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Ahmed Halloum Interdisciplinary Orthopaedics, Aalborg University Hospital, Hobrovej, Aalborg, Denmark

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Søren Kold Interdisciplinary Orthopaedics, Aalborg University Hospital, Hobrovej, Aalborg, Denmark

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Jan Duedal Rölfing Department of Orthopaedics, Aarhus University Hospital, Palle Juul-Jensens Boulevard, Aarhus, Denmark

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Ahmed A Abood Interdisciplinary Orthopaedics, Aalborg University Hospital, Hobrovej, Aalborg, Denmark
Department of Orthopaedics, Aarhus University Hospital, Palle Juul-Jensens Boulevard, Aarhus, Denmark

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Ole Rahbek Interdisciplinary Orthopaedics, Aalborg University Hospital, Hobrovej, Aalborg, Denmark

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Purpose

  • The objective of this scoping review was to describe the extent and type of evidence of using guided growth to correct rotational deformities of long bones in children.

Methods

  • This scoping review was conducted in accordance with the JBI methodology for scoping reviews. All published and unpublished studies investigating surgical methods using guided growth to perform gradual rotation of long bones were included.

Results

  • Fourteen studies were included: one review, three clinical studies, and ten preclinical studies. In the three clinical studies, three different surgical methods were used on 21 children. Some degree of rotation was achieved in all but two children. Adverse effects reported included limb length discrepancy (LLD), knee stiffness and rebound of rotation after removal of tethers. Of the ten preclinical studies, two were ex vivo and eight were in vivo. Rotation was achieved in all preclinical studies. Adverse effects reported included implant extrusions, LLD, articular deformities, joint stiffness and rebound of rotation after removal of tethers. Two of the studies reported on histological changes.

Conclusions

  • All studies conclude that guided growth is a potential treatment for rotational deformities of long bones. There is great variation in animal models and surgical methods used and in reported adverse effects. More research is needed to shed light on the best surgical guided growth method, its effectiveness as well as the involved risks and complications. Based on current evidence the procedure is still to be considered experimental.

Level of evidence

  • 4

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Hagen Schmal Department of Orthopaedics and Traumatology, Odense University Hospital, Odense, Denmark.
Department of Orthopaedics and Traumatology, Freiburg University Hospital, Freiburg, Germany.

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Michael Brix Department of Orthopaedics and Traumatology, Odense University Hospital, Odense, Denmark.

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Mats Bue Department of Orthopaedic Surgery, Horsens Regional Hospital, Horsens, Denmark

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Anna Ekman Orthopaedic Department, Södersjukhuset, Stockholm, Sweden

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Nando Ferreira Division of Orthopaedics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa

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Hans Gottlieb Department of Orthopaedic Surgery, Herlev Hospital, Herlev, Denmark

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Søren Kold Department of Orthopaedic Surgery, Aalborg University Hospital, Aalborg University, Aalborg, Denmark

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Andrew Taylor Department of Orthopaedic Surgery, Nottingham University Hospitals, UK

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Peter Toft Tengberg Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark

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Ilija Ban Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark

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Danish Orthopaedic Trauma Society Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark

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  • Nonunions are a relevant economic burden affecting about 1.9% of all fractures. Rather than specifying a certain time frame, a nonunion is better defined as a fracture that will not heal without further intervention.

  • Successful fracture healing depends on local biology, biomechanics and a variety of systemic factors. All components can principally be decisive and determine the classification of atrophic, oligotrophic or hypertrophic nonunions. Treatment prioritizes mechanics before biology.

  • The degree of motion between fracture parts is the key for healing and is described by strain theory. If the change of length at a given load is > 10%, fibrous tissue and not bone is formed. Therefore, simple fractures require absolute and complex fractures relative stability.

  • The main characteristics of a nonunion are pain while weight bearing, and persistent fracture lines on X-ray.

  • Treatment concepts such as ‘mechanobiology’ or the ‘diamond concept’ determine the applied osteosynthesis considering soft tissue, local biology and stability. Fine wire circular external fixation is considered the only form of true biologic fixation due to its ability to eliminate parasitic motions while maintaining load-dependent axial stiffness. Nailing provides intramedullary stability and biology via reaming. Plates are successful when complex fractures turn into simple nonunions demanding absolute stability. Despite available alternatives, autograft is the gold standard for providing osteoinductive and osteoconductive stimuli.

  • The infected nonunion remains a challenge. Bacteria, especially staphylococcus species, have developed mechanisms to survive such as biofilm formation, inactive forms and internalization. Therefore, radical debridement and specific antibiotics are necessary prior to reconstruction.

Cite this article: EFORT Open Rev 2020;5:46-57. DOI: 10.1302/2058-5241.5.190037

Open access
Signe Steenstrup Jensen Department of Orthopedic Surgery and Traumatology, Lillebaelt Hospital, Kolding, Denmark
Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark

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Niels Martin Jensen Department of Orthopedic Surgery and Traumatology, Lillebaelt Hospital, Kolding, Denmark

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Per Hviid Gundtoft Department of Orthopedic Surgery and Traumatology, Aarhus University Hospital, Aarhus, Denmark

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Søren Kold Department of Orthopedic Surgery, Aalborg University Hospital, Aalborg, Denmark

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Robert Zura Department of Orthopedic Surgery, Louisiana State University Medical Center, New Orleans, Louisiana, USA

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Bjarke Viberg Department of Orthopedic Surgery and Traumatology, Lillebaelt Hospital, Kolding, Denmark
Department of Orthopedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark

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Background

  • There are several studies on nonunion, but there are no systematic overviews of the current evidence of risk factors for nonunion. The aim of this study was to systematically review risk factors for nonunion following surgically managed, traumatic, diaphyseal fractures.

Methods

  • Medline, Embase, Scopus, and Cochrane were searched using a search string developed with aid from a scientific librarian. The studies were screened independently by two authors using Covidence. We solely included studies with at least ten nonunions. Eligible study data were extracted, and the studies were critically appraised. We performed random-effects meta-analyses for those risk factors included in five or more studies. PROSPERO registration number: CRD42021235213.

Results

  • Of 11,738 records screened, 30 were eligible, and these included 38,465 patients. Twenty-five studies were eligible for meta-analyses. Nonunion was associated with smoking (odds ratio (OR): 1.7, 95% CI: 1.2–2.4), open fractures (OR: 2.6, 95% CI: 1.8–3.9), diabetes (OR: 1.6, 95% CI: 1.3–2.0), infection (OR: 7.0, 95% CI: 3.2–15.0), obesity (OR: 1.5, 95% CI: 1.1–1.9), increasing Gustilo classification (OR: 2.2, 95% CI: 1.4–3.7), and AO classification (OR: 2.4, 95% CI: 1.5–3.7). The studies were generally assessed to be of poor quality, mainly because of the possible risk of bias due to confounding, unclear outcome measurements, and missing data.

Conclusion

  • Establishing compelling evidence is challenging because the current studies are observational and at risk of bias. We conclude that several risk factors are associated with nonunion following surgically managed, traumatic, diaphyseal fractures and should be included as confounders in future studies.

Open access