Comparison of Single-Stage and Dual-Stage Approaches for Nonunion Repair in the Absence of Evident Infections.

Objectives: The aim of the study was to determine if routine dual-stage nonunion repair (DSR) surgery leads to better outcomes than single-stage nonunion (SSR) repair surgery in fracture nonunions without evident clinical or laboratory signs of infection.

Methods:

Design: Retrospective comparison study.

Setting: Level 1 Trauma Center affiliated with an academic teaching hospital.

Patient selection criteria: Skeletally mature patients diagnosed with fracture nonunion between June 2013 and January 2022 were included. Patients with previous nonoperative treatment, definitive external fixation, previous or current diagnosis of fracture-related infection, or <12 months of follow-up were excluded.

Outcome measures and comparison: Patient characteristics and details of the primary and the revision surgery were recorded. Comparison of the primary outcome measures, fracture-related infection, recalcitrant nonunion, and implant failures was performed between SSR and DSR groups.

Results: A total of 113 patients met the eligibility criteria. Eighty-six patients (mean age 44.8 years, range 17-80 years, 64% men) underwent SSR, while 27 patients (mean age 50.8 years, range 21-77 years, 52% men) underwent DSR. Seventy-six percent underwent SSR and 24% underwent DSR. Baseline characteristics were similar between groups (open fractures, P = 0.918; smoking, P = 0.86; lower limb fractures, P = 0.238; diabetes, P = 0.503; erythocyte sedimentation rate, P = 0.27; C-reactive protein, P = 0.11; age, P = 0.11; Charlson comorbidity index, P = 0.06) except for a higher rate of DSR in cases initially treated elsewhere ( P = 0.015) and in obese patients ( P = 0.044). Bone grafting was more frequent in DSR using plates ( P = 0.030). No significant differences were observed in subsequent infections (6.97% vs. 7.41%, P = 0.939), persistent nonunion (28.2% vs. 14.81%, P = 0.169), or implant failure (19.76% vs. 22.22%, P = 0.782) between SSR and DSR.

Conclusions: No difference was found in infection, recalcitrant nonunion, and implant failure between SSR and DSR for nonunions without overt signs of infection. The study challenges the routine use of DSR, questions the necessity of subjecting patients to 2 surgical procedures, and advocates for a more judicious approach in the absence of overt fracture-related infection in a fracture nonunion.

Level of evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.