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Patient-specific risk factors may predict union, nonunion in patients with fractures
Results showed an overall nonunion rate of 4.9% with nonunion rate varying by fracture location.
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The risk of nonunion may be identified in patients who experience bone fracture through patient-specific risk factors, such as fracture severity, fracture location, disease comorbidity and medication use, according to a study.
“Patient characteristics at presentation (index fracture) are predictive of likelihood of union or nonunion,” Robert D. Zura, MD, the Robert D’Ambrosia chair of orthopedics at LSU Health New Orleans, told Orthopedics Today.
Nonunion rate
Zura and his colleagues identified analyzed 309,330 fractures in patients (57.9% women) ranging from 18 years to 63 years of age from a large payer database compiled by Truven Health Analytics. The database included patient-level health claims data for medical and drug expenses, laboratory test results, hospital discharge information and death data, which were submitted by hospitals, managed care organizations, Medicare and Medicaid programs and an estimated 200 large corporations in exchange for benchmark reports.
Results showed an overall nonunion rate of 4.9%, with the highest nonunion rates found for the scaphoid (15.5%), the tibia and fibula (14%) and femur (13.9%). Although women had more fractures, researchers noted a higher proportion of nonunions among men. Patients with seven or more fractures had a nonunion frequency of 24% compared with 4.4% in patients with one fracture, according to results. Severe fractures, high BMI, smoking and alcoholism were associated with elevated nonunion risk.
Researchers found patients with osteoarthritis (OA), OA with rheumatoid arthritis (RA) or type 1 diabetes had increased odds of nonunion by at least 40%. When it came to medication use, use of NSAIDs and opioids was associated with the largest risk of nonunion, after controlling for confounding variables. Risk factors that significantly increased odds ratios for nonunion fractures included the number of fractures, use of NSAIDs plus opioids, operative treatment, open fracture, anticoagulant use, OA with RA, anticonvulsant use with benzodiazepines, opioid use, diabetes, high-energy injury, anticonvulsant use, osteoporosis, male gender, insulin use, smoking, benzodiazepine use, obesity, antibiotic use, osteoporosis medication use, vitamin D deficiency, diuretic use and renal insufficiency. According to researchers, the largest risk factor for nonunion was the number of fractures.
“Nonunions can potentially be predicted,” Zura said. “If so, clinical measures could be undertaken to mitigate the rate of nonunion, particularly in high risk patients.”
Underestimated data
Of the data collected, R. Grant Steen, PhD, of Bioventus, noted the results may underestimate the impact that smoking and obesity may have on nonunion risk.
“The main problem with claims data is that if there is not a claim, there is not any data,” Steen said. “We are certain there were more smokers in the database than we know about; only smokers who were prescribed a medication for smoking cessation were identified. Nowadays, smoking cessation medications are available [over the counter] OTC, so our numbers greatly underestimate the total number of smokers. The same is true of obesity; those who were not seeking treatment for it were not identified.” – by Casey Tingle
- Reference:
- Zura R, et al. JAMA Surg. 2016;doi:10.1001/jamasurg.2016.2775.
- For more information:
- Robert Zura, MD, can be reached at LSU Health New Orleans, 433 Bolivar St., New Orleans, LA 70112; email: rzura@lsuhsc.edu.
- R. Grant Steen, PhD, can be reached at Bioventus LLC, 4721 Emperor Blvd., Suite 100, Durham, NC 27703; email: grant.steen@bioventusglobal.com.
Disclosures: Zura reports he is a paid consultant to Bioventus LLC. Steen reports he is an employee of Bioventus LLC.