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Assessment of CompromisedFracture Healing

Abstract

No standard criteria exist for diagnosing fracture nonunion, and

studies suggest that assessment of fracture healing varies among

orthopaedic surgeons. This variability can be problematic in both

clinical and orthopaedic trauma research settings. An

understanding of risk factors for nonunion and of diagnostic tests

used to assess fracture healing can facilitate a systematic

approach to evaluation and management. Risk factors for nonunion

include medical comorbidities, age, and the characteristics of the

injury. The method of fracture management also influences healing.

Comprehensive evaluation includes an assessment of the patient’ssymptoms, signs, and immune and endocrine status as well as the

biologic capacity of the fracture, presence of infection, and quality

of reduction and fixation. Diagnostic tests include plain radiography,

CT, ultrasonography, fluoroscopy, bone scan, MRI, and several

laboratory tests, including assays for bone turnover markers in the

peripheral circulation. A systematic approach to evaluating fracture

union can help surgeons determine the timing and nature of

interventions.

Nonunion

Currently, no standard criteria exist

to define when a fracture may be

classified as a nonunion. The FDA

defines nonunion as a fractured bone

that has not completely healed

within 9 months following injury

and shows no progression toward

healing on serial radiographs over

the course of 3 consecutive months.1

Fracture healing is dependent on

multiple factors, including the bone

involved, fracture site, and the initial

degree of bone loss. It is widely ac-

cepted that certain bones have a

greater propensity to go on to non-

union than do others; this propensity

can vary by location on a single bone

(eg, fifth metatarsal). Clinicians also

consider factors such as time elapsed

since injury and clinical and radio-graphic findings. In some cases asso-

ciated with severe soft-tissue injury

and bone loss, nonunion can be

anticipated at the time of the index

injury. Ultimately, fracture healing is

a continuum, and establishing a di-

agnosis of nonunion remains diffi-

cult.

Lack of Physician

Consensus

In the orthopaedic community, a

lack of consensus exists regarding as-

sessment of bony union. In 2002,

Bhandari et al2 surveyed 444 orthopae-

dic surgeons to examine methods of as-

sessing tibial shaft fracture healing. Sur-

geons were asked how often the

following criteria were used in the as-

Julius A. Bishop, MD

Ariel A. Palanca, MD

Michael J. Bellino, MD

David W. Lowenberg, MD

From the Department of

Orthopaedic Surgery, Stanford

University Medical Center, Redwood

City, CA.

Dr. Bishop or an immediate family

member is a member of a speakers’

bureau or has made paid

presentations on behalf of Synthes.

Dr. Lowenberg or an immediate

family member is a member of a

speakers’ bureau or has made paid

presentations on behalf of Stryker

and serves as a paid consultant to

Stryker and Ellipse Technologies.

Neither of the following authors or

any immediate family member has

received anything of value from or

owns stock in a commercial

company or institution related

directly or indirectly to the subject of

this article: Dr. Palanca and

Dr. Bellino.

J Am Acad Orthop Surg 2012;20:

273-282

http://dx.doi.org/10.5435/

JAAOS-20-05-273

Copyright 2012 by the American

Academy of Orthopaedic Surgeons.

Review Article

May 2012, Vol 20, No 5 273



sessment of fracture healing: callus size,

cortical continuity, progressive loss of

fracture line, pain with weight bearing,

and pain on palpation of the fracture

site. Substantial variability was report-

ed; 39.7% to 45.4% of surgeons al-

ways considered these parameters,whereas 20.7% to 26.9% considered

them occasionally or never. The au-

thors also asked the surgeons to pro-

vide a time point beyond which a de-

layed union becomes a nonunion.

Responses varied, with definitions of

delayed union ranging from 1 to 8

months and definitions of nonunion

ranging from 2 to 12 months.

