Reporting in the September 2, 2015 issue of The Journal of Bone and Joint Surgery, European researchers Moroder et al. found that 7 of 45 patients (17.5%) without substantial glenoid bone loss who underwent open Bankart repairs had a recurrence of instability during an average 22 years of follow-up.
This high failure rate is in line with findings from previous studies, but the authors include data indicating that, compared to patients who did not experience recurrent instability, “the recurrence of instability did not appear to significantly affect the subjective and objective outcome scores or the degree of work and sports impairment.”
The study found an unsurprising association between higher shoulder-specific activity levels and an increased risk for recurrence of instability. In fact, three of the seven late failures occurred during a high-energy sports accident. Etiologically, the authors hypothesize that “a lifestyle with high demands on the shoulders leads to weakening of the Bankart repair over time because of repetitive stress of the anterior capsulolabral complex.”
“Health-related quality of life” is easier to say than to measure. In the September 2, 2015 edition of The Journal, Schottel et al. document the impact of a diaphyseal nonunion on health-related quality of life using the well-accepted methodology of time trade-off. In this approach, patients are asked what percentage of their remaining life they would be willing to trade for perfect health, free from the disability in question.
Among the 832 long-bone nonunions studied, Schottel et al. found patients were willing to trade an average of 32% of their remaining lifespan for perfect health. Patients with nonunions of the forearm were willing to trade the greatest percentage of their lives (46%) to be rid of their disability.
This study demonstrates negative impacts of long bone nonunions that are greater than the patient-perceived impacts of diabetes, stroke, or AIDS, with all their attendant comorbidities and medical management issues. These findings serve to re-emphasize how important musculoskeletal function is for optimum quality of life—a fact that all practitioners who treat patients with musculoskeletal issues realize.
I’m certain more than a few of these patients developed a nonunion partly due to poor surgical indications and technique. Hence, our emphasis needs to be on curtailing long bone nonunions through injury-prevention strategies and optimum diagnosis and treatment of diaphyseal fractures. Also, as Mundi and Bhandari point out in their commentary to the Schottel et al. study, “It would behoove orthopaedic care providers to identify early patients with risk factors for nonunion, such that close surveillance and timely intervention can be initiated to minimize nonunion risk.”
Our orthopaedic community should be out in front of this issue with honest evaluations of surgical indications and outcomes so that we can all improve our judgment and surgical skill. While injury mechanisms and severity and patient characteristics undoubtedly also play a major role in the development of long bone nonunions, we orthopaedists should minimize as much as possible our part in creating these high-impact health problems.
Marc Swiontkowski, MD