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Chandran M, Akesson KE, Javaid MK, Harvey N, Blank RD, Brandi ML, Chevalley T, Cinelli P, Cooper C, Lems W, Lyritis GP, Makras P, Paccou J, Pierroz DD, Sosa M, Thomas T, Silverman S. Impact of osteoporosis and osteoporosis medications on fracture healing: a narrative review. Osteoporos Int 2024:10.1007/s00198-024-07059-8. [PMID: 38587674 DOI: 10.1007/s00198-024-07059-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 03/06/2024] [Indexed: 04/09/2024]
Abstract
Antiresorptive medications do not negatively affect fracture healing in humans. Teriparatide may decrease time to fracture healing. Romosozumab has not shown a beneficial effect on human fracture healing. BACKGROUND Fracture healing is a complex process. Uncertainty exists over the influence of osteoporosis and the medications used to treat it on fracture healing. METHODS Narrative review authored by the members of the Fracture Working Group of the Committee of Scientific Advisors of the International Osteoporosis Foundation (IOF), on behalf of the IOF and the Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT). RESULTS Fracture healing is a multistep process. Most fractures heal through a combination of intramembranous and endochondral ossification. Radiographic imaging is important for evaluating fracture healing and for detecting delayed or non-union. The presence of callus formation, bridging trabeculae, and a decrease in the size of the fracture line over time are indicative of healing. Imaging must be combined with clinical parameters and patient-reported outcomes. Animal data support a negative effect of osteoporosis on fracture healing; however, clinical data do not appear to corroborate with this. Evidence does not support a delay in the initiation of antiresorptive therapy following acute fragility fractures. There is no reason for suspension of osteoporosis medication at the time of fracture if the person is already on treatment. Teriparatide treatment may shorten fracture healing time at certain sites such as distal radius; however, it does not prevent non-union or influence union rate. The positive effect on fracture healing that romosozumab has demonstrated in animals has not been observed in humans. CONCLUSION Overall, there appears to be no deleterious effect of osteoporosis medications on fracture healing. The benefit of treating osteoporosis and the urgent necessity to mitigate imminent refracture risk after a fracture should be given prime consideration. It is imperative that new radiological and biological markers of fracture healing be identified. It is also important to synthesize clinical and basic science methodologies to assess fracture healing, so that a convergence of the two frameworks can be achieved.
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Affiliation(s)
- M Chandran
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, DUKE NUS Medical School, Singapore, Singapore.
| | - K E Akesson
- Clinical and Molecular Osteoporosis Research Unit, Department of Clinical Sciences, Lund University, Department of Orthopedics, Skåne University Hospital, Malmö, Sweden
| | - M K Javaid
- NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK
| | - N Harvey
- MRC Lifecourse Epidemiology Centre, University of Southampton, NIHR Southampton Biomedical Research Centre, University of Southampton, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - R D Blank
- Garvan Institute of Medical Research, Medical College of Wisconsin, Darlinghurst, NSW, Australia
- Medical College of Wisconsin, Milwaukee, WI, USA
| | - M L Brandi
- Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Largo Palagi 1, Florence, Italy
| | - T Chevalley
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - P Cinelli
- Department of Trauma Surgery, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - C Cooper
- MRC Lifecourse Epidemiology Centre, University of Southampton, NIHR Southampton Biomedical Research Centre, University of Southampton, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
- NIHR Oxford Biomedical Research Unit, University of Oxford, Oxford, UK
| | - W Lems
- Department of Rheumatology, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - G P Lyritis
- Hellenic Osteoporosis Foundation, Athens, Greece
| | - P Makras
- Department of Medical Research, 251 Hellenic Air Force & VA General Hospital, Athens, Greece
| | - J Paccou
- Department of Rheumatology, MABlab ULR 4490, CHU Lille, Univ. Lille, 59000, Lille, France
| | - D D Pierroz
- International Osteoporosis Foundation, Nyon, Switzerland
| | - M Sosa
- University of Las Palmas de Gran Canaria, Investigation Group on Osteoporosis and Mineral Metabolism, Canary Islands, Spain
| | - T Thomas
- Department of Rheumatology, North Hospital, CHU Saint-Etienne and INSERM U1059, University of Lyon-University Jean Monnet, Saint‑Etienne, France
| | - S Silverman
- Cedars-Sinai Medical Center and Geffen School of Medicine UCLA, Los Angeles, CA, USA
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Fuchs J, Spühler DL, Luz S, Zdravkovic V, Hainich J. Corrective osteotomy of the distal radius with palmar locking plate osteosynthesis without bone grafting and without cortical contact. J Hand Surg Eur Vol 2024; 49:359-365. [PMID: 37310077 DOI: 10.1177/17531934231179875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The aim of this study was to assess bone healing and secondary fracture displacement after corrective osteotomy of the distal radius without any cortical contact using palmar locking plates without bone grafting. Between 2009 and 2021, 11 palmar corrective osteotomies of extra-articular malunited distal radius fractures and palmar plate fixations without the use of bone grafts and without cortical contact, were assessed. All patients showed complete osseous restoration and significant improvement in all radiographic parameters. Except for one patient, there were no secondary dislocations or loss of reduction in the postoperative follow-up. Bone grafts may not be mandatory for bone healing and prevention of secondary fracture displacement after palmar corrective osteotomy without cortical contact and fixation with palmar locking plate.Level of evidence: IV.