Incidence and Prevalenceof Nonunion

In the United States, delayed healing

has been reported in approximately

600,000 fractures per year, and

100,000 progress to nonunion.3 Re-

ported incidence and prevalence of

nonunion remain variable given the

lack of standard criteria and differ-

ences in fracture healing among ana-

tomic regions. For example, the re-

ported rates of humeral nonunionrange from <5% to 39%.4,5 In addi-

tion, some authors have reported

conflicting data regarding the actual

anatomic location on the humerus.

Some report that fractures at the

proximal to middle third junction of

the humerus are at increased risk of

nonunion; others suggest that the

middle to distal third junction of the

bone is at increased risk.6-8 The in-

consistencies in the literature reflect

the complexity involved in under-

standing and characterizing fracture

nonunion.

Risk Factors for Nonunion

Patient Dependent

Patient-dependent risk factors for

nonunion include various medical

comorbidities, age, sex, smoking, use

of nonsteroidal anti-inflammatory

drugs (NSAIDs), genetic disorders

(eg, neurofibromatosis, osteogenesis

imperfecta, osteopetrosis), metabolic

disease, and nutritional status. Frac-

ture healing can be inhibited by sev-eral medical conditions, including di-

abetes and vascular disease.9,10 The

roles of age and sex in fracture heal-

ing have been studied less frequently

than those of smoking and anti-

inflammatory use; however, in per-

sons with clavicle fracture, female

sex and advanced age have been as-

sociated with an increased risk of

nonunion.11

Basic science research has demon-

strated that smoking and nicotineuse are deleterious to several bio-

chemical pathways important for

fracture healing, with nicotine nega-

tively affecting arteriolar blood

flow.12 This research has been cor-

roborated by increasingly strong

clinical evidence linking nicotine and

tobacco use to fracture healing

complications.13-16 Because normal

fracture healing is associated with in-

flammation and prostaglandin syn-

thesis, NSAIDs that interfere withthese processes should theoretically

interfere with fracture healing, as

well. Although this theory remains

controversial, several basic science

and clinical studies have substanti-

ated this hypothesis.17-20

Metabolic or endocrine pathology

may also play a role in fracture heal-

ing; a recent study demonstrated that

patients with unexplained nonunion

had a high incidence of previously

undiagnosed metabolic or endocrine

pathology, including hypothyroidism

or vitamin D deficiency.21 The nutri-

tional status of the host also plays a

role in fracture healing; chronically

ill or polytraumatized patients who

are in a catabolic state have compro-

mised healing potential. Knowledge

of all of these risk factors is impor-

tant in understanding both the nor-

mal and interrupted processes of

fracture healing (Table 1).

Patient Independent

Patient-independent factors that af-

fect fracture healing are associated

with the characteristics of the injury,

including the pattern of bony injury,

location of the fracture, status of the

soft-tissue envelope, and extent of

bone loss. Researchers have reported

that, in various anatomic regions,

several osseous details are associated

with an increased risk of nonunion.11

For example, in fractures of the clav-

icle, comminution and lack of corti-

cal apposition between fragments

have been associated with increased

risk of nonunion. The location of the

Table 1

Risk Factors for CompromisedFracture Healing

Patient Dependent

Medical comorbidities (eg, diabetes,vascular disease)

Advanced age

Sex

Smoking/nicotine use

Alcohol abuse

Nonsteroidal anti-inflammatory drug use

Nutritional deficiency

Radiation treatment

Genetic disorders (eg, neurofibromato-sis, osteogenesis imperfecta, osteo-petrosis)

Metabolic disease or endocrine pathol-ogy (eg, hypothyroidism, vitamin Ddeficiency)

Patient Independent

Pattern of bony injury

Degree of comminution

Cortical apposition

Interposed soft tissue

Bone involved

Fracture site on the bone

Status of the soft tissues

Extent of bone loss

Quality of surgical treatment

Infection

Assessment of Compromised Fracture Healing

274 Journal of the American Academy of Orthopaedic Surgeons



fracture on a bone can be an impor-

tant prognostic factor for nonunion.

Sites such as the scaphoid waist,

metadiaphyseal region of the fifth

metatarsal, and tarsal navicular body

have a relatively tenuous blood sup-

ply, and fractures in these areas arebelieved to have compromised heal-

ing potential.22-24 Similarly, open

fractures display compromised heal-

ing secondary to soft-tissue stripping

and increased risk of infection asso-

ciated with these severe injuries.25

Bone loss is also a risk factor for

nonunion and, although the absolute

amount of bone loss beyond which

healing cannot occur has not been

defined, the concept of the critical-

sized defect has been introduced tocharacterize an osseous defect that is

not expected to heal without second-

ary intervention.26

Methods of fracture management

have a strong influence on fracture

healing. Some believe that surgical

fixation is associated with improved

outcomes in patients with fractures

in areas with tenuous blood supply,

such as the scaphoid and metadia-

physeal fifth metatarsal.22,23 Intraop-

erative technique plays a critical rolewhen fixation is indicated; excessive

stripping of the periosteum by the

surgeon can compromise the biologic

environment of the fracture and re-

tard healing. Inadequately stabilized

fractures may not heal. Interfrag-

mentary micromotion and low

amounts of strain have been found

to stimulate both intramembranous

and endochondral ossification; how-

ever, large amounts of strain and ex-

cessive motion lead to deposition of

only connective tissue, not fracture

healing.27 The amount of strain de-

pends on fracture comminution, the

size of the fracture gap, and the over-

all stability of the construct. Basic

principles of fracture fixation assert

that comminuted fractures respond

well to bridge plating and relative

stability, whereas simple fractures

should be anatomically reduced,

compressed, and stabilized rigidly.28

Although some authors have hypoth-

esized that overly rigid stabilization

may result in nonunion, the data are

still preliminary,29 and extremely

rigid stabilization (ie, 90° doubleplating) of established nonunions re-

mains a mainstay of management.

Shear is another factor believed to

inhibit fracture healing. In a study of

the correlation of shear to compres-

sion in oblique fractures, shear be-

came an overwhelming force when

axial load was applied to a fracture

with obliquity >30° that was stabi-

lized with external fixation.30 Al-

though much of the research on

shear has been done in the setting of external fixation, the same principles

may apply to oblique fractures man-

aged nonsurgically or with internal

fixation.

Evaluation

Clinical

Initial evaluation of suspected non-

union begins with a thorough history

and physical examination. Importantelements of the patient history in-

clude mechanism of injury, whether

the fracture was open or closed,

presence of pain with weight bear-

ing, subjective instability, and his-

tory or symptoms of infection. Physi-

cians should specifically ask about

delayed wound healing, postopera-

tive wound drainage, and a diagnosis

of cellulitis made by another physi-

cian. A history of any of these issues

raises suspicion of deep infection in

the setting of persistent pain or com-

promised healing. In addition, a

thorough knowledge of all previous

interventions and any associated

complications is essential for assess-

ment of compromised fracture heal-

ing.

Physical examination should assess

tenderness on palpation, motion at

the fracture site, deformity, status of

the soft-tissue envelope, limb vascu-

larity, and range of motion at joints

adjacent to the fracture site. Before

management is initiated, limb-length

inequality in the lower extremity

must be detected and characterized.In the case of a long-standing non-

union with deformity, the surgeon

must account for compensatory

changes at adjacent joints. In chronic

nonunions about the knee, associ-

ated joint contracture is common.

These contractures must be fully

characterized before intervention be-

cause the final functional result can

be compromised if the patient cannot

adequately straighten the knee to

bear weight effectively. Similarly, dis-

tal tibial nonunions are often associ-

ated with an equinus deformity of

the ankle. This deformity must be

recognized and addressed at the time

of nonunion repair. In our experi-

ence, untreated equinus can be the

source of ongoing disability for the

patient and is often what bothers

him or her most after the fracture

has healed.

Radiographic

Orthogonal AP, lateral, and oblique

views of the affected limb are ob-

tained to assess the personality of the

nonunion and limb alignment. In the

lower extremity, if possible, a long

weight-bearing view from hips to an-

kles of both limbs can better define

deformity and limb-length inequality.

Distinct radiographic characteris-

tics are expected based on the initial

management strategy. When ana-

tomic reduction and interfragmen-

tary compression have been

achieved, primary bone healing with-

out fracture callus should be ex-

pected. When nonsurgical manage-

ment or less stable fixation has been

used, secondary bone healing with

callus formation should be observed.

Signs of nonunion include the ab-

Julius A. Bishop, MD, et al

May 2012, Vol 20, No 5 275



sence of bone bridging at the fracture

site, sclerotic fracture edges, persis-

tent fracture lines, and lack of pro-

gressive healing on serial radio-

graphs as well as loosening or

breakage of surgical implants.

Several authors have proposed cri-teria for radiographic fracture heal-

ing, such as bridging callus visible on

two radiographic views, contact of

three of four cortices, and disappear-

ance of fracture lines.31-33 However,

clinical research has shown that

plain radiography alone is not al-

ways a reliable indicator of fracture

healing, with poor agreement re-

ported among surgeons in several

trials.2,34-37 More recently, a radio-

graphic union scale for tibial frac-tures (ie, RUST) has been introduced

(Table 2).38,39 In this system, fracture

callus on each of four cortices seen

on standard AP and lateral views is

graded on a scale of one to three,

with a score of one indicating the

presence of a fracture line without

callus and a score of three indicating

the absence of a fracture line with

bridging callus. This scoring system

has shown early promise with

greater interobserver reliability thanother conventional techniques for as-

sessing radiographic union; however,

correlation with functional outcome

has not yet been established, and ad-

ditional validation research is ongo-

ing.38,39 We believe that plain radiog-

raphy provides a great deal of

information and can be used to de-

termine whether a fracture is healed

in most cases.

Once diagnosis of nonunion has

been established, a classification sys-tem can be used to categorize the

type of nonunion based on radio-

graphic appearance (Table 3). Non-

unions can be characterized as hyper-

trophic, atrophic, or oligotrophic.

The radiographic appearance of a

hypertrophic nonunion is marked by

abundant callus formation without

bony bridging (Figure 1). This ap-

pearance implies adequate biologic

capacity for healing but inadequate

mechanical stability. Radiographiccharacteristics of an atrophic non-

union include sclerotic bone ends

and the absence of callus, which im-

plies inadequate osteogenic potential

at the fracture site (Figure 2). Oligo-

trophic nonunions exist in the con-

tinuum between hypertrophic and

atrophic nonunions and share some

of the radiographic and biologic

characteristics of each. Typically oli-

gotrophic nonunions possess ade-

quate biologic capacity for healingbut demonstrate little to no callus

formation.

CT also can be used to assess frac-

ture union. The accuracy of this mo-

dality for diagnosis of tibial non-

union has been investigated recently.

Bhattacharyya et al40 evaluated the

CT scans of 35 patients with possible

tibial nonunion. The benchmark for

union was defined as union at the

time of surgery or following 6

months of observation. In this study,CT was 100% sensitive, 62% spe-

cific, and 89.9% accurate for detec-

tion of nonunion. Although the high

sensitivity of CT suggests that it may

be effective as an initial screening

test in equivocal cases of tibial frac-

ture healing, it is limited by low

specificity that could produce false-

Table 2

Radiographic Union Scale for Tibial Fractures (RUST)

Radiographic Criteria

Score per Cortexa Callus Fracture Line

1 Absent Visible2 Present Visible

3 Present Invisible

aThe individual cortical scores (anterior, posterior, medial, and lateral) are added to provide

an overall RUST value ranging from 4 (ie, definitely not healed) to 12 (ie, definitely healed)for a set of radiographs.Adapted with permission from Kooistra BW, Dijkman BG, Busse JW, Sprague S, SchemitschEH, Bhandari M: The radiographic union scale in tibial fractures: Reliability and validity. J Orthop Trauma 2010;24(suppl 1):S81-S86.

