• Matthias Wittauer, Marc-Antoine Burch, Martin McNally, Thomas Vandendriessche, Martin Clauss, Gregory J Della Rocca, Peter V Giannoudis, Willem-Jan Metsemakers, and Mario Morgenstern.
• Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland, Spitalstrasse 21, 4031 Basel, Switzerland; University of Basel, Petersplatz 1, 4001 Basel, Switzerland.
• Injury. 2021 Nov 1; 52 (11): 3200-3205.

AimAlthough nonunions are among the most common complications after long-bone fracture fixation, the definition of fracture nonunion remains controversial and varies widely. The aim of this study was to identify the definitions and diagnostic criteria used in the scientific literature to describe nonunions after long-bone fractures.MethodsA comprehensive literature search was performed in PubMed, Cochrane Library, Web of Science, and Embase. Prospective clinical studies, in which adult long-bone fracture nonunions were investigated as main subject, were included in this analysis. Data on nonunion definitions described in each study were extracted and collected in a database.ResultsAlthough 148 studies met the inclusion criteria, only 50% (74/148) provided a definition for their main study subject. Nonunion was defined in these studies based on time-related criteria in 85% (63/74), on radiographic criteria in 62% (46/74), and on clinical criteria in 45% (33/74). A combination of clinical, radiographic and time-related criteria for definition was found in 38% (28/74). The time interval between fracture and the time point when authors defined an unhealed fracture as a nonunion showed considerable heterogeneity, ranging from three to twelve months.ConclusionIn the current orthopaedic literature, we found a lack of consensus with regard to the definition of long-bone nonunions. Without valid and reliable definition criteria for nonunion, standardization of diagnostic and treatment algorithms as well as the comparison of clinical studies remains problematic. The lack of a clear definition emphasizes the need for a consensus-based approach to the diagnosis of fracture nonunion centred on clinical, radiographical and time-related criteria.Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.

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