title: Delayed union and nonunions: epidemiology, clinical issues, and financial aspects.
abstract: Fracture healing is a critically important clinical event for fracture patients and for clinicians who take care of them. The clinical evaluation of fracture healing is based on both radiographic findings and clinical findings. Risk factors for delayed union and nonunion include patient dependent factors such as advanced age, medical comorbidities, smoking, non-steroidal anti-inflammatory use, various genetic disorders, metabolic disease and nutritional deficiency. Patient independent factors include fracture pattern, location, and displacement, severity of soft tissue injury, degree of bone loss, quality of surgical treatment and presence of infection. Established nonunions can be characterised in terms of biologic capacity, deformity, presence or absence of infection, and host status. Hypertrophic, oligotrophic and atrophic radiographic appearances allow the clinician to make inferences about the degree of fracture stability and the biologic viability of the fracture fragments while developing a treatment plan. Non-unions are difficult to treat and have a high financial impact. Indirect costs, such as productivity losses, are the key driver for the overall costs in fracture and non-union patients. Therefore, all strategies that help to reduce healing time with faster resumption of work and activities not only improve medical outcome for the patient, they also help reduce the financial burden in fracture and non-union patients.
authors.affiliation: Department of Orthopaedics Denver Health/University of Colorado, 777 Bannock Street, MC 0188, Denver, CO 80204, USA. Electronic address: david.hak@dhha.org.
authors.forename: David J
authors.initials: DJ
authors.lastname: Hak
authors.affiliation: Slocum Center for Orthopedics and Sports Medicine, Eugene, OR, USA.
authors.forename: Daniel
authors.initials: D
authors.lastname: Fitzpatrick
authors.affiliation: Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway Street, Pavilion A, Redwood City, CA, USA.
authors.forename: Julius A
authors.initials: JA
authors.lastname: Bishop
authors.affiliation: Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, IA, USA.
authors.forename: J Lawrence
authors.initials: JL
authors.lastname: Marsh
authors.affiliation: Department of Orthopaedic Trauma Surgery, University Hospital Giessen-Marburg GmbH, Rudolf-Buchheim-Str. 7, 35385 Giessen, Germany.
authors.forename: Susanne
authors.initials: S
authors.lastname: Tilp
authors.affiliation: Department of Orthopaedic Trauma Surgery, University Hospital Giessen-Marburg GmbH, Rudolf-Buchheim-Str. 7, 35385 Giessen, Germany.
authors.forename: Reinhard
authors.initials: R
authors.lastname: Schnettler
authors.affiliation: Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh, UK.
authors.forename: Hamish
authors.initials: H
authors.lastname: Simpson
authors.affiliation: Department of Orthopaedic Trauma Surgery, University Hospital Giessen-Marburg GmbH, Rudolf-Buchheim-Str. 7, 35385 Giessen, Germany.
authors.forename: Volker
authors.initials: V
authors.lastname: Alt
mesh_terms: D005593:Fracture Fixation, Internal / Q000009:adverse effects*; D017102:Fracture Healing / Q000502:physiology*; D050723:Fractures, Bone / Q000191:economics / Q000628:therapy*; D005599:Fractures, Ununited / Q000000981:diagnostic imaging / Q000191:economics* / Q000453:epidemiology*; D017048:Health Care Costs; D006801:Humans; D015994:Incidence; D011859:Radiography; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
keywords: Aetiology; Cost of treatment; Incidence; Non-union