Table 3

Types and Characteristics of Nonunion

Type Biologic Characteristics Radiographic FindingsTechnetium-99 Bone

Scan Findings

Hypertrophic Biologic capacity for healing withinadequate mechanical stability

Abundant callusLack of bony bridging

Increased uptake

Oligotrophic Biologic potential for healing withno initiation of healing

Little to no callus formation Increased uptake

Atrophic Litt le to no osteogenic potential Sclerotic bone endsAbsence of callus

Decreased uptake





positive results, leading to unneces-

sary surgery.

The use of other, less commonly

employed imaging modalities such as

ultrasonography, fluoroscopy, and

technetium-99 bone scan has also

been promoted. Ultrasonographycan be used to detect hyperechoic

fracture callus. In a clinical setting,

Moed et al33 demonstrated that ul-

trasonography had a positive predic-

tive value of 97% and sensitivity of

100% in detecting healing in tibial

fractures managed with intramedul-

lary nailing. Using ultrasonography,

the investigators were able to predict

union at a mean of 38 days post sur-

gery compared with a mean of 127

days required for diagnostic confir-mation with conventional radiogra-

phy. Despite the advantages of ear-

lier detection of union and avoidance

of ionizing radiation, ultrasonogra-

phy remains user dependent and is

not used routinely to assess fracture

healing.

Fluoroscopy can also be useful for

evaluation of possible nonunion;

stress can be applied at the fracture

site, and a direct assessment of mo-

tion can be made. This technique ismore helpful in evaluating question-

ably healed fractures with no hard-

ware in place to prevent the surgeon

from producing the gross motion

necessary to detect nonunion on flu-

oroscopy. Bone scan can be used to

characterize the vascularity and bio-

logic activity of the fracture site. In-

creased uptake is observed in vascu-

larized and viable fractures, and

decreased uptake is observed in avas-

cular and nonviable fractures.41 In

our practice, this modality does not

play a significant role in the evalua-

tion of fracture union. Prior to the

emergence of CT technology, tomog-

raphy was used to scrutinize the de-

tails of fracture healing, but this mo-

dality is now primarily of historical

interest.

MRI has some diagnostic benefit in

AP (A), lateral (B), and internal rotation oblique (C) radiographsdemonstrating hypertrophic nonunion in a distal tibial shaft fracture in a 52-year-old woman initially managed with open reduction and internal fixationthat was later complicated by infection and loss of fixation. The patient wastreated with irrigation, débridement, hardware removal, and casting. Thehypertrophic nonunion is characterized by abundant callus formation withoutbridging bone.

Figure 1

AP (A) and lateral (B) radiographs of an atrophic nonunion of the humerus ina 22-year-old man with a humeral shaft fracture that was treated with flexibleintramedullary nails. The atrophic nonunion is characterized by lack offracture callus and sclerotic bone ends.

Figure 2


May 2012, Vol 20, No 5 277



the workup of a potentially infected

nonunion. This modality can be used

to assess the presence and extent of

pathologic changes in the bone mar-

row and surrounding soft tissues.

Evaluation of fracture healing is best

done before and after administrationof gadolinium to facilitate assess-

ment of the enhancement pattern in

order to differentiate between infec-

tious focus and fibrovascular scar.42

Laboratory

Laboratory analysis is performed af-

ter clinical and radiographic evalua-

tion and plays a critical role in the

assessment of fracture healing. When

nonunion is suspected, a workup for

infection must be completed, includ-

ing a complete blood count with dif-

ferential, platelet count, erythrocyte

sedimentation rate, and C-reactive

protein level. However, the presence

of normal inflammatory markers

does not exclude the possibility of in-

fection at the nonunion site; in our

experience, normal markers are more

common than not in nonunion with

an indolent infection.

Patients with unexplained or unex-

pected nonunions may warrant more

sophisticated laboratory tests. In a

study of metabolic and endocrine ab-

normalities in patients with non-

unions, Brinker et al21 studied 37

patients who met the following

screening criteria: (1) unexplained

nonunion despite adequate reduction

and stabilization, (2) history of mul-

tiple low-energy fractures with at

least one progressing to nonunion, or

(3) nonunion of a nondisplaced pel-

vic fracture. The authors referred

these patients to an endocrinologist

for metabolic and endocrine evalua-

tion. Thirty-one of 37 patients had a

newly diagnosed endocrine or meta-

bolic disorder, with vitamin D defi-

ciency being the most common.

Other pathology included poor di-

etary calcium intake, hypothyroid-

ism, and hypogonadism. Age, sex,

and nonunion type were not found

to be predictive of endocrine abnor-

mality. Based on these findings, the

authors recommend referring pa-

tients who meet these criteria to an

endocrinologist (Figure 3). An endo-crine evaluation should also be con-

sidered for the apparently healthy

patient with nonunion who has un-

dergone technically appropriate and

uncomplicated treatment. When en-

docrinology consultation is readily

available, we prefer that the endocri-

nologist order more sophisticated

laboratory tests at his or her discre-

tion. If endocrinology consultation is

unavailable, the initial laboratory

screening, including tests to checkserum calcium, serum 25-hydroxy-

vitamin D, thyroid-stimulating hor-

mone, and phosphorus and alkaline

phosphatase levels, can be ordered

by the orthopaedic surgeon.

Recently, several studies have ana-

lyzed the role of various bone turn-

over markers in fracture union

assessment.43-45 During fracture healing,

quantitative changes can be detected in

systemically circulating bone resorption

markers, bone formation markers, andosteoclast regulatory proteins such

as C-telopeptide of type-I collagen,

C-terminal telopeptide of type-I colla-

gen, pyridinoline, deoxypyridinoline,

tartrate-resistant acid phosphatase, os-

teocalcin, and bone-specific alkaline

phosphatase. However, analysis of

these markers has yet to find a routine

and practical role in clinical practice;

their application remains a promising

area for future research.

Characterization ofNonunion

Once diagnosis of nonunion has

been established, the final step before

formulating a treatment plan is to

comprehensively characterize the

nonunion in terms of biologic capac-

ity, presence of deformity and/or in-

fection, and host status.

Biologic Capacity

The biologic capacity of a fracture

refers to the environment in which

the fractured bone ends exist, whichhas direct bearing on the ability of

the fracture to progress to union.

There must be adequate vascular

supply not just to the surrounding

tissues but also to the fracture frag-

ments, as well. As previously men-

tioned, the hypertrophic, atrophic,

or oligotrophic radiographic appear-

ance of an unhealed fracture can be

used to make inferences about bio-

logic capacity. A hypertrophic ap-

pearance implies adequate biologic

capacity, and clinical experience cor-

roborates this; these fractures gener-

ally heal with stabilization alone. In

contrast, an atrophic appearance im-

plies inadequate biologic capacity,

and the addition of an osteoinductive

agent is generally required for heal-

ing to occur. Oligotrophic nonunions

share some of the characteristics of

both hypertrophic and atrophic non-

union; they typically possess ade-

quate biologic capacity for healing

but demonstrate little to no callus

formation.

Deformity

Deformity associated with nonunion

must be completely evaluated and

understood before the treatment plan

is formulated. A nonunion can be

well aligned, poorly aligned, and/or

associated with bone loss. As with

any fracture, the length, alignment,

and rotation must all be evaluated.

