Residual axial and rotational deformities in tibial shaft fracture, after minimally invasive osteosynthesis (MIO) treatment, are widely described in literature. Nevertheless, there is still a lack of evidence about the malunion treatment strategies and results. The aim of our study is to present an innovative technique for tibial shaft malunion: a derotational proximal tibial osteotomy without removing the original plate (Plate-Retaining-Osteotomy: PR-Osteotomy).

We present the results of two consecutive patients' treatment, affected by tibial shaft fracture malunion, as sequelae of MIO treatment. The two patients, male 60 years old and female 39 years old, underwent previous surgical treatment with an average of 9 months span time before surgical revision. The affected limb showed significant external torsional defect associated with gait impairment, pain and limping. The amount of rotational deformity and the bone healing condition is assessed through a methodical preoperative planning, including weight bearing lower limbs Xray and bilateral computed tomography (CT) scan of the lower limbs. The surgical technique involves a monoplanar tibial osteotomy, in a perpendicular fashion to the tibial axis, at a level that would allow at least 3 proximal screw-holes to become available for subsequent fixation. Proximal to the osteotomy line the screws are removed, while the distal ones, if stable after testing, are left in place. The amount of torsional correction, planned on CT, is reproduced intraoperatively with the assistance of graduated templates. A fibular osteotomy may be performed if required. After temporary stabilization, the correct functional reduction is checked with the aid of fluoroscopy and empirical rod measurement, using the contralateral limb alignment as a reference. Once the desired correction is achieved, absolute stability is applied to the osteotomy site. Postoperative rehabilitation protocol involves partial weight bearing for 6-8 weeks with progression to full weight bearing by 10-12 weeks.

Both patients showed complete osteotomy healing at the 13th and 16th week respectively, with no complications and full recovery of normal gait and daily life activities.

To our knowledge, this is the first description of such surgical technique. Less invasiveness, fast recovery time and cost reductions are the foremost proposed benefits. Further larger case series with longer follow up are needed to assess the advantages of the proposed treatment strategy.

Delayed union, malunion, and nonunion are serious complications in the healing of fractures. Predicting the risk of nonunion before or after surgery is challenging.

To compare the most prevalent predictive scores of nonunion used in clinical practice to determine the most accurate score for predicting nonunion.

We collected data from patients with tibial shaft fractures undergoing surgery from January 2016 to December 2020 in three different trauma hospitals. In this retrospective multicenter study, we considered only fractures treated with intramedullary nailing. We calculated the tibia FRACTure prediction healING days (FRACTING) score, Nonunion Risk Determination score, and Leeds-Genoa Nonunion Index (LEG-NUI) score at the time of definitive fixation.

Of the 130 patients enrolled, 89 (68.4%) healed within 9 months and were classified as union. The remaining patients (n = 41, 31.5%) healed after more than 9 months or underwent other surgical procedures and were classified as nonunion. After calculation of the three scores, LEG-NUI and FRACTING were the most accurate at predicting healing.

LEG-NUI and FRACTING showed the best performances by accurately predicting union and nonunion.

Diaphyseal fractures represent a complex biological entity that could often end into impaired bone-healing, with delayed union and non-union occurring up to 10% of cases. The role of the modern orthopaedic surgeon is to optimize the fracture healing environment, recognize and eliminate possible interfering factors, and choose the best suited surgical fixation technique. The impaired reparative process after surgical intervention can be modulated with different surgical techniques, such as dynamization or exchange nailing after failed intramedullary nailing. Moreover, the mechanical stability of a nail can be improved through augmentation plating, bone grafting or external fixation techniques with satisfactory results. According to the "diamond concept", local therapies, such as osteoconductive scaffolds, bone growth factors, and osteogenic cells can be successfully applied in "polytherapy" for the enhancement of delayed union and non-union of long bones diaphyseal fractures. Moreover, systemic anti-osteoporosis anabolic drugs, such as teriparatide, have been proposed as off-label treatment for bone healing enhancement both in fresh complex shaft fractures and impaired unions, especially for fragility fractures. The article aims to review the biological and mechanical principles of failed reparative osteogenesis of diaphyseal fractures after surgical treatment. Moreover, the evidence about the modern non-surgical and pharmacological options for bone healing enhancement will discussed.

Extremely low-frequency pulsed electromagnetic field (ELF-PEMF) therapy is proposed to support bone healing after injuries and surgical procedures, being of special interest for elderly patients. This study aimed at investigating the effect of a specific ELF-PEMF, recently identified to support osteoblast function in vitro, on bone healing after high tibial osteotomy (HTO). Patients who underwent HTO were randomized to ELF-PEMF or placebo treatment, both applied by optically identical external devices 7 min per day for 30 days following surgery. Osseous consolidation was evaluated by post-surgical X-rays (7 and 14 weeks). Serum markers were quantified by ELISA. Data were compared by a two-sided t-test (α = 0.05). Device readouts showed excellent therapy compliance. Baseline parameters, including age, sex, body mass index, wedge height and blood cell count, were comparable between both groups. X-rays revealed faster osseous consolidation for ELF-PEMF compared to placebo treatment, which was significant in patients ≥50 years (∆mean = 0.68%/week; p = 0.003). Findings are supported by post-surgically increased bone-specific alkaline phosphatase serum levels following ELF-PEMF, compared to placebo (∆mean = 2.2 µg/L; p = 0.029) treatment. Adverse device effects were not reported. ELF-PEMF treatment showed a tendency to accelerate osseous consolidation after HTO. This effect was stronger and more significant for patients ≥50 years. This ELF-PEMF treatment might represent a promising adjunct to conventional therapy supporting osseous consolidation in elderly patients.

