Do Systemic Factors Influence the Fate of Nonunions to Become Atrophic? A Retrospective Analysis of 162 Cases

Introduction. Nonunions are a challenge for orthopedic surgeons. In hypertrophic nonunions, improvement of mechanical stability usually is the satisfactory treatment, whereas in atrophic nonunions improvement of the biological environment is most important. However, scientific evidence revealed that "avital" nonunions are not avascular and fibrous tissue contains cells with osteogenic potential. To find out if systemic factors suppress this intrinsic potential in atrophic nonunions, this study compares characteristics of hypertrophic with atrophic nonunion patients. Methods. We analyzed medical records of 162 surgically treated patients suffering from aseptic long bone nonunions. Atrophic and hypertrophic nonunions were distinguished by absence or presence of callus and calcification in the fracture gap. Mechanical implant loosening and patient characteristics such as age, gender, and body mass index were assessed. Fracture classification according to AO/OTA, open and closed fractures, and osteosynthesis were recorded. In addition, comorbidities and allergies between both groups were compared. Results. A higher number of hypertrophic nonunion patients were male with often allergies. Hypertrophic nonunion occurred more often after intramedullary nailing compared to atrophic nonunions. Atrophic nonunion patients being nonallergic were significantly older than nonallergic patients suffering from hypertrophic nonunions. In both atrophic and hypertrophic nonunion patients, age was lower in patients with accompanying injuries compared with age of patients with isolated fractures. Conclusion. Systemic factors influence development of nonunion types. In nonallergic patients, atrophic nonunions occur more often in the elderly. This manuscript is a first step to identify different factors which might influence the nature of nonunion. To enable nonunion treatment which is tailored to individual patient characteristics, further prospective studies with more sophisticated research methods are necessary.

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