Clinical management and innovation in fracture nonunion

ABSTRACT

Introduction

With the introduction and continuous improvement in operative fracture fixation, even the most severe bone fractures can be treated with a high rate of successful healing. However, healing complications can occur and when healing fails over prolonged time, the outcome is termed a fracture nonunion. Nonunion is generally believed to develop due to inadequate fixation, underlying host-related factors or infection. Despite the advancements in fracture fixation and infection management, there is still a clear need for earlier diagnosis, improved prediction of healing outcomes and innovation in the treatment of nonunion.

Areas covered

This review provides a detailed description of nonunion from a clinical perspective including state of the art in diagnosis, treatment, and currently available biomaterials and orthobiologics.

Subsequently, recent translational development from the biological, mechanical and infection research fields are presented including the latest in smart implants, osteoinductive materials and in silico modeling.

Expert opinion

The first challenge for future innovations is to refine and to identify new clinical factors for the proper definition, diagnosis and treatment of nonunion. However, integration of in vitro, in vivo, and in silico research will enable a comprehensive understanding of nonunion causes and correlations, leading to the development of more effective treatments.

GRAPHICAL ABSTRACT

KEYWORDS:

• Bone
• nonunion
• fracture
• Fracture-related infection (FRI)
• bone healing

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Article highlights

• Healing complications can occur, and failed bone healing is defined as fracture non-union.

• Many non-union cases have poorly understood etiologies, and treatment approaches can vary.

• Despite the advancements in fracture fixation, non-unions still occur and there is still a clear need for improved patient outcomes through refined management of non-union, as well as innovation in the prediction, diagnosis, and treatment of non-union.

• This review covers several aspects of non-union giving first a detailed description of the problem from a clinical perspective. It then describes the available clinical diagnosis and treatment options and finally it outlines all the recent translational development from the biological, mechanical and infection research fields.

Declaration of interests

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Author contributions statement

C Siverino led the scope, content and structure of the review, overview all contributions from the authors. All authors contributed to the content and the scope of the review. FT Moriarty provided critical feedback and helped shape the manuscript.

Modified from (15) ©2019 Andrzejowski et al., licensed with CC BY 4.0 and from (12), © 2021, Springer Nature Limited.

Additional information

Funding

This paper was not funded.