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Risk Factors Associated With Nonunion After Elective Foot and Ankle Reconstruction: A Case-Control Study

      Abstract

      Postoperative nonunion is not uncommon in the lower extremity, and significant morbidity can be associated with nonunion of the foot and ankle after surgical reconstruction. For the purposes of the present study, we retrospectively reviewed and compared a cohort of patients who had undergone elective foot and ankle reconstruction to better assess the modifiable risk factors associated with postoperative nonunion. We hypothesized that the presence of endocrine and metabolic abnormalities are often associated with nonunion after foot and ankle surgical reconstruction. We formulated a matched case-control study that included 29 patients with nonunion and a control group of 29 patients with successful fusion to assess the prevalence of certain modifiable risk factors known to have an association with nonunion after foot and ankle arthrodesis. The modifiable risk factors assessed included body mass index, tobacco use, diabetes mellitus, vitamin D abnormality, thyroid dysfunction, and parathyroid disease. A statistically significant (p < .05) difference was found between the 2 groups for endocrine and metabolic disease diagnoses in the medical records of the 58 patients identified. Thus, 76% versus 26% (p < .05) of patients experienced nonunion in the endocrine disease group versus the nonendocrine disease group, respectively. Patients with vitamin D deficiency or insufficiency were 8.1 times more likely to experience nonunion (95% confidence interval 1.996 to 32.787). No statistically significant differences were found between the groups in terms of age, sex, tobacco use, body mass index, or procedure selection (p = .56, p = .43, p = .81, p = .28, and p = 1.0, respectively). A greater prevalence of endocrine abnormalities, in particular, vitamin D deficiency and insufficiency, was associated with nonunion after elective foot and ankle reconstruction. Patients with such abnormalities appear to have a greater risk of developing nonunion after arthrodesis procedures.

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      References

        • Catanzariti A.R.
        • Mendicino R.W.
        • Lee M.S.
        • Gallina M.R.
        The modified Lapidus arthrodesis: a retrospective analysis.
        J Foot Ankle Surg. 1999; 38: 322-332
        • Holt E.S.
        • Hansen S.T.
        • Mayo K.A.
        • Sangeorzan B.J.
        Ankle arthrodesis using internal screw fixation.
        Clin Orthop Relat Res. 1991; 268: 21-28
        • Child B.J.
        • Hix
        • Catanzariti A.R.
        • Medicicino R.W.
        • Saltrick K.
        The effect of hindfoot realignment in triple arthrodesis.
        J Foot Ankle Surg. 2009; 48: 285-293
        • Peterson K.S.
        • Catanzariti A.R.
        • Mendicino M.R.
        • Mendicino R.W.
        Surgical approach for combined ankle and subtalar joint chronic mechanical instability.
        J Foot Ankle Surg. 2013; 52: 537-542
        • Best M.J.
        • Bullier L.T.
        • Miranda A.
        National trends in foot and ankle arthrodesis: 17-year analysis of the national survey of ambulatory surgery and national hospital discharge survey.
        J Foot Ankle Surg. 2015; 54: 1037-1041
        • Astion D.J.
        • Deland J.T.
        • Otis J.C.
        • Kenneally S.
        Motion of the hindfoot after simulated arthrodesis.
        J Bone Joint Surg Am. 1997; 79: 241-246
        • Easley M.E.
        • Trunka H.J.
        • Schon L.C.
        • Myerson M.S.
        Isolated subtalar arthrodesis.
        J Bone Joint Surg Am. 2000; 82: 613-624
        • Catanzariti A.R.
        • Mendicino R.W.
        • Saltrick K.R.
        • Orsini R.C.
        • Dombek M.F.
        • Lamm B.M.
        Subtalar joint arthrodesis.
        J Am Podiatr Med Assoc. 2005; 95: 34-41
        • Maskill M.P.
        • Loveland J.D.
        • Mendicino R.W.
        • Saltrick K.
        • Catanzariti A.R.
        Triple arthrodesis for the adult-acquired flatfoot deformity.
        Clin Podiatr Med Surg. 2007; 24: 765-778
        • Mendicino R.W.
