title: Medial open wedge high tibial osteotomy: can delayed or nonunion be predicted?
abstract: BACKGROUND
  The opening wedge approach to high tibial osteotomy (HTO) is perceived to have some advantages relative to the closing wedge approach but it may be associated with delayed and nonunions. Because nonunions evolve over months, it would be advantageous to be able to identify risk factors for and early predictors of nonunion after medial opening wedge HTO.
  
  
  OBJECTIVE
  We sought to determine whether (1) preoperatively identifiable patient factors, including tobacco use, body mass index > 30 kg/m(2), and degree of correction, are associated with nonunion, and (2) a modified Radiographic Union Score for Tibial Fractures (RUST) score, taken at 6 weeks and 3 months, would be predictive for delayed or nonunion after medial opening wedge HTO.
  
  
  METHODS
  The medical records and radiographs of 185 patients, 21 bilateral cases, treated with a medial open wedge HTO using the TomoFix(®) device were retrospectively evaluated. For all patients, demographic data regarding risk factors were collected from their records. Diagnosis for delayed or nonunion was already done earlier for standard medical care by the orthopaedic surgeon based on clinical and radiographic grounds. For the retrospective radiographic evaluation, a modified RUST score was used in which each tibial cortex is scored by one observer. Logistic regression analysis was used to identify preoperative and postoperative predictive factors for developing delayed or nonunion. In the series, a total of 19 patients (9.2%) developed clinically delayed/nonunion of whom 10 patients (4.9%) developed a nonunion.
  
  
  RESULTS
  Smoking was identified as a risk factor for developing delayed/nonunion (19% for smokers versus 5.4% for nonsmokers; p = 0.005; odds ratio, 4.1; 95% confidence interval, 1.5-10.7). By contrast, body mass index, lateral cortical hinge fracture, age, infection, and degree of correction were not risk factors. Patients with delayed/nonunion had lower RUST scores at all time points when a radiograph was taken compared with the total study group.
  
  
  CONCLUSIONS
  The RUST score at 6 weeks and 3 months after surgery and the use of tobacco were identified as predictive factors for development of delayed union and nonunion after open wedge HTO. Based on these results, we now actively try to stop patients from smoking and these data are helpful in doing that. The RUST score may be of use to identify which patients are at risk for developing a delayed union so that interventions may be offered earlier in the course of care.
  
  
  METHODS
  Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
authors.affiliation: Sint Maartenskliniek, Nijmegen, Hengstdal 3, 6522 JV, Nijmegen, The Netherlands, albert.h.vanhouten@gmail.com.
authors.forename: Albert H
authors.initials: AH
authors.lastname: van Houten
authors.forename: Petra J C
authors.initials: PJ
authors.lastname: Heesterbeek
authors.forename: Ronald J
authors.initials: RJ
authors.lastname: van Heerwaarden
authors.forename: Tony G
authors.initials: TG
authors.lastname: van Tienen
authors.forename: Ate B
authors.initials: AB
authors.lastname: Wymenga
mesh_terms: D000328:Adult; D000368:Aged; D016009:Chi-Square Distribution; D005260:Female; D017102:Fracture Healing; D005599:Fractures, Ununited / Q000000981:diagnostic imaging / Q000209:etiology* / Q000517:prevention & control; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010027:Osteotomy / Q000009:adverse effects*; D011859:Radiography; D012189:Retrospective Studies; D012307:Risk Factors; D012907:Smoking / Q000009:adverse effects; D016540:Smoking Cessation; D000074606:Smoking Prevention; D013977:Tibia / Q000000981:diagnostic imaging / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult