- and injury-related factors had moderate fit and predictive ability in the prediction of distal femur fracture nonunion leading to secondary surgery. BMI was the most important variable in prediction of nonunion. Surgeon-controlled factors had a minor role in prediction of nonunion. Cite this article: Bone Jt Open 2023;4(8):584–593.

Aims Postoperative malalignment of the femur is one of the main complications in distal femur fractures. Few papers have investigated the impact of intraoperative malalignment on postoperative function and bone healing outcomes. The aim of this study was to investigate how intraoperative fracture malalignment affects postoperative bone healing and functional outcomes. Methods In total, 140 patients were retrospectively identified from data obtained from a database of hospitals participating in a trauma research group. We divided them into two groups according to coronal plane malalignment of more than 5°: 108 had satisfactory fracture alignment (< 5°, group S), and 32 had unsatisfactory alignment (> 5°, group U). Patient characteristics and injury-related factors were recorded. We compared the rates of nonunion, implant failure, and reoperation as healing outcomes and Knee Society Score (KSS) at three, six, and 12 months as functional outcomes. We also performed a sub-analysis to assess the effect of fracture malalignment by plates and nails on postoperative outcomes. Results The rates of nonunion and reoperation in group U were worse than those in group S (25.0% vs 14.3%; 15.6% vs 5.6%), but the differences were not significant (p = 0.180 and p = 0.126, respectively). Mean KSS in group U at all follow-up periods was significantly worse that in group S (75.7 (SD 18.8) vs 86.0 (SD 8.7); p < 0.001; 78.9 (SD 17.2) vs 89.1 (SD 9.8); p < 0.001; 85.0 (SD 11.9) vs 91.1 (SD 7.2); p = 0.002, respectively). In the sub-analysis of plates, mean KSS was significantly worse in group U at three and six months. In the sub-analysis of nails, the rate of reoperation was significantly higher in group U (28.6% vs 5.8%; p = 0.025), and mean KSS at six and 12 months was significantly worse in Group U. Conclusion To obtain good postoperative functional results, intraoperative alignment of the coronal plane should be accurately restored to less than 5°. Cite this article: Bone Jt Open 2022;3(2):165–172.

Nonunion occurs in 2-10% of all forearm fractures due to different mechanical and biological factors, patient characteristics, and surgeon-dependent causes. It is a condition that causes functional and psychosocial disability for the patient because it is a unique anatomical segment in which all the bones and structures involved embody a complex functional unit; therefore, it is a challenge for the orthopedic surgeon. The ultimate goal of the care of these patients is the restoration of function and limitations related to impairment and disability. The aim of this review is to provide an extended description of nonunion forearm fractures, related risk factors, diagnosis, classification systems, and the available evidence for different types of treatment as a tool to better manage this pathology.

<h4>Objective</h4>To develop an approach for identifying, investigating, and initially managing common causes of chronic wrist pain seen by primary care practitioners.<h4>Sources of information</h4>Relevant clinical evidence and literature were identified using the PubMed database.<h4>Main message</h4>Chronic wrist pain is a common presentation in the primary care setting. The complex anatomy of the wrist leads to a broad differential diagnosis. Elements of history, findings of physical examinations and investigations, and management relevant to the following pathologies are discussed, including scaphoid fracture nonunion, thumb carpometacarpal joint osteoarthritis, scapholunate ligament instability, triangular fibrocartilage complex injuries, de Quervain tenosynovitis, extensor carpi ulnaris tendinopathy, carpal tunnel syndrome, and ganglion cysts. When evaluating chronic wrist pain, diagnostic imaging with x-ray scans can serve as an important ancillary investigation tool but should not override clinical suspicion. Advanced imaging (computed tomography or magnetic resonance imaging) is generally best ordered by a hand surgeon when it will help clarify a diagnosis and guide treatment.<h4>Conclusion</h4>Chronic wrist pain is a functionally limiting problem best managed with timely diagnosis and treatment. A thorough history and physical examination are the cornerstones of an effective evaluation. When diagnosis is delayed, some wrist pathologies can lead to relatively poor outcomes, such as a scaphoid fracture nonunion resulting in diffuse wrist osteoarthritis.