        • Richter M.
        • Thermann H.
        • Schuberth J.M.
        Techniques of arthrodesis in the foot and ankle.
        Foot Ankle Spec. 2012; 5: 408-416
        • Mendicino R.W.
        • Lamm B.M.
        • Catanzariti A.R.
        • Statler T.K.
        • Paley D.
        Realignment arthrodesis of the rearfoot and ankle: a comprehensive evaluation.
        J Am Podiatr Med Assoc. 2005; 95: 60-71
        • Catanzariti A.R.
        • Dix B.T.
        • Richardson P.E.
        • Mendicino R.W.
        Triple arthrodesis for adult acquired flatfoot.
        Clin Podiatr Med Surg. 2014; 31: 415-433
        • Shibuya N.
        • Humphers J.M.
        • Fluhman B.L.
        • Jupiter D.C.
        Factors associated with nonunion, delayed union, and malunion in foot and ankle surgery in diabetic patients.
        J Foot Ankle Surg. 2013; 52: 207-211
        • Hak D.J.
        • Fizpatrick D.
        • Bishop J.A.
        • Marsh J.L.
        • Tilp S.
        • Schnettler R.
        • Simpson H.
        • Alt V.
        Delayed union and nonunions: epidemiology, clinical issues, and financial aspects.
        Injury. 2014; 45: S3-S7
        • Moucha C.S.
        • Clyburn T.
        • Evans R.P.
        • Prokuski L.
        Modifiable risk factors for surgical site infection.
        J Bone Joint Surg Am. 2011; 93: 398-404
        • Goodnough L.T.
        • Maniatis A.
        • Earnshaw P.
        • Benoni G.
        • Beris P.
        • Bisbe E.
        • Fergusson D.A.
        • Gombotz H.
        • Habler O.
        • Monk T.G.
        • Ozier Y.
        • Slappendel R.
        • Szpalski M.
        Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines.
        Br J Anaesth. 2011; 106: 13-22
        • Thevendran G.
        • Wang C.
        • Pinney S.J.
        • Penner M.J.
        • Wing K.J.
        • Younger A.S.
        Nonunion risk assessment in foot and ankle surgery: proposing a predictive risk assessment model.
        Foot Ankle Int. 2015; 36: 901-907
        • Fong K.
        • Truong V.
        • Foote C.J.
        • Petrisor B.
        • Williams D.
        • Ristevski B.
        • Sprague S.
        • Bhandari M.
        Predictors of nonunion and reoperative in patients with fractures of the tibia: an observational study.
        BMC Musculoskeletal Disorders. 2013; 14: 103
        • Brinker M.R.
        Nonunions: Evaluation and Treatment.
        in: Browner B.D. Levine A.M. Jupiter J.B. Trafton P.G. Skeletal Trauma: Basic Science, Management, and Reconstruction. ed 3. WB Saunders, Philadelphia, PA2002: 507-604
        • Haverstock B.D.
        • Mandracchia V.J.
        Cigarette smoking and bone healing: implications in foot and ankle surgery.
        J Foot Ankle Surg. 1998; 37: 69-74
        • Ma L.
        • Zheng L.W.
        • Sham M.H.
        • Cheung L.K.
        Uncoupled angiogenesis and osteogenesis in nicotine-compromised bone healing.
        J Bone Miner Res. 2010; 25: 1305-1313
        • Day S.M.
        • DeHeer D.H.
        Reversal of the detrimental effects of chronic protein malnutrition on long bone fracture healing.
        J Orthop Trauma. 2001; 15: 47-53
        • Pountos I.
        • Georgouli T.
        • Blokhuis T.J.
        • Pape H.C.
        • Giannoudis P.V.
        Pharmacological agents and impairment of fracture healing: what is the evidence?.
        Injury. 2008; 39: 384-394
        • O’Brien C.A.
        • Jia D.
        • Plotkin L.I.
        • Bellido T.
        • Powers C.C.
        • Stewart S.A.
        • Manolagas S.C.
        • Weinstein R.S.
