Incidence and Risk Factors of Delayed Union and Nonunion in Fracture Patients in Iraq
DOI:
https://doi.org/10.31149/ijimm.v4i5.2905Keywords:
Delayed Union, Nonunion, Fracture Healing, Risk Factors, Iraq, Orthopedics, Long-Bone FracturesAbstract
Delayed union and nonunion of fractures is yet another clinically significant issue seen with fractures that cause long-term disability and extra financial strain on our healthcare system. The purpose of this investigation was to determine the overall incidence of delayed unions and nonunions, as well as to find risk factors associated with long bone fracture patients in Iraq who had a fractured long bone and had been treated for the fracture at private health care institutions in Iraq. This was a retrospective cohort study of patients with long-bone fractures (tibial, femoral, or humeral) who were treated at three private hospitals in Iraq (Baghdad, Fallujah, and Basrah) between January 2022 and December 2024 and were followed for at least 9 months. The definitions utilized for delayed union and nonunion were as follows: 1) Delayed union was defined as the absence of radiological evidence of union by six months post fracture and (2) Nonunion was defined as a fracture that has been persistent of a fracture line at nine months post fracture without three months or more of progress, and is persistent of the fracture line for a minimum of three additional months (total nine months). Of an estimated 420 potential participants, 60 (14.3%) experienced delayed union, and 34 (8.1%) experienced nonunion. Based on the multivariable regression analyses, the most significant predictors of impaired fracture healing were: infection (OR 5.8), open fracture (OR 3.2), smoking (OR 2.4), diabetes mellitus (OR 2.1) and mechanism of injury - high energy (OR 1.9). In conclusion, these findings highlight the importance of risk-stratifying patients in the early stages of care, implementing aggressive methods for both preventing and treating infection, optimally managing comorbidities, and counselling patients about smoking cessation to reduce delayed unions and nonunions among fracture patients in Iraq.
References
GBD 2019 Fracture Collaborators, “Global, regional, and national burden of bone fractures in 204 countries and territories, 1990–2019: A systematic analysis from the Global Burden of Disease Study 2019,” The Lancet Healthy Longevity, vol. 2, no. 9, pp. e580–e592, 2021.
E. Antonova, T. K. Le, R. Burge, and J. Mershon, “Tibia shaft fractures: Costly burden of nonunions,” BMC Musculoskeletal Disorders, vol. 14, p. 42, 2013.
K. M. Bowers and D. E. Anderson, “Delayed union and nonunion: Current concepts, prevention, and correction: A review,” Bioengineering, vol. 11, no. 6, p. 525, 2024.
M. R. Brinker, A. Trivedi, and D. P. O’Connor, “Debilitating effects of femoral nonunion on health-related quality of life,” Journal of Orthopaedic Trauma, vol. 31, no. 2, pp. e37–e42, 2017.
J. L. Kehoe and J. D. Thomas, “Bone nonunion,” in StatPearls [Internet]. Treasure Island, FL, USA: StatPearls Publishing, 2023.
J. A. Nicholson, N. Makaram, A. H. R. W. Simpson, and J. F. Keating, “Fracture nonunion in long bones: A literature review of risk factors and surgical management,” Injury, vol. 52, Suppl. 2, pp. S3–S11, 2021.
J. Ahn and M. Sullivan, General Principles in the Assessment and Treatment of Nonunions. Orthopaedic Trauma Association, 2017.
R. Zura, Z. Xiong, T. Einhorn, et al., “Epidemiology of fracture nonunion in 18 human bones,” JAMA Surgery, vol. 151, no. 11, p. e162775, 2016.
N. S. Makaram, J. M. Leow, N. D. Clement, W. M. Oliver, Z. H. Ng, C. Simpson, and J. F. Keating, “Risk factors associated with delayed and aseptic nonunion following tibial diaphyseal fractures managed with intramedullary nailing,” Bone & Joint Open, vol. 2, no. 4, pp. 227–235, 2021.
R. G. Pearson, R. G. Clement, K. L. Edwards, and B. E. Scammell, “Do smokers have greater risk of delayed and non-union after fracture, osteotomy and arthrodesis? A systematic review with meta-analysis,” BMJ Open, vol. 6, no. 11, p. e010303, 2016.
R. Zura, S. Mehta, G. J. Della Rocca, and R. G. Steen, “Biological risk factors for nonunion of bone fracture,” JBJS Reviews, vol. 4, no. 1, p. e5, 2016.
M. Tanios, B. Brickman, E. Cage, et al., “Diabetes and impaired fracture healing: A narrative review of recent literature,” Current Osteoporosis Reports, vol. 20, no. 5, pp. 229–239, 2022.
Y. Chen, Y. Zhou, J. Lin, and S. Zhang, “Challenges to improve bone healing under diabetic conditions,” Frontiers in Endocrinology, vol. 13, p. 861878, 2022.
J. A. Nicholson, L. Z. Y. Yapp, J. F. Keating, and A. H. R. W. Simpson, “Monitoring of fracture healing: Update on current and future imaging modalities to predict union,” Injury, vol. 52, Suppl. 2, pp. S29–S34, 2021.
A. P. Kurmis, T. P. Kurmis, J. X. O’Brien, and T. Dalén, “The effect of nonsteroidal anti-inflammatory drug administration on acute phase fracture-healing: A review,” Journal of Bone and Joint Surgery American Volume, vol. 94, no. 9, pp. 815–823, 2012.
M. Y. Alwaaly, “Patterns of non-union of femoral shaft fracture in Basrah Teaching Hospital: A retrospective review,” Basrah Journal of Surgery, vol. 27, no. 2, pp. 37–45, 2021.
