Current Options for Determining Fracture Union

Using impedance to track fracture healing rates in mice in vivo: A pilot study

Fracture injuries are highly prevalent worldwide, with treatment of problematic fractures causing a significant burden on the U.S. healthcare system. Physicians typically monitor fracture healing by conducting physical examinations and taking radiographic images. However, nonunions currently take over 6 months to be diagnosed because these techniques are not sensitive enough to adequately assess fracture union. In this study, we display the utility of impedance spectroscopy to track different healing rates in a pilot study of an in vivo mouse tibia fracture model. We have developed small (56 μm) sensors and implanted them in an externally-stabilized fracture for twice-weekly measurement. We found that impedance magnitude increases steadily over time in healing mice but stalls in non-healing mice, and phase angle displays frequency-dependent behavior that also reflects the extent of healing at the fracture site. Our results demonstrate that impedance can track differences in healing rates early on, highlighting the potential of this technique as a method for early detection of fracture nonunion.

Triangular block bridge method for surgical treatment of complex proximal humeral fractures: theoretical concept, surgical technique and clinical results

INTRODUCTION

Criteria for classification, indication and choice of a surgical device to treat proximal humeral fractures are still controversial. We report an original technique based on a mechanical concept with a structural principle of a triangle as a rigid body applied to the humeral head fractures in association with other devices. This retrospective study aims to describe in detail the surgical technique and results at long time follow up.

METHODS AND MATERIAL

We analysed two series of 101 patients with proximal humeral fractures (mean age, 52.9 y; range 19-78 y) treated between 2001 and 2012 reporting the clinical and radiological results. In the first series of 23 cases (mean age 51.4 y, range 35-74 y) we used as support a bone piece taken from allograft or autologous tricortical iliac crest and shaped as a triangular pyramid during the operation; while in the second series of 78 cases (mean age 53.6 years, range 29-78 years, SD 13.5 years) a triangular titanium cage was used in 69 patients while in 9 allograft or bone substitute was used as augmentation. An analytical retrospective study was done to understand the mechanical function of medial augmentation composed by a solid body in association with different types of synthesis to stabilize properly a proximal humeral fracture.

RESULTS

We obtained excellent and good results in 83,2% of patients, fair in 12,8% and bad in 4% in terms of active anterior elevation, external and internal rotation, pain and strength according to Constant and DASH score.

CONCLUSION

A medial solid body, especially in titanium material and shaped as trapezoidal/pyramidal form used to fill the secondary bone loss in complex instable proximal humeral fracture, allows an anatomic reduction and stable fixation in association with simple and more complex tools and it provides a better biomechanical environment for union and maintenance of alignment.

The effects of low-intensity pulsed ultrasound on fresh fracture: A meta-analysis

BACKGROUND

Low-intensity pulsed ultrasonography (LIPUS) is a form of mechanical stimulation that is delivered via a special device to the fracture site for the acceleration of fracture healing. We conducted a meta-analysis to assess the effect of LIPUS for fresh fractures in adults.

METHODS

MEDLINE, EMBASE and the Cochrane Library searched between Jan 1980 and Nov 2016. Studies should be quasi-randomized and randomized controlled trials (RCTs) comparing treatment with LIPUS to placebo or no treatment in adults with fresh fractures, reporting outcomes such as function; time to union; delayed union or non-union. Summary standard mean difference (SMD) and the risk ratio (RR) with their 95% confidence interval (CI) calculated with a random effects model. I statistic was used to assess the heterogeneity. Risk of bias was assessed by the Cochrane risk-of-bias tool. The GRADE system was used to evaluate the evidence quality.

RESULTS

A total of 12 trials with 1099 patients were included. The pooled results showed that LIPUS significantly reduced the time to fracture union (SMD: 0.65, 95% CI: 1.13 to 0.17), improved the quality of life (SMD: 0.20, 95% CI: 0.03-0.37) without affecting the time to full weight bearing (SMD: 0.76, 95% CI: 1.92 to 0.4), the time to return to work (SMD: 0.06, 95% CI: 0.14 to 0.27), or the incidence rate of delayed union and nonunion (RR: 1.02, 95% CI: 0.60-1.74).

CONCLUSIONS

Moderate-to-high quality evidence shows that LIPUS treatment reduces the time to fracture union and improves the quality of life without affecting functional recovery and incident rate of delayed union and nonunion, suggesting that LIPUS treatment may be a good treatment modality for adults with fresh fractures. However, there are some methodological limitations in the eligible trials, further studies are needed to determine the clinical circumstances under which LIPUS is truly valid and to examine the optimal approach for the use of this adjunctive therapy.

A comparison of minimally invasive approach vs conventional approach for volar plating of distal radial fractures

Background

The aim of this study was to introduce and to evaluate the functional results of volar plating of distal radial fractures through a longitudinal minimally invasive approach.

Methods

From January 2010 to January 2013, 157 patients with distal radial fractures were randomly allocated to group A (n = 83; 49 men, 34 women; mean age: 42 (18–67)) and B (n = 74; 46 men, 28 women; mean age: 41 (22–65)), including type A2, A3, B3, C1, and C2 fractures, based on AO Foundation and Orthopaedic Trauma Association Classification. Patients in group A were treated through a 1.5- to 2-cm longitudinal incision, and patients in group B were treated through the conventional flexor carpi radialis approach. All fractures were treated with a locking volar plate. The functional results were compared with range of motion, grip and pronation strengths for each fracture type.

Results

After a follow-up of 2 years, similar measurements were noted on range of motion and grip strength in both groups. Regarding pronation strength, group A was superior to group B (p < 0.05).

Conclusions

Minimally invasive volar plating of distal radial fractures is a safe and reliable technique, resulting in better pronation function and appearance.

Level of Evidence

Level I, Therapeutic study

Bone healing in 2016

Delayed fracture healing and nonunion occurs in up to 5-10% of all fractures, and can present a challenging clinical scenario for the treating physician. Methods for the enhancement of skeletal repair may benefit patients that are at risk of, or have experienced, delayed healing or nonunion. These methods can be categorized into either physical stimulation therapies or biological therapies. Physical stimulation therapies include electrical stimulation, low-intensity pulsed ultrasonography, or extracorporeal shock wave therapy. Biological therapies can be further classified into local or systemic therapy based on the method of delivery. Local methods include autologous bone marrow, autologous bone graft, fibroblast growth factor-2, platelet-rich plasma, platelet-derived growth factor, and bone morphogenetic proteins. Systemic therapies include parathyroid hormone and bisphosphonates. This article reviews the current applications and supporting evidence for the use of these therapies in the enhancement of fracture healing.

The radiographic union scale in tibial (RUST) fractures: Reliability of the outcome measure at an independent centre

Objectives

The radiographic union score for tibial (RUST) fractures was developed by Whelan et al to assess the healing of tibial fractures following intramedullary nailing. In the current study, the repeatability and reliability of the RUST score was evaluated in an independent centre (a) using the original description, (b) after further interpretation of the description of the score, and (c) with the immediate post-operative radiograph available for comparison.

Methods

A total of 15 radiographs of tibial shaft fractures treated by intramedullary nailing (IM) were scored by three observers using the RUST system. Following discussion on how the criteria of the RUST system should be implemented, 45 sets (i.e. AP and lateral) of radiographs of IM nailed tibial fractures were scored by five observers. Finally, these 45 sets of radiographs were rescored with the baseline post-operative radiograph available for comparison.

Results

The initial intraclass correlation (ICC) on the first 15 sets of radiographs was 0.67 (95% CI 0.63 to 0.71). However, the original description was being interpreted in different ways. After agreeing on the interpretation, the ICC on the second cohort improved to 0.75. The ICC improved even further to 0.79, when the baseline post-operative radiographs were available for comparison.

Conclusion

This study demonstrates that the RUST scoring system is a reliable and repeatable outcome measure for assessing tibial fracture healing. Further improvement in the reliability of the scoring system can be obtained if the radiographs are compared with the baseline post-operative radiographs.

Cite this article: Mr J.M. Leow. The radiographic union scale in tibial (RUST) fractures: Reliability of the outcome measure at an independent centre. Bone Joint Res 2016;5:116–121. DOI: 10.1302/2046-3758.54.2000628.

Impedance spectroscopy to monitor fracture healing

An estimated 7.9 million fracture injuries occur each year in the United States, of which a substantial fraction result in delayed or non-union. Current methods of monitoring fracture healing include taking x-rays and making clinical observations. However, x-ray confirmation of bone healing typically lags behind biologic healing, and physician assessment of healing is fraught with subjectivity. No standardized methods exist to assess the extent of healing that has taken place in a fracture. Without such knowledge, interventions to aid healing and prevent fracture non-union are often delayed, leading to increased morbidity and suffering to patients. We are developing an objective measurement tool that utilizes electrical impedance spectroscopy to distinguish between the various types of tissue present during the different stages of fracture healing. Preliminary measurements of cadaveric tissues reveal adequate spread in impedance measurements and differences in frequency response among different tissue types. Electrodes implanted in a simulated fracture created in an ex vivo cadaver model yield promising results for our system's ability to differentiate between the stages of fracture healing.

Thermal changes during healing of distal radius fractures-Preliminary findings

INTRODUCTION

The bone healing process is very complex. In simple terms, bone healing comprises three basic steps, the inflammation phase, the repair phase and the remodelling phase. The increase in blood flow around the fracture during the healing process increases the temperature of the surrounding tissue. Infrared thermography is a method of measuring body temperature that can detect temperature changes during bone healing. Studies on the application of thermography in traumatology are scarce, and there are no studies of thermal changes during normal bone healing. The authors have tried to determine the dynamics of thermal changes during bone healing.

MATERIAL AND METHODS

The Flir ThermaCam B2 (FLIR Systems, Inc., Oregon, USA) was used for all measurements. Thermographic recordings were made one, three, five, 11 and 23 weeks after fracture. The contralateral, healthy, forearm was used for comparison.

RESULTS

A total of 25 patients of mean age 65.9±10.4 years (range 50-80 years) with fracture of the distal radius were examined in this study. The mean temperature difference between healthy and fractured distal forearm one week after fracture was 1.20±0.48°C, three weeks after fracture was 1.42±0.54°C, five weeks after fracture was 1.04±0.53°C, 11 weeks after fracture was 0.50±0.30°C, and 23 weeks after fracture was 0.22±0.25°C.

CONCLUSION

Preliminary findings during this research showed significant temperature changes during healing of distal radius fractures. Infrared thermography is a simple and reliable method in clinical practice that could be used as a good follow-up method in traumatology, but further investigations on more patients are needed.

Retrograde nailing of femoral fractures: a retrospective study

BACKGROUND

Retrograde femoral nailing is a common method to repair femoral shaft fractures in polytrauma patients. Studies have reported varying incidences of complications associated with retrograde femoral nailing such as knee pain, nonunion, and arthrofibrosis. The objective of this retrospective study was to describe healing and complication rates of 31 patients who underwent retrograde femoral nailing at our academic medical center.

METHODS

Clinical notes and radiographs were reviewed retrospectively. Data points such as demographics, fracture location on femur, time to union after surgery, presence or absence of comminution, associated injuries, and complications were assessed.

RESULTS

Average time to union was 4.69 months with no statistically significant relationship found between time to union and age, sex, comminution, or location of fracture. Knee pain was present in 23 % of patients, and distal screw removal was necessary in 19.4 % of patients.

DISCUSSION

Retrograde femoral nailing is an effective method of femoral shaft fracture fixation in polytrauma patients. The healing rate of femoral shaft fractures fixed with a retrograde nail is the same regardless of location of fracture, age, sex, or comminution. Prevention of tip of nail lying into the knee and early physical therapy are important to prevent arthrofibrosis knee.