Abstract The cases of non-union or delayed union are the main diagnoses related to complications of orthopedic fractures within the veterinary surgery of companion animals, mainly dogs. Bone graft transplantation is a growing competence as an adjuvant treatment in these cases. The study reveals its use through the evaluation of the data obtained in an advanced research on the topic referring to the main scientific databases, resulting in a systematic review, in addition to proving its means of extraction and conservation. Although there is the possibility of performing autograft and xenograft, among other substitute materials, a choice on the part of the veterinarian must make a tiny assessment of each case. However, this therapeutic approach requires greater professional, structural and, consequently, financial investment by veterinarians and hospital doctors. As well as, the realization of scientific works with the objective of contributing to the evolution of this method of associated treatment and bringing more and more benefits to the orthopedic patient.

Although nonunions are among the most common complications after long-bone fracture fixation, the definition of fracture nonunion remains controversial and varies widely. The aim of this study was to identify the definitions and diagnostic criteria used in the scientific literature to describe nonunions after long-bone fractures. A comprehensive literature search was performed in PubMed, Cochrane Library, Web of Science, and Embase. Prospective clinical studies, in which adult long-bone fracture nonunions were investigated as main subject, were included in this analysis. Data on nonunion definitions described in each study were extracted and collected in a database. Although 148 studies met the inclusion criteria, only 50% (74/148) provided a definition for their main study subject. Nonunion was defined in these studies based on time-related criteria in 85% (63/74), on radiographic criteria in 62% (46/74), and on clinical criteria in 45% (33/74). A combination of clinical, radiographic and time-related criteria for definition was found in 38% (28/74). The time interval between fracture and the time point when authors defined an unhealed fracture as a nonunion showed considerable heterogeneity, ranging from three to twelve months. In the current orthopaedic literature, we found a lack of consensus with regard to the definition of long-bone nonunions. Without valid and reliable definition criteria for nonunion, standardization of diagnostic and treatment algorithms as well as the comparison of clinical studies remains problematic. The lack of a clear definition emphasizes the need for a consensus-based approach to the diagnosis of fracture nonunion centred on clinical, radiographical and time-related criteria.

All three patients with a fair or poor result had had a severe reinjury to the ankle. Based on the findings in this study, we concluded that this procedure will restore good long-term function in a high percentage of patients who are disabled by ankle instability due to unhealed or neglected tears of the lateral ligaments. Published in The Journal of bone and joint surgery. American volume (1985)

<b>Background</b>: This systematic review aimed to evaluate the current evidence regarding the clinical outcome of single- and two-stage revision procedures for long-bone fracture-related infection (FRI). The review focused on unhealed fractures without critical-sized bone defects, treated with internal fixation. <b>Methods</b>: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. A systematic search was carried out in PubMed, Embase via Elsevier, and Web of Science Core collection. <b>Results</b>: Out of 21 126 articles initially identified, 35 studies, including 985 patients, were eligible for the final analysis. A total of 27 studies assessed single-stage revisions, 5 examined two-stage procedures, and 3 included both approaches. The mean bone-healing rate was 80 % for single-stage approaches and 77 % for two-stage approaches. The mean infection eradication rate for single-stage revisions was 87 %, whereas two-stage revisions demonstrated a mean infection eradication rate of 81 %. Only five studies included patients ( n= 34) diagnosed with an FRI within 6 months after the primary fracture fixation. <b>Conclusion</b>: For patients with unhealed long-bone FRIs without critical-sized bone defects, the current literature is of poor quality, heterogeneous, and lacks strong evidence to recommend either a single-stage or two-stage approach with internal fixation. For both protocols, the rate of revision surgery remains high. Furthermore, high-quality studies focusing on two-stage procedures, especially for the treatment of FRIs occurring within 6 months after initial fracture fixation, are almost non-existent. The identification of positive cultures during single-stage procedures for presumed aseptic fracture non-unions might be linked to poorer clinical outcomes.