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Commentary and Perspective   |    
Tibial Nonunion Is Worse Than Having a Myocardial InfarctionCommentary on an article by Mark R. Brinker, MD, et al.: “The Devastating Effects of Tibial Nonunion on Health-Related Quality of Life”
Hans J. Kreder, MD, FRCSC1
1 University of Toronto, Toronto, Ontario, Canada
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The author did not receive payments or services, either directly or indirectly (i.e., via his institution), from a third party in support of any aspect of this work. He, or his 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. The author has not had any other relationships, or 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):e199 1. doi: 10.2106/JBJS.M.01180
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Tibial fracture nonunion is expensive in terms of health-care and personal costs1. Compared with patients with a healed tibial fracture, those with a nonunion have poorer physical and mental function and more posttraumatic psychological distress2. Reliance on walking aids and opioids is commonly associated with tibial nonunion1,2.
In the present study, quality of life was measured in a heterogeneous cohort of patients with tibial shaft nonunion at three to 244 months after injury; these patients had undergone zero to twenty-three operations. Although there was no matched cohort of patients with a healed tibial shaft fracture for comparison, the authors compared their outcomes with the normal population and patients with other health conditions such as chronic cardiovascular disease and arthritis. They found that patients with nonunion, on average, reported physical health worse than 90% of the normal population and mental health worse than 75% of the normal population. This is below the quality of life experienced by many individuals living with diabetes and those who have survived myocardial infarction. Patients with tibial shaft nonunion who also had depression, obesity, and diabetes (especially in combination) reported particularly poor function and high levels of chronic pain. Although smoking has been well established as a risk factor for the development of nonunion3, the current study revealed that patients with nonunion who smoked had similar function to those with nonunion who did not smoke.
Given the profound deficits in quality of life experienced by individuals with tibial nonunion, attempts should be focused on prevention and timely, effective treatment. Zlowodzki et al. showed that, one year after successful treatment of tibial nonunion, Short Form (SF)-36 physical and social function scores had improved significantly from the values before treatment4, although others found less improvement in SF-36 scores despite eventual fracture-healing1.
The best evidence to date suggests that statically locked, reamed intramedullary nailing of both open and closed tibial shaft fractures is associated with the best outcomes, including minimizing the risk of nonunion5. For those with delayed union following tibial shaft fracture, smoking cessation and avoidance of chronic nonsteroidal anti-inflammatory drug use may be helpful in maximizing the likelihood of achieving union with well-planned and well-executed surgical treatment3-5. For established tibial nonunions, nonsurgical treatment alone (such as pulsed ultrasound or interferential current) is not likely to succeed5.
Despite ultimate union, patients may continue to report persistent pain and psychological difficulties. Future studies are needed to establish the best way to avoid and to treat tibial nonunion and the accompanying psychological problems.
Antonova  E;  Le  TK;  Burge  R;  Mershon  J. Tibia shaft fractures: costly burden of nonunions. BMC Musculoskelet Disord.  2013;14:42.  Epub 2013 Jan 26.[CrossRef][PubMed]
 
Zeckey  C;  Mommsen  P;  Andruszkow  H;  Macke  C;  Frink  M;  Stübig  T;  Hüfner  T;  Krettek  C;  Hildebrand  F. The aseptic femoral and tibial shaft non-union in healthy patients - an analysis of the health-related quality of life and the socioeconomic outcome. Open Orthop J.  2011;5:193-7.  Epub 2011 May 18.[CrossRef][PubMed]
 
Patel  RA;  Wilson  RF;  Patel  PA;  Palmer  RM. The effect of smoking on bone healing: A systematic review. Bone Joint Res.  2013;2(  6):102-11.  Epub 2013 Jun 14.[CrossRef][PubMed]
 
Zlowodzki  M;  Obremskey  WT;  Thomison  JB;  Kregor  PJ. Functional outcome after treatment of lower-extremity nonunions. J Trauma.  2005 Feb;58(  2):312-7.[CrossRef]
 
Helmy  N;  Blachut  PA. Tibial diaphyseal fractures: what is the best treatment? In: Wright  JG, editor. Evidence-based orthopaedics. Philadelphia: W.B. Saunders; 2009. p 420-5.
 

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References

Antonova  E;  Le  TK;  Burge  R;  Mershon  J. Tibia shaft fractures: costly burden of nonunions. BMC Musculoskelet Disord.  2013;14:42.  Epub 2013 Jan 26.[CrossRef][PubMed]
 
Zeckey  C;  Mommsen  P;  Andruszkow  H;  Macke  C;  Frink  M;  Stübig  T;  Hüfner  T;  Krettek  C;  Hildebrand  F. The aseptic femoral and tibial shaft non-union in healthy patients - an analysis of the health-related quality of life and the socioeconomic outcome. Open Orthop J.  2011;5:193-7.  Epub 2011 May 18.[CrossRef][PubMed]
 
Patel  RA;  Wilson  RF;  Patel  PA;  Palmer  RM. The effect of smoking on bone healing: A systematic review. Bone Joint Res.  2013;2(  6):102-11.  Epub 2013 Jun 14.[CrossRef][PubMed]
 
Zlowodzki  M;  Obremskey  WT;  Thomison  JB;  Kregor  PJ. Functional outcome after treatment of lower-extremity nonunions. J Trauma.  2005 Feb;58(  2):312-7.[CrossRef]
 
Helmy  N;  Blachut  PA. Tibial diaphyseal fractures: what is the best treatment? In: Wright  JG, editor. Evidence-based orthopaedics. Philadelphia: W.B. Saunders; 2009. p 420-5.
 
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