Healing of tibia fractures occurs over a wide time range of months, with a number of risk factors contributing to prolonged healing. In this prospective, multicentre, observational study, we investigated the capability of FRACTING (tibia FRACTure prediction healING days) score, calculated soon after tibia fracture treatment, to predict healing time.

The study included 363 patients. Information on patient health, fracture morphology, and surgical treatment adopted were combined to calculate the FRACTING score. Fractures were considered healed when the patient was able to fully weight-bear without pain.

319 fractures (88%) healed within 12 months from treatment. Forty-four fractures healed after 12 months or underwent a second surgery. FRACTING score positively correlated with days to healing: r = 0.63 (p < 0.0001). Average score value was 7.3 ± 2.5; ROC analysis showed strong reliability of the score in separating patients healing before versus after 6 months: AUC = 0.823.

This study shows that the FRACTING score can be employed both to predict months needed for fracture healing and to identify immediately after treatment patients at risk of prolonged healing. In patients with high score values, new pharmacological and nonpharmacological treatments to enhance osteogenesis could be tested selectively, which may finally result in reduced disability time and health cost savings.

Human immunodeficiency virus (HIV) infection could potentially play an important role in the management of fractures as they have been shown to affect fracture healing and the post-operative risk of implant sepsis.

A systematic review of the relevant literature was performed on PubMed and Scopus databases. Twenty-six studies were identified, critiqued and analysed accordingly. No randomised controlled trials were identified.

HIV positivity was not shown to influence an individual's risk of early wound infection in operatively managed closed fractures. The rate of pin track infection in open injuries managed with external fixators was low. However, in open injuries managed with internal fixation, early wound infection rates were increased in the HIV-positive population compared to HIV-negative individuals. Regarding late implant infection, in closed fractures there appeared to be no increased risk of infection but there is limited evidence for open injuries. Additionally, further evidence is needed to establish if the rate of union in both open and closed fractures are influenced by HIV status.

Overall, no evidence was found to suggest that surgical management of fractures in the HIV population should be avoided, and fixation of closed fractures in the HIV population appeared to be safe. The effect of anti-retroviral therapy is unclear and this should be further researched. However, based on the limited evidence, caution should be taken in the management of open fractures due to the potentially increased infection risk. The impact of anti-retroviral therapy on the outcomes of surgery needs further evaluation.

Older patients are commonly at a higher risk of experiencing a bone fracture. Complications during fracture healing, including delayed union and non-union, can arise as a result of a multitude of patient and treatment factors. This review describes those factors which contribute to a greater risk of delayed union and non-union with particular reference to the elderly population and discusses therapies that may enhance the fracture healing process in the hope of reducing the incidence of delayed union and non-union. Increasing age does seem to increase the risk of delayed union or non-union. In addition, smoking and the treatment of post-fracture pain with non-steroidal anti-inflammatory drugs (NSAIDs) put the patient at the greatest risk, while ultrasound therapy appears to be a non-invasive, effective treatment option to reduce the risk of delayed union or non-union. The use of growth factors and of stem cells and the role of surgery are also discussed.

A fit 42-year-old woman presented to our department with a closed isolated distal tibial and fibular shaft fracture (AO 42-B1.3), which was addressed with a minimally invasive plate osteosynthesis (MIPO) with a bridging technique for both the tibia and the fibula. No risk factors for healing issues were known at the time of surgery. At the 6-month follow-up, the leg was still painful during walking and the fracture site was still evident on the radiographs. Bone and CT-scans confirmed the diagnosis of oligotrophic non-union. A revision surgery was then successfully performed with a reamed IM tibial nail and a fibular osteotomy taking into consideration both biological and mechanical factors. Surgeons must treat tibial shaft fractures avoiding unnecessary damage to soft tissue, restoring an appropriate reduction of the bony segment and providing an adequate fixation; however, other factors may play a role in the development of "unexpected non-union".

Bisphosphonates (BPs) are widely used for the treatment of osteoporosis. Oversuppression of bone turnover with BPs may paradoxically limit the reserve capacity of bone to heal. The aim of this review was to study the predisposition of some patients to delayed/non-union of upper limb fractures associated with BPs and give recommendations on how they should be treated.

A systematic search of two electronic databases was conducted to identify relevant studies for inclusion. All relevant studies found were included and assessed through methodology criteria predetermined by two independent reviewers.

Six papers comprising of three case reports, one nested case control study, one restrospective review and one randomized clinical trial were used. In comparative studies of pre-fracture BP use, a 6-day delay in average healing times was reported among BP users. There was no elevation in risk of non-union. Post-fracture BP use was associated with an approximate doubling of the risk of non-union. Timing of BP therapy initiation following a fracture was not associated with a difference in healing times. An atypical ulna fracture treated conservatively resulted in non-union, there was no effect of type of surgical treatment on distal radius fracture healing and there was insufficient evidence to comment on humeral fracture treatment.

Differences in union time between BP users and non-users are not significant enough to change current practice patterns and do not outweigh the benefits of BP therapy. There is no evidence to encourage early surgical management of BP-related upper limb fractures.