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Affiliation(s)
- Johannes Fuchs
- Hand, Plastic and Reconstructive Surgery, Cantonal Hospital St. Gallen, Switzerland
| | | | - Stephanie Luz
- Hand, Plastic and Reconstructive Surgery, Cantonal Hospital St. Gallen, Switzerland
| | - Vilijam Zdravkovic
- Department of Orthopedics and Traumatology, Cantonal Hospital St. Gallen, Switzerland
| | - Jörg Hainich
- Hand, Plastic and Reconstructive Surgery, Cantonal Hospital St. Gallen, Switzerland
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van Veelen NM, van de Wall BJM, Hoepelman RJ, IJpma FFA, Link BC, Babst R, Groenwold RHH, van der Velde D, Diwersi N, van Heijl M, Houwert RM, Beeres FJP. Let's Agree to Disagree on Operative Versus Nonoperative Treatment for Distal Radius Fractures in Older People: Protocol for a Prospective International Multicenter Cohort Study. JMIR Res Protoc 2024; 13:e52917. [PMID: 38349719 PMCID: PMC10900084 DOI: 10.2196/52917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 12/11/2023] [Accepted: 12/11/2023] [Indexed: 03/01/2024] Open
Abstract
BACKGROUND Distal radius fractures are the most frequently encountered fractures in Western societies, typically affecting patients aged 50 years and older. Although this is a common injury, the best treatment for these fractures in older patients is still under debate. OBJECTIVE This prospective study aims to compare the outcome of operatively and nonoperatively treated distal radius fractures in the older population. Only patients with distal radius fractures for which equipoise regarding the optimal treatment exists will be included. METHODS This prospective international multicenter observational cohort study will be designed as a natural experiment. Natural experiments are observational studies in which treatment allocation is determined by factors outside the control of the investigators but also (largely) independent of patient characteristics. Patients aged 65 years and older with an acute distal radius fracture will be considered for inclusion. Treatment allocation (operative vs nonoperative) will be based on the local preferences of the treating hospital either in Switzerland or the Netherlands. Hence, the process governing treatment allocation resembles that of randomization. Patients will be identified after treatment has been initiated. Based on the radiographs and baseline information of the patient, an expert panel of 6 certified trauma surgeons from 2 regions will provide their treatment recommendation. Only patients for whom the experts disagree on treatment recommendations will ultimately be included in the study (ie, for whom there is a clinical equipoise). For these patients, both operative and nonoperative treatment of distal radius fractures are viable, and treatment choice is predominantly determined by personal or local preference. The primary outcome will be the Patient-Rated Wrist Evaluation score at 12 weeks. Secondary outcomes will include the Physical Activity Score for the Elderly, the EQ questionnaire, pain, the living situation, range of motion, complications, and radiological outcomes. By including outcomes such as living situation and the Physical Activity Score for the Elderly, which are not relevant for younger cohorts, valuable information to tailor treatment to the needs of the older population can be gained. According to the sample size collection, which was based on the minimal important clinical difference of the Patient-Rated Wrist Evaluation, 92 patients will have to be included, with at least 46 patients in each treatment group. RESULTS Enrollment began in July 2023 and is expected to continue until summer 2024. The final follow-up will be 2 years after the last patient is included. CONCLUSIONS Although many trials on this topic have previously been published, there remains an ongoing debate regarding the optimal treatment for distal radius fractures in older patients. This observational study, which will use a fairly new methodological study design, will provide further information on treatment outcomes for older patients with distal radius fractures for which to date equipoise exists regarding the optimal treatment. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/52917.
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Affiliation(s)
- Nicole Maria van Veelen
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Luzern, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Luzern, Switzerland
| | - Bryan J M van de Wall
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Luzern, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Luzern, Switzerland
| | - Ruben J Hoepelman
- Department of Trauma Surgery, Universitair Medisch Centrum Utrecht, Utrecht, Netherlands
| | - Frank F A IJpma
- Department of Trauma Surgery, Universitair Medisch Centrum Groningen, Groningen, Netherlands
| | - Björn-Christian Link
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Luzern, Switzerland
| | - Reto Babst
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Luzern, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Luzern, Switzerland
| | - Rolf H H Groenwold
- Department of Clinical Epidemiology, Universitair Medisch Centrum Leiden, Leiden, Netherlands
| | | | - Nadine Diwersi
- Department of General and Trauma Surgery, Kantonsspital Obwalden, Sarnen, Switzerland
| | - Mark van Heijl
- Department of Surgery, Diakonessenhuis Utrecht, Utrecht, Netherlands
| | - R Marijn Houwert
- Department of Trauma Surgery, Universitair Medisch Centrum Utrecht, Utrecht, Netherlands
| | - Frank J P Beeres
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Luzern, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Luzern, Switzerland
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Czerniecki S, Mishu M, Schmucker R. Metacarpal and Phalangeal Nonunions. Hand Clin 2024; 40:129-139. [PMID: 37979984 DOI: 10.1016/j.hcl.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2023]
Abstract
The majority of phalangeal and metacarpal fractures will proceed to union when appropriately treated. However, when a nonunion does occur, it can lead to significant functional impairment for patients and societal costs. Operative intervention is typically required in these cases, but the technique can vary depending on each individual patient scenario. This article provides an overview of nonunions of the metacarpals and phalanges in the hand, including incidence, risk factors, current treatment options, and postoperative care.
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Affiliation(s)
- Stefan Czerniecki
- Department of Plastic and Reconstructive Surgery, The Ohio State University Columbus, OH, USA
| | - Mark Mishu
- Department of Plastic and Reconstructive Surgery, The Ohio State University Columbus, OH, USA
| | - Ryan Schmucker
- Department of Plastic and Reconstructive Surgery, The Ohio State University Columbus, OH, USA.
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Rozental TD, Watkins IT. Principles and Evaluation of Bony Unions. Hand Clin 2024; 40:1-12. [PMID: 37979981 DOI: 10.1016/j.hcl.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2023]
Abstract
Nonunion is a common and costly problem. Unfortunately, there is no widely agreed upon and standardized definition for nonunion. The evaluation of bony union should start with a thorough history and physical examination. The clinician should consider patient-dependent as well as patient-independent characteristics that may influence the rate of healing and evaluate the patient for physical examination findings suggestive of bony union and infection. Radiographs and clinical examination can help confirm a diagnosis of union. When the diagnosis is in doubt, however, advanced imaging modalities as well as laboratory studies can help a surgeon determine when further intervention is necessary.
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Affiliation(s)
- Tamara D Rozental
- Hand and Upper Extremity Surgery, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue - Stoneman 10, Boston, MA, 02215, USA.
| | - Ian T Watkins
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; Division of Hand and Upper Extremity Surgery, Department of Orthopedics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Tong L, Yang Z, Dai W, Sun Z, Yang J, Xue Q, Li Y. Experimental study on determining the degree of bone healing by wall thickness ratio analysis. J Orthop Surg Res 2024; 19:79. [PMID: 38243260 PMCID: PMC10799492 DOI: 10.1186/s13018-024-04565-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 01/16/2024] [Indexed: 01/21/2024] Open
Abstract
To verify the reliability and accuracy of wall thickness ratio analysis to determine the degree of bone healing, fracture models were established with 6 beagles. X-ray, micro-CT, and CT scans were performed at 24 weeks. The healthy side and the affected side were used to simulate the three-dimensional geometric model after internal fixation, and the mesh was divided. The mean and median CT wall thickness values were obtained through the wall thickness analysis. X-ray, CT, micro-CT, and gross appearance were used to determine the degree of bone healing, which was compared with wall thickness analysis. There was a positive correlation between the average CT value and the median wall thickness. The correlation coefficient analysis of the median wall thickness ratio (R2) and healing index ratio (R3) showed a positive correlation. The results of the wall thickness ratio (R2) and the healing index ratio (R3) were used to determine bone healing, and the results were consistent with the results of the actual mechanical test and image analysis. The results of wall thickness ratio analysis were significantly correlated with the degree of bone healing. This method is simple, rapid, and practical to analyze and judge the degree of bone healing.