Depending on the location of the

nonunion, this often requires a com-

parison of the absolute and relative

limb length of both the injured and

contralateral extremities. Full-length

standing AP radiographs of the

lower extremities or a single-cut CT

scanogram are effective for this com-





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May 2012, Vol 20, No 5 279



parison. Rotational deformities, in

particular, can be difficult to charac-

terize; a CT of the affected and con-

tralateral extremity can be helpfulfor comparison. More frequently,

however, we rely on our detailed

clinical assessment to characterize

the rotational problem. Compensa-

tory changes in adjacent bones and

joints need to be assessed. In the set-

ting of a well-aligned nonunion, the

primary goal of management is to at-

tain union. In the setting of defor-

mity, goals include restoration of

length, alignment, and rotation.

Infection

Determining whether a nonunion is

infected is a critical step in formulat-

ing an appropriate treatment plan.

After a thorough initial history and

physical examination and a complete

radiographic and laboratory evalua-

tion, the surgeon must decide

whether he or she suspects an indo-

lent infection. Aspiration or biopsy

can be performed when uncertainty

persists. If fluid collection can be ap-

preciated at the site of nonunion, ei-

ther clinically or with the use of ul-

trasonography, then aspiration can

be useful. It can be performed in

clinic or a radiology suite, and often

only local anesthesia is required. If

no collection can be detected, we

prefer open biopsy, which we per-

form ourselves in the operating

room.

To maximize the chance of identi-

fying an organism, we recommend

that antibiotics be discontinued 2

weeks before the open biopsy is per-

formed. Biopsy specimens should be

submitted for Gram stain, cell count,

culture, and pathology. If any cloudy

fluid or necrotic tissue is encountered

at the time of biopsy, suspicion of in-

fection should be heightened. The

presence of a subclinical infection is

not uncommon, even when an or-

ganism cannot be successfully identi-

fied. When infection is present, the

goals of management must extend

beyond fracture union and correc-

tion of deformity to include eradica-

tion of infection because infection

can further complicate nonunion

management.

Host StatusConsideration of the overall medical

status of the patient is essential for

treatment planning and prognostica-

tion. In 1985, Cierny et al46 intro-

duced a classification system for the

clinical staging of osteomyelitis that

evaluates not only the anatomic type

of osteomyelitis but also stratifies the

host based on perceived ability to

clear infection and withstand and

benefit from treatment (Table 4).

The authors classified healthy pa-

tients as A hosts, whereas B hosts

possess comorbidities known to have

a detrimental effect on wound heal-

ing. C hosts are patients who are

considered candidates for palliative

care only, not curative surgery, be-

cause the treatment could be more

harmful than the underlying infec-tion. Although this system was de-

signed for osteomyelitis rather than

nonunion, we find it to be useful for

characterizing patients who present

with unhealed fractures.

Summary

No standard criteria exist to define

when a fracture may be classified as

a nonunion; thus, assessment of frac-ture healing varies among orthopae-

dic surgeons. An improved under-

standing of the risk factors for

compromised fracture healing, com-

bined with an expanding armamen-

tarium of imaging techniques, labo-

ratory tests, and clinical scoring

systems, should facilitate more sys-

tematic and less variable evaluations.

The surgeon must understand the bi-

ologic properties of the fracture and

the nature of any associated defor-mity, determine whether an infection

is present, and consider the overall

medical status of the host before for-

mulating a plan for management of

nonunion.

References

Evidence-based Medicine: Levels of

evidence are listed in the table of

contents. In this article, references 2,

8, 11, 38, and 39 are level II studies.

References 13, 16, and 33-36 are level

III studies. References 4-7, 9, 10, 21,

25, and 46 are level IV studies.

References 37 and 42 are level V

expert opinion.

References printed in bold type are

those published within the past 5

years.

Table 4

Cierny-Mader Host Physiologic Status Classification

Host Physiologic Class Description

A Good immune system and delivery

B Immune response is compromised in local wound

healing (BL

) or systemically (BS

) or combined(BL,S)

C Requires suppressive or no treatment, minimal dis-ability, treatment worse than disease, not a surgi-cal candidate

Adapted with permission from Cierny G III, Mader JT, Penninck JJ: A clinical staging systemfor adult osteomyelitis. Clin Orthop Relat Res 2003;(414):7-24.





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