Thurs., 10/18/07 Reconstruction, Paper #15, 4:45 pm OTA-2007
Metabolic and Endocrine Abnormalities in Patients with Nonunions: Have We Been Missing the Boat?
Mark R. Brinker, MD (b-Smith+Nephew Orthopaedics); Daniel P. O’Connor, PhD (n);
Yomna T. Monla, MD (n); Thomas P. Earthman, MD (n);
The Center for Problem Fractures and Limb Restoration, Fondren Orthopedic Group,
Texas Orthopedic Hospital, Houston, Texas, USA
Purpose: A fracture nonunion most commonly arises as a result of suboptimal biomechanics, poor biology, or a combination of the two. In some cases, however, a fracture may fail to unite despite excellent fixation in a seemingly healthy host with good biology at the fracture site. In an effort to understand other possible factors that may contribute to poor healing in patients with unexplained nonunions, we undertook this prospective study.
Methods: From a series of 683 consecutive patients with a nonunion, 37 patients were referred to an endocrinologist to undergo an evaluation for metabolic or endocrine abnormalities. The criteria for referral to an endocrinologist were: (1) an unexplained nonunion that occurred despite adequate reduction and stabilization without obvious technical error and without any other obvious etiology; (2) a history of multiple low-energy fractures with at least one progressing to a nonunion; or (3) a nonunion of a nondisplaced pubic rami or sacral ala fracture.
Results: Thirty-one of the 37 patients (84%) who met our screening criteria had one or more new diagnoses of metabolic or endocrine abnormalities. The most common newly diagnosed abnormality was vitamin D deficiency (68%). Other abnormalities included calcium imbalances, central hypogonadism, thyroid disorders, and parathyroid hormone disorders. With the numbers available, the prevalence of newly diagnosed metabolic or endocrine abnormalities was unrelated to gender (P = 0.162), patient age (P = 0.531), and nonunion type (P = 0.373).
Conclusion and Significance: The prevalence of metabolic or endocrine abnormalities in our nonunion population who met the screening criteria was staggeringly high (nearly 85%). It is clear that many patients with nonunions have one or more undiagnosed metabolic or endocrine abnormalities that are likely to be interfering with the normal process of fracture healing. We believe these abnormalities are routinely missed, as many traumatologists limit their evaluation to physical examination and radiographic/imaging studies alone; these examinations and studies are incapable of detecting metabolic and endocrine disorders. Evaluation for underlying endocrine and metabolic abnormalities in certain subsets of patients with fracture nonunion must become routine practice and standard of care.
If noted, the author indicates something of value received. The codes are identified as a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options; e-consultant or employee; n-no conflicts disclosed, and *disclosure not available at time of printing.
• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing.