title: Factors Associated With Development of Nonunion or Delayed Healing After an Open Long Bone Fracture: A Prospective Cohort Study of 736 Subjects.
abstract: OBJECTIVE
  To determine factors associated with developing nonunion or delayed healing after open fracture.
  
  
  METHODS
  Prospective cohort between 2001 and 2009.
  
  
  METHODS
  Three level 1 Canadian trauma centers.
  
  
  METHODS
  Seven hundred thirty-six (791 fractures) subjects were enrolled. Six hundred eighty-nine (94%) subjects (739 fractures) provided adequate outcome data.
  
  
  METHODS
  Subjects were followed until fracture(s) healed; phone interviews and chart reviews were conducted 1 year after fracture. Patient, fracture, and injury information, and time to surgery and antibiotics were recorded during hospitalization.
  
  
  METHODS
  Nonunion defined as unplanned surgical intervention after definitive wound closure or incomplete radiographic healing at 1 year and delayed healing defined as 2 consecutive clinical assessments showing no radiographic progression or incomplete radiographic healing between 6 months and 1 year.
  
  
  RESULTS
  There were 413 (52%) tibia/fibular, 285 (36%) upper extremity, and 93 (13%) femoral fractures. Nonunion developed in 124 (17%) and delayed healing in 63 (8%) fractures. The median time to surgery was not different for fractures that developed nonunion compared with those who did not (P = 0.36). Deep infection [Odd ratio (OR) 12.75; 95% confidence interval (CI) 6.07-26.8], grade 3A fractures (OR 2.49; 95% CI, 1.30-4.78), and smoking (OR 1.73; 95% CI, 1.09-2.76) were significantly associated with developing a nonunion. Delayed healing was also significantly associated with deep infection (OR 4.34; 95% CI, 1.22-15.48) and grade 3B/C fractures (OR 3.69; 95% CI, 1.44-9.44). Multivariate regression found no association between nonunion and time to surgery (P = 0.15) or antibiotics (P = 0.70).
  
  
  CONCLUSIONS
  Deep infection and higher Gustilo grade fractures were associated with nonunion and delayed healing.
  
  
  METHODS
  Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: *Department of Surgery, University of Alberta, Edmonton, Alberta, Canada; †Department of Surgery, University of Calgary, Calgary, Alberta, Canada; and ‡Departments of Physical Therapy, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Joseph
authors.initials: J
authors.lastname: Westgeest
authors.forename: Donald
authors.initials: D
authors.lastname: Weber
authors.forename: Sukhdeep K
authors.initials: SK
authors.lastname: Dulai
authors.forename: Joseph W
authors.initials: JW
authors.lastname: Bergman
authors.forename: Richard
authors.initials: R
authors.lastname: Buckley
authors.forename: Lauren A
authors.initials: LA
authors.lastname: Beaupre
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000416:Alberta / Q000453:epidemiology; D015331:Cohort Studies; D005260:Female; D005593:Fracture Fixation, Internal / Q000706:statistics & numerical data*; D017102:Fracture Healing; D050723:Fractures, Bone / Q000453:epidemiology* / Q000601:surgery*; D017759:Fractures, Malunited / Q000453:epidemiology* / Q000601:surgery*; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D011446:Prospective Studies; D012086:Reoperation / Q000706:statistics & numerical data*; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult