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The Devastating Effects of Tibial Nonunion on Health-Related Quality of Life
Mark R. Brinker, MD1; Bryan D. Hanus, MD2; Milan Sen, MD3; Daniel P. O’Connor, PhD4
1 Fondren Orthopedic Group, Center for Problem Fractures and Limb Restoration, Texas Orthopedic Hospital, 7401 South Main Street, Houston, TX 77030
2 Department of Surgery, Vanderbilt University School of Medicine, D-4314 Medical Center North, Nashville, TN 37232
3 Department of Orthopaedic Surgery, University of Texas Medical School at Houston, 6431 Fannin Street, Houston, TX 77030
4 Laboratory of Integrated Physiology, University of Houston, 3855 Holman Street, GAR104, Houston, TX 77204-6015. E-mail address: doconnor2@uh.edu
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Investigation performed at Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, Texas

A commentary by Hans J. Kreder, MD, FRCSC, is linked to the online version of this article at jbjs.org.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Dec 18;95(24):2170-2176. doi: 10.2106/JBJS.L.00803
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Tibial nonunion is disabling, but to our knowledge no quantitative evaluation of its effect on health-related quality of life has been reported.


We evaluated 243 tibial shaft fracture nonunions in 237 consecutive patients (seventy-nine female [age, 49.4 ± 14.9 years] and 158 male [age, 46.3 ± 15.4 years]) who were referred to a single surgeon at our tertiary care center over a ten-year period. The most frequently affected tibial segment was the distal third (49%), and infection was present in 18% of all cases.


The Short Form (SF)-12 Physical Component Summary score averaged 27.4 ± 6.7, indicating an extremely disabling effect on physical health. The AAOS (American Academy or Orthopaedic Surgeons) Lower Limb Core Scale score averaged 52.0 ± 19.4, also consistent with high levels of physical disability attributable to the lower limb. The SF-12 Mental Component Summary score averaged 42.3 ± 7.1, indicating a substantial detrimental effect on mental health.


The impact of tibial shaft fracture nonunion on physical health was comparable with the reported impact of end-stage hip arthrosis and worse than that of congestive heart failure. Tibial shaft fracture nonunion is a devastating chronic medical condition that negatively affects both physical and mental health and quality of life.

Level of Evidence: 

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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