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Affiliation(s)
- Liangcheng Tong
- Department of Orthopedics, Air Force Hospital of Eastern Theater Command, Anhui Medical University, No. 1 Malu Road, Nanjing, 210002, Jiangsu, China
| | - Zhiwei Yang
- Department of Orthopedics, Air Force Hospital of Eastern Theater Command, Anhui Medical University, No. 1 Malu Road, Nanjing, 210002, Jiangsu, China
| | - Wei Dai
- Department of Orthopedics, Air Force Hospital of Eastern Theater Command, Anhui Medical University, No. 1 Malu Road, Nanjing, 210002, Jiangsu, China
| | - Zhongyang Sun
- Department of Orthopedics, Air Force Hospital of Eastern Theater Command, Anhui Medical University, No. 1 Malu Road, Nanjing, 210002, Jiangsu, China
| | - Junsheng Yang
- Department of Orthopedics, Air Force Hospital of Eastern Theater Command, Anhui Medical University, No. 1 Malu Road, Nanjing, 210002, Jiangsu, China
| | - Qing Xue
- Department of Orthopedics, Air Force Hospital of Eastern Theater Command, Anhui Medical University, No. 1 Malu Road, Nanjing, 210002, Jiangsu, China
| | - Ying Li
- Department of Orthopedics, Air Force Hospital of Eastern Theater Command, Anhui Medical University, No. 1 Malu Road, Nanjing, 210002, Jiangsu, China.
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7
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Factor S, Druckmann I, Kazum E, Atlan F, Tordjman D, Rosenblatt Y, Eisenberg G, Pritsch T. A novel pulsed electromagnetic field device as an adjunct therapy to surgical treatment of distal radius fractures: a prospective, double-blind, sham-controlled, randomized pilot study. Arch Orthop Trauma Surg 2024; 144:543-550. [PMID: 37971511 DOI: 10.1007/s00402-023-05117-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/20/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION The purpose of this study is to evaluate whether using a Fracture Healing Patch (FHP) device that generates pulsed electromagnetic fields (PEMF), applied at the fracture site immediately after open reduction and internal fixation surgery, can accelerate healing of acute distal radius fractures. METHODS In a prospective, double-blind, randomized, and sham-controlled study, thirty-two patients with DRFs treated with ORIF were included. Patients were allocated to a PEMF (active) group (n = 15) or a control (sham) group (n = 17). All patients were assessed with regard to functional Patient-Rated Wrist Evaluation (PRWE), SF12, and radiological union outcomes (X-rays and computed tomography (CT) scans) at 2, 4, 6, and 12 weeks postoperatively. RESULTS Patients treated with the FHP demonstrated significantly bone bridging at 4 weeks as assessed by CT (70% vs 54%, p = 0.05). Mean grip strength in the active group was significantly higher as compared to control (16 ± 9 kg vs 7 ± 3.5 kg, respectively, p = 0. 02). The function subscale of the PRWE was significantly better in PEMF-treated group at 6 weeks after surgery (27.2 VS 35.5, p = 0.04). No statistically significant differences were found in SF12. CONCLUSION PEMF application after ORIF of DRFs is safe, may accelerate bone healing which could lead to an earlier return to daily life activities and work. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Shai Factor
- Hand Surgery Unit, Division of Orthopedic Surgery, Tel Aviv Medical Center, 6423906, Tel Aviv, Israel.
- Affiliated to Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Ido Druckmann
- Division of Radiology, Tel Aviv Medical Center, 6 Weitzman St., 6423906, Tel Aviv, Israel
| | - Efi Kazum
- Hand Surgery Unit, Division of Orthopedic Surgery, Tel Aviv Medical Center, 6423906, Tel Aviv, Israel
- Affiliated to Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Franck Atlan
- Hand Surgery Unit, Division of Orthopedic Surgery, Tel Aviv Medical Center, 6423906, Tel Aviv, Israel
- Affiliated to Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Tordjman
- Hand Surgery Unit, Division of Orthopedic Surgery, Tel Aviv Medical Center, 6423906, Tel Aviv, Israel
- Affiliated to Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yishai Rosenblatt
- Hand Surgery Unit, Division of Orthopedic Surgery, Tel Aviv Medical Center, 6423906, Tel Aviv, Israel
- Affiliated to Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gilad Eisenberg
- Hand Surgery Unit, Division of Orthopedic Surgery, Tel Aviv Medical Center, 6423906, Tel Aviv, Israel
- Affiliated to Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tamir Pritsch
- Hand Surgery Unit, Division of Orthopedic Surgery, Tel Aviv Medical Center, 6423906, Tel Aviv, Israel
- Affiliated to Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Rava A, Alberghina F, Cravino M, Canavese F, Andreacchio A. Closed reduction and cast immobilization of overriding distal forearm fractures under nitrous oxide as conscious sedation without the use of imaging control. Musculoskelet Surg 2023; 107:413-421. [PMID: 37273144 DOI: 10.1007/s12306-023-00785-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 05/02/2023] [Indexed: 06/06/2023]
Abstract
PURPOSE The management of overriding distal forearm fractures is still controversial. This study aimed to evaluate the efficacy of immediate closed reduction and cast immobilization (CRCI) at the emergency department (ED) using equimolar nitrous oxide (eN2O2) as conscious sedation, and without the use fluoroscopic assistance. METHODS Sixty patients with overriding distal forearm fracture were included in the study. All procedures were performed in the ED without fluoroscopic assistance. Antero-posterior and lateral wrist radiographs were taken after CRCI. Follow-up radiographs were taken 7 and 15 days post-reduction, and at cast removal to evaluate callus formation. Depending on the radiological outcome, two groups of patients could be identified: Group 1 (satisfactory reduction and maintenance of alignment) and Group 2 (poor reduction or secondary displacement requiring further manipulation and surgical fixation). Group 2 was additionally divided into Group 2A (poor reduction) and Group 2B (secondary displacement). Pain was assessed using Numeric Pain Intensity (NPI) score, while functional outcome was measured according to Quick DASH questionnaire. RESULTS Mean age at the time of injury was 9.2 ± 2.4 years (range, 5-14). Twenty-three (38%) patients were aged between 4 and 9 years old, 20 (33%) patients between 9 and 11, 11 (18%) patients between 11 and 13, and 6 (10%) patients between 13 and 14. The mean follow-up time was 45.6 ± 12 months (range, 24-63). Satisfactory reduction with maintenance of alignment was achieved in 30 (50%) patients (Group 1). Re-reduction was performed in the remaining 30 (50%) patients (Group 2) due to poor reduction (Group 2A) or secondary displacement (Group 2B). No complications related to the administration of eN2O were recorded. No statistically significant difference could be identified between the three groups for any clinical variable (Quick DASH and NPI). CONCLUSION Overriding distal forearm fractures may be safely treated with CRCI at ED using eN2O2 as conscious sedation. However, fluoroscopic assistance during CRCI might significantly improve the quality of reduction thus avoiding further treatment as the lack of relaxed muscle can restrain reduction.
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Affiliation(s)
- A Rava
- Orthopedic Surgery Department, Ospedale Degli Infermi, Via Rivalta 29, 10098, Rivoli, Italy
| | - F Alberghina
- Pediatric Orthopedic Surgery Department, Regina Margherita Children's Hospital, Piazza Polonia 94, 10126, Turin, Italy
| | - M Cravino
- Pediatric Orthopedic Surgery Department, Regina Margherita Children's Hospital, Piazza Polonia 94, 10126, Turin, Italy
| | - F Canavese
- Dept. of Pediatric Orthopedic Surgery, Lille University Center, Jeanne de Flandre Hospital, Av. Eugène Avinée, 59000, Lille, France
| | - A Andreacchio
- Pediatric Orthopedic Surgery Department, Vittore Buzzi Children's Hospital, Via Lodovico Castelvetro 32, 20154, Milan, Italy.
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Li Y, Yang Z, Tong L, Yang J, Wang J, Wen Y. Wall thickness analysis method for judging the degree of lower extremity long bone healing. Sci Rep 2023; 13:20650. [PMID: 38001361 PMCID: PMC10673992 DOI: 10.1038/s41598-023-48212-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 11/23/2023] [Indexed: 11/26/2023] Open
Abstract
To evaluate the possibility of judging the degree of bone healing by wall thickness analysis provide reference for quantitative analysis of bone healing. Patients with lower limb fracture from April 2014 to October 2019 were recruited and divided into bone healing (group A), poor bone healing (group B), and nonunion (group C). Models were built in Mimics 20.0 with DICOM 3.0 data obtained from patient's CT. Three-dimensional geometric models of unaffected limb and affected limb after simulated removal of internal fixation were established, corresponding to basic phase and simulated phase, respectively. Wall thickness analysis was performed to obtain median wall thickness after meshing. R2 (median wall thickness ratio), R4 (CT value ratio), and R5 (healing index ratio) were obtained by calculating the ratio of each value in simulated phase to that in basic phase. Receiver operating characteristic curve analysis was used to evaluate the ability of Wall Thickness Analysis to indicate fracture healing. 112 CT scans of 79 patients were included in the study. The frequency of categorization in groups A, B, and C was 49, 37 and 26, respectively. The median R2 in groups A, B, and C was 0.91, 0.80, and 0.67, respectively (group A > group B > group C, all P < 0.05). The best cutoff point for R2 in predicting bone healing was 0.84, and predicting bone nonunion was 0.74. The Wall Thickness Analysis can be used to quantitatively evaluate fracture healing state, with median wall thickness ratio as a more intuitive and reliable judgment index.
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Affiliation(s)
- Ying Li
- Department of Orthopedics, Air Force Hospital of Eastern Theater Command, Nanjing, Jiangsu, China
- Department of Clinical Medicine, Anhui Medical University, Hefei, Anhui, China
| | - Zhiwei Yang
- Department of Orthopedics, Air Force Hospital of Eastern Theater Command, Nanjing, Jiangsu, China
| | - Liangcheng Tong
- Department of Orthopedics, Air Force Hospital of Eastern Theater Command, Nanjing, Jiangsu, China
| | - Junsheng Yang
- Department of Orthopedics, Air Force Hospital of Eastern Theater Command, Nanjing, Jiangsu, China
| | - Jianling Wang
- Department of Orthopedics, Air Force Hospital of Eastern Theater Command, Nanjing, Jiangsu, China
| | - Yaoke Wen
- School of Mechanical Engineering, Nanjing University of Science and Technology, No. 200 Xiaolingwei, Nanjing, 210094, Jiangsu, China.
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Leow JM, Oliver WM, Bell KR, Molyneux SG, Clement ND, Duckworth AD. The Radiographic Union Score for ulnar fractures (RUSU) predicts ulnar shaft nonunion. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3167-3173. [PMID: 37071221 DOI: 10.1007/s00590-023-03556-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/11/2023] [Indexed: 04/19/2023]
Abstract
AIMS To develop a reliable and effective radiological score to assess the healing of isolated ulnar shaft fractures (IUSF), the Radiographic Union Score for Ulna fractures (RUSU). METHODS Initially, 20 patients with radiographs six weeks following a non-operatively managed ulnar shaft fracture were selected and scored by three blinded observers. After intraclass correlation (ICC) analysis, a second group of 54 patients with radiographs six weeks after injury (18 who developed a nonunion and 36 who united) were scored by the same observers. RESULTS In the initial study, interobserver and intraobserver ICC were 0.89 and 0.93, respectively. In the validation study, the interobserver ICC was 0.85. The median score for patients who united was significantly higher than those who developed a nonunion (11 vs. 7, p < 0.001). A ROC curve demonstrated that a RUSU ≤ 8 had a sensitivity of 88.9% and specificity of 86.1% in identifying patients at risk of nonunion. Patients with a RUSU ≤ 8 (n = 21) were more likely to develop a nonunion (n = 16/21) than those with a RUSU ≥ 9 (n = 2/33; OR 49.6, 95% CI 8.6-284.7). Based on a PPV of 76%, if all patients with a RUSU ≤ 8 underwent fixation at 6 weeks, the number of procedures needed to avoid one nonunion would be 1.3. CONCLUSION The RUSU shows good interobserver and intraobserver reliability and is effective in identifying patients at risk of nonunion six weeks after fracture. This tool requires external validation but may enhance the management of patients with isolated ulnar shaft fractures.