        Glucocorticoids act directly on osteoblasts and osteocytes to induce their apoptosis and reduce bone formation and strength.
        Endocrinology. 2004; 145: 1835-1841
        • Jeffcoach D.R.
        • Sams V.G.
        • Lawson C.M.
        • Enderson B.L.
        • Smith S.T.
        • Kline H.
        • Barlow P.B.
        • Wylie D.R.
        • Krumenacker L.A.
        • McMillen J.C.
        • Pyda J.
        • Daley B.J.
        Nonsteroidal anti-inflammatory drugs’ impact on nonunion and infection rates in long-bone fractures.
        J Trauma Acute Care Surg. 2014; 76: 779-783
        • Perren S.M.
        Physical and biological aspects of fractures healing with special reference to internal fixation.
        Clin Orthop Relat Res. 1979; 138: 175-196
        • Perren S.M.
        Evolution of internal fixation of long bone fractures: the scientific basis of biological internal fixation: choosing a new balance between stability and biology.
        J Bone Joint Surg Br. 2002; 84: 1093-1110
        • Mandracchia V.J.
        • Nelson S.C.
        • Barp E.A.
        Current concepts of bone healing.
        Clin Podiatr Med Surg. 2001; 18: 55-77
        • McKibbin B.
        The biology of fracture healing in long bones.
        J Bone Joint Surg Br. 1978; 60: 150-162
        • Lindholm R.
        • Lindholm S.
        • Liukko P.
        • Paasimaki J.
        • Isokaanta S.
        • Rossi R.
        • Autio E.
        • Tamminen E.
        The mast cell as a component of callus in healing fractures.
        J Bone Joint Surg Br. 1969; 51: 148-155
        • Ham A.W.
        A histological study of the early phases of bone repair.
        J Bone Joint Surg Am. 1930; 12: 827-844
        • Sangeorzan B.J.
        • Smith D.
        • Veith R.
        • Hansen Jr., S.T.
        Triple arthrodesis using internal fixation in treatment of adult foot disorders.
        Clin Orthop Relat Res. 1993; 294: 299-307
        • Chatziyiannakis A.A.
        • Verettas D.A.
        • Raptis V.K.
        • Charpantitis S.T.
        Nonunion of tibial fractures treated with external fixation: contributing factors studied in 71 fractures.
        Acta Orthop Scand Suppl. 1997; 275: 77-79
        • Palmer M.
        • Costerton W.
        • Sewecke J.
        • Altman D.
        Molecular techniques to detect biofilm bacteria in long bone nonunion: a case report.
        Clin Orthop Relat Res. 2011; 469: 3037-3042
        • Brinker M.R.
        • O’Conner D.P.
        • Monla Y.T.
        • Earthman T.P.
        Metabolic and endocrine abnormalities in patients with nonunions.
        J Orthop Trauma. 2007; 21: 557-570
        • Dhanwal D.D.
        Thyroid disorders and bone mineral metabolism.
        Indian J Endocrinol Metab. 2011; 15: S107-S112
        • Guntur A.R.
        • Rosen C.J.
        Bone as an endocrine organ.
        Endocr Pract. 2012; 18: 758-762
        • Hoogwerf B.J.
        • Sferra J.
        • Donley B.G.
        Diabetes mellitus—overview.
        Foot Ankle Clin. 2006; 11: 703-715
        • Wukich D.K.
        • Lowery N.J.
        • McMillen R.L.
        • Frykberg R.G.
        Postoperative infection rates in foot and ankle surgery: a comparison of patients with and without diabetes mellitus.
        J Bone Joint Surg Am. 2010; 92: 287-295
        • Wukich D.K.
        • McMillen R.L.
        • Lowery N.J.
        • Frykberg
        Surgical site infections after foot and ankle surgery: a comparison of patients with and without diabetes.
        Diabetes Care. 2011; 34: 2211-2213
        • Grunfeld R.
        • Kunselman A.
        • Bustillo J.
        • Juliano P.J.
        Wound complications in thyroxine-supplemented patients following foot and ankle surgery.
        Foot Ankle Int. 2011; 32: 38-46