Risk Factors for Failure of Bone Grafting of Tibia Nonunions and Segmental Bone Defects: A New Preoperative Risk Assessment Score.

OBJECTIVE

To develop a clinically useful prediction model of success at the time of surgery to promote bone healing for established tibial nonunion or traumatic bone defects.

DESIGN

Retrospective case controlled.

SETTING

Level 1 trauma center.

PATIENTS: Adult patients treated with surgery for established tibia fracture nonunion or traumatic bone defects from 2007 to 2016. Two hundred three patients met the inclusion criteria and were available for final analysis.

INTERVENTION: Surgery to promote bone healing of established tibia fracture nonunion or segmental defect with plate and screw construct, intramedullary nail fixation, or multiplanar external fixation.

MAIN OUTCOME MEASURES: Failure of the surgery to promote bone healing that was defined as unplanned revision surgery for lack of bone healing or deep infection. No patients were excluded who had a primary outcome event.

RESULTS

Multivariate logistic modeling identified 5 significant (P < 0.05) risk factors for failure of the surgery to promote bone healing: (1) mechanism of injury, (2) Increasing body mass index, (3) cortical defect size (mm), (4) flap size (cm), and (5) insurance status. A prediction model was created based on these factors and awarded 0 points for fall, 17 points for high energy blunt trauma (OR = 17; 95% CI, 1-286, P = 0.05), 22 points for industrial/other (OR = 22; 95% CI, 1-4, P = 0.04), and 28 points for ballistic injuries (OR = 28; 95% CI, 1-605, P = 0.04). One point is given for every 10 cm of flap size (OR = 1; 95% CI, 1-1.1, P < 0.001), 10 mm of mean cortical gap distance (OR = 1; 95% CI, 1-2, P = 0.004), and 10 units BMI, respectively (OR = 1.5; 95% CI, 1-3, P = 0.16). Two points are awarded for Medicaid or no insurance (OR = 2; 95% CI, 1-5, P = 0.035) and 3 points for Medicare (3; 95% CI, 1-9, P = 0.033). Each 1-point increase in risk score was associated with a 6% increased chance of requiring at least 1 revision surgery (P < 0.001).

CONCLUSIONS

This study presents a clinical score that predicts the likelihood of success after surgery for tibia fracture nonunions or traumatic bone defects and may help clinicians better determine which patients are likely to fail these procedures and require further surgery.