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Affiliation(s)
- Jun Min Leow
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, Midlothian, EH16 4SA, UK.
| | - William M Oliver
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, Midlothian, EH16 4SA, UK
| | - Katrina R Bell
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, Midlothian, EH16 4SA, UK
| | - Samuel G Molyneux
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, Midlothian, EH16 4SA, UK
| | - Nicholas D Clement
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, Midlothian, EH16 4SA, UK
| | - Andrew D Duckworth
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, Midlothian, EH16 4SA, UK
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, 49 Little France Crescent, Edinburgh, Midlothian, EH16 4SB, UK
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11
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Factor S, Druckmann I, Atlan F, Rosenblatt Y, Tordjman D, Krespi R, Kazum E, Pritsch T, Eisenberg G. The Effects of Novel Pulsed Electromagnetic Field Therapy Device on Acute Distal Radius Fractures: A Prospective, Double-Blind, Sham-Controlled, Randomized Pilot Study. J Clin Med 2023; 12:jcm12051866. [PMID: 36902653 PMCID: PMC10003714 DOI: 10.3390/jcm12051866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 02/20/2023] [Accepted: 02/22/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND this pilot study aimed at determining whether the application of a novel new method of generating pulsed electromagnetic field (PEMF), the Fracture Healing Patch (FHP), accelerates the healing of acute distal radius fractures (DRF) when compared to a sham treatment. METHODS 41 patients with DRFs treated with cast immobilization were included. Patients were allocated to a PEMF group (n = 20) or a control (sham) group (n = 21). All patients were assessed with regard to functional and radiological outcomes (X-rays and CT scans) at 2, 4, 6 and 12 weeks. RESULTS fractures treated with active PEMF demonstrated significantly higher extent of union at 4 weeks as assessed by CT (76% vs. 58%, p = 0.02). SF12 mean physical score was significantly higher in PEMF treated group (47 vs. 36, p = 0.005). Time to cast removal was significantly shorter in PEMF treated patients, 33 ± 5.9 days in PEMF vs. 39.8 ± 7.4 days in sham group (p = 0.002). CONCLUSION early addition of PEMF treatment may accelerate bone healing which could lead to a shorter cast immobilization, thus allowing an earlier return to daily life activities and work. There were no complications related to the PEMF device (FHP).
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Affiliation(s)
- Shai Factor
- Division of Orthopedic Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
- Correspondence: ; Tel.: +972-52-7360753; Fax: +972-74-7219810
| | - Ido Druckmann
- Division of Radiology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Franck Atlan
- Division of Orthopedic Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Yishai Rosenblatt
- Division of Orthopedic Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Daniel Tordjman
- Division of Orthopedic Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Raphael Krespi
- Division of Orthopedic Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Efi Kazum
- Division of Orthopedic Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Tamir Pritsch
- Division of Orthopedic Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Gilad Eisenberg
- Division of Orthopedic Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
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12
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Fan Y, Bai D, Cheng C, Tian G. The effectiveness and safety of blood flow restriction training for the post-operation treatment of distal radius fracture. Ann Med 2023; 55:2240329. [PMID: 37505919 PMCID: PMC10392265 DOI: 10.1080/07853890.2023.2240329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/10/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
INTRODUCTION Distal radius fracture (DRF) is a common injury in the upper extremities. Blood flow restriction (BFR) has been proven to be effective in improving function in low-load training, which is suitable for post-op rehabilitation. We explored the effectiveness and safety of BFR therapy in DRF patients who underwent surgery. MATERIALS AND METHODS Thirty-five patients were randomly assigned to either the BFR or the regular training (RT; no BFR therapy) groups. All patients completed the same 4-week postoperative rehabilitation program, including anti-inflammatory treatments, strengthening and range of motion (ROM) training. In the BFR group, the pressure was 120 mmHg in strengthening training course. Pain, circumferences of wrists and forearms, ROM, muscle strength, and D-dimer levels were evaluated at weeks 0, 2, and 4. Radius union scoring system (RUSS) was measured at weeks 4 and 12. Finally, wrist functionality (Cooney modification) was evaluated at week 12. RESULTS The BFR group had significantly decreased pain levels compared with the RT group (p < 0.01, effect size= 2.33, -2.44 at weeks 2 and 4). Swelling was effectively relieved in both groups. The wrist swelling was less in the BFR group (p < 0.01, effect size = -2.17 at week 4). The isometric strength of wrist extension (p < 0.01, effect size = 1.5, 3.02 at weeks 2 and 4), flexion (p < 0.01, effect size = 1.33, 2.53 at weeks 2 and 4), and functionality significantly increased in the BFR group (p < 0.01, effect size = 2.80 at week 12). No risk of VT in the BFR group was found. BFR did not threaten bone healing. CONCLUSIONS In patients with DRF who underwent corrective surgery, BFR therapy effectively relieved pain and swelling, increased muscle strength and wrist function, and had no additional risks for bone healing and VT.
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Affiliation(s)
- Yi Fan
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dingqun Bai
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chongyuan Cheng
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Guihua Tian
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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13
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Munaretto N, Tagliero A, Patel R, Rhee PC. Distal Radius Fracture Treatment Outcomes in Patients With Ipsilateral Hemiplegia or Hemiparesis. Hand (N Y) 2022; 17:19S-24S. [PMID: 33789515 PMCID: PMC9793617 DOI: 10.1177/1558944721999733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Little information exists to guide decision-making with regard to distal radius fractures in the setting of ipsilateral hemiparesis or hemiplegia. METHODS Patients who sustained a distal radius fracture in the setting of ipsilateral hemiparesis or hemiplegia secondary to brain injury were evaluated. Investigated variables included perioperative pain, preinjury House functional classification score, length of immobilization, radiographic outcome measurements, and time to union. RESULTS There were 15 patients with distal radius fractures with a mean age of 65.9 years. The mean clinical and radiographic follow-up was 2.8 and 2.9 years, respectively. Wrists were placed into the nonoperative group (NOG, n = 10) and operative group (OG, n = 5). Pain significantly decreased at final follow-up for both groups. Baseline House functional classification scores averaged 1.3 and 1.6 for the NOG and OG, respectively, and were maintained at final follow-up. Length of immobilization for the NOG was 46 days and OG was 37 days, P = .15. Radiographic outcomes at final follow-up in the NOG and OG, respectively, were a mean radial height of 9.3 versus. 11.6 mm, radial inclination of 18.3° versus 22.3°, 4.2° dorsal tilt versus 5.3° volar tilt, and tear drop angle of 45.6° versus 44.5°. There were no significant differences in these measurements. Time to radiographic union averaged 58 days for the NOG and 67 days for the OG, P = .42. There were no revision surgeries. CONCLUSIONS Based on this small case series, patients with distal radius fracture and ipsilateral hemiparesis or hemiplegia may have similar clinical, functional, and radiographic outcomes, regardless of nonoperative or operative treatment.
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14
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Gouda N, Zangrilli J, Voskerijian A, Wang ML, Beredjiklian PK, Rivlin M. Safety and Duration of Low-Dose Adjuvant Dexamethasone in Regional Anesthesia for Upper Extremity Surgery: A Prospective, Randomized, Controlled Blinded Study. Hand (N Y) 2022; 17:1236-1241. [PMID: 33880959 PMCID: PMC9608287 DOI: 10.1177/15589447211008558] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Orthopedic procedures concerning the upper extremity commonly use a brachial plexus nerve block to achieve postoperative analgesia. The addition of dexamethasone to peripheral nerve blocks has been shown to significantly prolong its effect. We hypothesize that 1 mg doses of dexamethasone will prolong brachial plexus nerve block with similar efficacy to 4 mg and better than ropivacaine alone. METHODS Seventy-nine patients who received a brachial plexus nerve block prior to undergoing upper extremity surgery were randomized to 1 of 4 treatment groups: group 1 received only 30 mL of 0.5% ropivacaine without dexamethasone (control); groups 2, 3, and 4 received 4, 2, and 1 mg of dexamethasone, respectively, added to 30 mL of 0.5% ropivacaine. RESULTS Comparison of block duration, specifically "first signs of the block wearing off" to the 0-mg group, referencing the 1-, 2-, and 4-mg groups (P = .02, .04, and .01, respectively) that received steroid adjuvant therapy demonstrated a significant increase in time until the block began to wear off. All study groups receiving steroids also demonstrated a significant increase in duration of the block prior to its effects being completely gone when compared with the control group (P < .01 for all groups). CONCLUSIONS Our findings demonstrate that adjuvant dexamethasone can prolong brachial plexus nerve blocks effectively at low doses compared with high doses, in addition to prolonging analgesia compared with local anesthetic alone.
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Affiliation(s)
- Nura Gouda
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Armen Voskerijian
- Jefferson Surgery Center at the Navy Yard, Philadelphia, PA, USA
- United Anesthesia Services, P.C., Bryn Mawr, PA, USA
| | - Mark L. Wang
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Michael Rivlin
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
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15
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Zangrilli J, Gouda N, Voskerijian A, Wang ML, Beredjiklian PK, Rivlin M. A Multimodal Pain Management Regimen for Open Treatment of Distal Radius Fractures: A Randomized Blinded Study. Hand (N Y) 2022; 17:1187-1193. [PMID: 33356569 PMCID: PMC9608278 DOI: 10.1177/1558944720975146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Adequate pain control is critical after outpatient surgery where patients are not as closely monitored. A multimodal pain management regimen was compared to a conventional pain management method in patients undergoing operative fixation for distal radius fractures. We hypothesized that there would be a decrease in the amount of narcotics used by the multimodal group compared to the conventional pain management group, and that there would be no difference in bone healing postoperatively. METHODS Forty-two patients were randomized into 2 groups based on pain protocols. Group 1, the control, received a regional block, acetaminophen, and oxycodone. Group 2 received a multimodal pain regimen consisting of daily doses of pregabalin, celecoxib, and acetaminophen up until postoperative day (POD) #3. They also received a regional block with oxycodone for breakthrough pain. RESULTS From POD#3 to week 1, there was a significant increase in oxycodone use in the study group correlating with the point in time when the multimodal regimen was discontinued. The shortened Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) scores taken at 2 weeks postoperation showed a significantly lower average score in the study group compared to the control. There was no difference in bone healing. CONCLUSIONS The 2 regimens yielded similar pain control after surgery. The rebound increase in narcotic use after the multimodal regimen was discontinued, and significant difference in QuickDASH scores seen at 2 weeks postoperatively supported that multimodal regimens may not necessarily lead to decreased narcotic use in outpatient upper extremity surgery, but in the short term are shown to improve functional status.
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Affiliation(s)
- Julian Zangrilli
- Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
| | - Nura Gouda
- Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Armen Voskerijian
- Jefferson Surgery Center at The Navy Yard, Philadelphia, PA, USA
- United Anesthesia Services, P.C., Bryn Mawr, PA, USA
| | - Mark L. Wang
- Rothman Orthopaedic Institute, Philadelphia, PA, USA
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16
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De Francesco F, Gravina P, Varagona S, Setti S, Gigante A, Riccio M. Biophysical Stimulation in Delayed Fracture Healing of Hand Phalanx: A Radiographic Evaluation. Biomedicines 2022; 10:biomedicines10102519. [PMID: 36289781 PMCID: PMC9599654 DOI: 10.3390/biomedicines10102519] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 09/30/2022] [Accepted: 10/01/2022] [Indexed: 11/16/2022] Open
Abstract
Phalangeal fractures are common events among the upper limbs accounting for 10% of all human body fractures. Fracture complete healing process may persevere several months or years. Most phalangeal fractures present favorable union within 3 to 6 weeks. In the literature, biophysical stimulation has yielded favorable outcomes in the treatment of hand fractures. A survey involving hospitals in the US reported the use of biophysical stimulation (72%) in relation to nonhealing fractures at three months after trauma. A noninvasive procedure such as biophysical stimulation may be preferential prior to consideration of invasive procedures. In this retrospective study, we analyzed 80 phalangeal fractures, 43 of which did not show any radiographic sign of healing 30 days after surgery; on radiograms, we calculated radiographic data and the total active motion (TAM) for clinical comparison. All radiographic images were evaluated using Adobe Photoshop CS3 (version 10.0, Adobe Systems Inc., San Jose, CA, USA). We calculated the index of relative bone healing each month after surgery starting from 30 days, which was considered as T1, and followed up for a total of 6 months after stimulation (T6) with better results in stimulated groups. We concluded that prompt administration of biophysical stimulation supports fracture healing and yields an important improvement in the union rate compared with nontreatment. Above all, our patients experienced less injury-related distress between the fracture and repair period, which consequently reduced immobilization time, envisaging an early rehabilitation interval, with a better patient hand outcome.
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Affiliation(s)
- Francesco De Francesco
- Department of Reconstructive Surgery and Hand Surgery, Azienda Ospedaliera Universitaria delle Marche, Via Conca, 71, 60126 Ancona, Italy
- Correspondence: ; Tel.: +39-071-5963945; Fax: +39-071-5965297
| | - Pasquale Gravina
- Department of Reconstructive Surgery and Hand Surgery, Azienda Ospedaliera Universitaria delle Marche, Via Conca, 71, 60126 Ancona, Italy
- Clinical Orthopedics, Polytechnic University of Marche, Via Conca, 71, 60126 Ancona, Italy
| | - Stefano Varagona
- Clinical Orthopedics, Polytechnic University of Marche, Via Conca, 71, 60126 Ancona, Italy
| | - Stefania Setti
- IGEA SpA, Clinical Biophysics, Via Parmenide, 10/A, 41012 Carpi, Italy
| | - Antonio Gigante
- Clinical Orthopedics, Polytechnic University of Marche, Via Conca, 71, 60126 Ancona, Italy
| | - Michele Riccio
- Department of Reconstructive Surgery and Hand Surgery, Azienda Ospedaliera Universitaria delle Marche, Via Conca, 71, 60126 Ancona, Italy
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17
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Radiographic Scoring of Humeral Shaft Fractures Helps Identify Patients at Risk of Surgery for Delayed Union. J Orthop Trauma 2022; 36:453-457. [PMID: 35149620 DOI: 10.1097/bot.0000000000002358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Assessing external validity and clinical relevance of modified radiographic union score (mRUS) to predict delayed union in closed humeral shaft fractures initially treated with conservative management. DESIGN Retrospective cohort. SETTING Single urban academic level 1 trauma center. PATIENTS Patients undergoing initial nonoperative treatment of a humeral shaft fracture with a minimum of 3 months follow-up and at least one set of follow-up orthogonal x-rays within 12-weeks of injury. MAIN OUTCOME MEASUREMENTS Interobserver and intraobserver reliability of the (mRUS) system for humeral shaft fractures, and establishing an mRUS threshold at 6 and 12 weeks postinjury to predict surgery for delayed union. RESULTS mRUS demonstrated substantial interobserver agreement on all assessments. Intraobserver agreement was nearly perfect for all reviewers on repeat assessment. mRUS of ≤7 at 6 ± 1 weeks follow-up was associated with surgery for delayed union with an odds ratio of 4.88 (95% CI, 2.52-9.44, P < 0.01), sensitivity of 0.286, and specificity of 0.924. At 12 ± 1 weeks follow-up, the same threshold demonstrated a stronger association with an odds ratio of 14.7 (95% CI, 4.9-44.1, P < 0.01), sensitivity of 0.225, and specificity of 0.981. CONCLUSIONS The mRUS for humeral shaft fractures is reliable and reproducible providing an objective way to track subtle changes in radiographs over time. An mRUS of ≤7 at 6 or 12 weeks postinjury is highly specific for delayed union. This can be helpful when counseling patients about the risk of nonunion and potential early surgical intervention. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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18
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Guevel B, Gokaraju K, Mohamed F, Sorensen F, Gillott E, Domos P. A comparative study of 6-week and 12-week Radiographic Union Scores for HUmeral fractures (RUSHU) as a predictor of humeral shaft non-union. Shoulder Elbow 2022; 14:295-303. [PMID: 35599708 PMCID: PMC9121295 DOI: 10.1177/17585732211033154] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 04/17/2021] [Accepted: 06/18/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Non-union in non-operatively managed humeral shaft fractures are associated with significant morbidity. Hence, developing a robust system that could help with early diagnosis is important. We aimed to evaluate the validity of the Radiographic Union Score for HUmeral fractures (RUSHU) at 6 weeks (RUSHU-6) and test whether a RUSHU at 12 weeks (RUSHU-12) would be a better predictor of non-union. METHODS We retrospectively reviewed all non-operatively managed humeral diaphyseal fractures from 2012 to 2018. Statistical analysis was used to determine the cut-off RUSHU-12 and evaluate the effect of RUSHU-6 and RUSHU-12 on non-union prediction. RESULTS In sum, 32 patients had radiographs at 6 weeks post-injury, 27 of which also had radiographs at 12 weeks. A RUSHU cut-off of 9 was the best predictor of non-union at 12 weeks. Only RUSHU-12 had a statistically significant influence predicting non-union (P = 0.011) and there was a significant correlation (P = 0.003) between score progression from RUSHU-6 to RUSHU-12 and the development of non-union. DISCUSSION A RUSHU-12 of <9 and a low score progression between 6 and 12 weeks suggest superior predictive value in determining the likelihood of non-union. Further validation in the form of a large multicentred study is however required.
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Affiliation(s)
- Borna Guevel
- Borna Guevel, Royal Free London NHS
Foundation Trust, Barnet and Chase Farm Hospitals, London, UK.
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19
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TANG CQY, CHIOW SM, LAI SHS, CHIA DSY. The Effect of Hand Dominance, Age, Gender, Fracture Comminution and ASA Status on Time to Fracture Healing Following Surgical Fixation of Distal Radius Fractures. J Hand Surg Asian Pac Vol 2022; 27:459-465. [DOI: 10.1142/s2424835522500461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: There is recent renewed interest in the effect of hand dominance on distal radius fractures. Current studies focus on functional or patient-reported outcomes, with lack of studies pertaining to radiological outcomes. The primary aim of this study is to examine the effect of hand dominance on time to fracture healing following surgical fixation of distal radius fracture. We also looked at the effect of age, gender, fracture comminution and American Society of Anaesthesiologists (ASA) status on time to fracture healing. Methods: Patients who underwent distal radius fracture fixation surgery in our department from 1 January 2015 to 31 December 2015 were included. Time to fracture healing was taken from the day of surgery to when radiographic union was present as evidence by bridging callus or osseous bone. We looked at the effect of hand dominance, age, gender, fracture comminution and ASA status on time to fracture healing. Results: One hundred and forty-five consecutive patients (80 females and 65 males) had a mean period of 56.2 ± 41.8 days to fracture healing post-operatively. Patients with dominant hand injury had a shorter duration to fracture healing than patients with non-dominant hand injury (mean 47.3 ± 31.1 days versus 62.1 ± 46.8 days, p = 0.023). Patients ≥ 65 years and with pre-existing medical conditions (ASA Class II and above) had a longer duration to fracture healing (mean 63.7 ± 53.0 days versus 51.9 ± 33.4 days, p = 0.036 and mean 47.9 ± 30.0 days versus 62.0 ± 47.7 days, p = 0.016, respectively). In addition, patients with comminuted fractures took longer to heal than patients with non-comminuted fractures (mean 57.6 ± 33.4 days versus 48.3 ± 20.8 days, p = 0.038). Conclusion: Time to fracture healing post distal radius fracture fixation surgery was significantly related to hand dominance, as well as age, ASA classification and fracture configuration. Dominant wrist injuries had shorter time to fracture healing. Level of Evidence: Level IV (Therapeutic)
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Affiliation(s)
- Camelia Qian Ying TANG
- Department of Hand and Reconstructive Microsurgery, Tan Tock Seng Hospital, Tan Tock Seng, Singapore
| | - Si Min CHIOW
- Department of Radiology, Tan Tock Seng Hospital, Tan Tock Seng, Singapore
| | - Sean Han Sheng LAI
- Department of Rehabilitation Medicine, Tan Tock Seng Hospital, Tan Tock Seng, Singapore
| | - Dawn Sinn Yii CHIA
- Department of Hand and Reconstructive Microsurgery, Tan Tock Seng Hospital, Tan Tock Seng, Singapore
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20
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Postmortem and Antemortem Forensic Assessment of Pediatric Fracture Healing from Radiographs and Machine Learning Classification. BIOLOGY 2022; 11:biology11050749. [PMID: 35625477 PMCID: PMC9138832 DOI: 10.3390/biology11050749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 04/27/2022] [Accepted: 05/10/2022] [Indexed: 11/17/2022]
Abstract
Simple Summary Being able to estimate from X-rays alone how long ago a child’s bone was fractured is important for prosecuting suspected child abuse of living or dead children. This estimate can also help identify a child when all that remains are bones. Experts use various indicators to make these estimates of the age of healing and fully healed fractures, in living and deceased persons, even years after the injury occurred. However, it is not a precise science. We proposed a method using a new combination of indicators to classify fracture healing in children and adolescents. We tested its accuracy with a public database of X-rays of children’s fractures taken during the treatment and healing process. We used part of the X-ray database for training artificial intelligence (AI, or machine learning) programs to classify stages of bone healing when using our new system. We used another portion of the same database to test the performance of the AI system that had been trained with our new classification system. Our new system addresses certain classification ambiguities of a currently used system and is similar in accuracy. Abstract A timeline of pediatric bone healing using fracture healing characteristics that can be assessed solely using radiographs would be practical for forensic casework, where the fracture event may precede death by days, months, or years. However, the dating of fractures from radiographs is difficult, imprecise, and lacks consensus, as only a few aspects of the healing process are visible on radiographs. Multiple studies in both the clinical and forensic literature have attempted to develop a usable scale to assess pediatric bone healing on radiographs using various healing characteristics. In contrast to the orthopedic definition, a fracture in forensic casework is only considered to be healed when the area around the fracture has been remodeled to the point that the fracture is difficult to detect on a radiograph or on the surface of the bone itself, a process that can take several years. We subjectively assessed visible characteristics of healing in radiograms of fractures occurring in 942 living children and adolescents. By dividing these assessments into learning and test (validation) sets, the accuracy of a newly proposed fracture healing scale was compared to a previous study. Two machine learning models were used to test predictions of the new scale. All three models produced similar estimates with substantial imprecision. Results corroborate the Malone model with an independent dataset and support the efficacy of using less complex models to estimate fracture age in children.
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21
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Panchoo P, Laubscher M, Held M, Maqungo S, Ferreira N, Simpson H, Graham SM. Radiographic union score for tibia (RUST) scoring system in adult diaphyseal femoral fractures treated with intramedullary nailing: an assessment of interobserver and intraobserver reliability. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:1555-1559. [PMID: 34596748 DOI: 10.1007/s00590-021-03134-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 09/23/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The Radiographic Union Score for Tibia (RUST) scoring system has been validated in multiple studies assessing the healing of tibial fractures. Our objective was to assess the interobserver and intraobserver reliability for the RUST in diaphyseal femoral fractures treated with intramedullary (IM) nailing. PATIENTS AND METHODS A total of 60 sets of anteroposterior (AP) and lateral radiographs of diaphyseal femoral fractures treated by reamed IM nailing were randomly selected from a prospectively collected database. The 60 sets of radiographs were then scored by three reviewers using the RUST system. Interobserver reliability was measured at initial scoring. The 60 sets of radiographs were scored again by the three reviewers to calculate the intraobserver reliability. RESULTS The RUST scores ranged from 4 to 12 with a mean score of 11.3 ± 1.3. The interobserver intraclass correlation coefficient (ICC) was 0.87 (95% CI, 0.81-0.92) and the intraobserver ICC was 0.91 (95% CI, 0.88-0.94), which indicated excellent agreement. CONCLUSION This study demonstrated that the RUST system can be used reliably in the assessment of healing in diaphyseal femur fractures treated by reamed intramedullary nailing, with excellent interobserver and intraobserver reliability.
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Affiliation(s)
- Pravesh Panchoo
- Division of Orthopaedic Surgery, Groote Schuur Hospital, H49 Old Main Building, Observatory, Cape Town, South Africa. .,Orthopaedic Research Unit (ORU), University of Cape Town, Cape Town, South Africa.
| | - Maritz Laubscher
- Division of Orthopaedic Surgery, Groote Schuur Hospital, H49 Old Main Building, Observatory, Cape Town, South Africa.,Orthopaedic Research Unit (ORU), University of Cape Town, Cape Town, South Africa
| | - Michael Held
- Division of Orthopaedic Surgery, Groote Schuur Hospital, H49 Old Main Building, Observatory, Cape Town, South Africa.,Orthopaedic Research Unit (ORU), University of Cape Town, Cape Town, South Africa
| | - Sithombo Maqungo
- Division of Orthopaedic Surgery, Groote Schuur Hospital, H49 Old Main Building, Observatory, Cape Town, South Africa.,Orthopaedic Research Unit (ORU), University of Cape Town, Cape Town, South Africa.,Division of Global Surgery, University of Cape Town, Cape Town, South Africa
| | - Nando Ferreira
- Division of Orthopaedic Surgery, Stellenbosch University, Cape Town, South Africa
| | - Hamish Simpson
- Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh, UK
| | - Simon Matthew Graham
- Division of Orthopaedic Surgery, Groote Schuur Hospital, H49 Old Main Building, Observatory, Cape Town, South Africa.,Orthopaedic Research Unit (ORU), University of Cape Town, Cape Town, South Africa.,Institute of Population Health Sciences, University of Liverpool, Liverpool, UK.,Department of Orthopaedics and Trauma Surgery, Liverpool University Teaching Hospital Trust, Liverpool, UK
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22
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Abstract
Distal radius fractures (DRFs) are among the most common upper extremity injuries. Multiple medical conditions now are evaluated by standardized outcome sets that enable comparability. Recent international working groups have provided consensus statements for outcomes measurement after DRFs. These statements emphasized the growing importance of patient-reported outcome measures as well as traditional measures, including pain assessment, radiographic alignment, performance, and assessment of complications. A standardized instrument and timeline for measuring outcomes following DRFs offers clinicians, researchers, and health care economists a powerful tool. This article reviews the current evidence and provides recommendations for a DRF standardized outcome set.
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Affiliation(s)
- Matthew J Hall
- Harvard Combined Orthopaedic Residency Program, 55 Fruit Street, Boston, MA 02114, USA
| | - Peter J Ostergaard
- Harvard Combined Orthopaedic Residency Program, 55 Fruit Street, Boston, MA 02114, USA
| | - Tamara D Rozental
- Division of Hand and Upper Extremity Surgery, Department of Orthopedics, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Stoneman 10, Boston, MA 02115, USA.
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Reliability of radiographic union scale in tibial fractures and modified radiographic union scale in tibial fractures scores in the evaluation of pediatric forearm fracture union. Jt Dis Relat Surg 2021; 32:185-191. [PMID: 33463435 PMCID: PMC8073431 DOI: 10.5606/ehc.2021.78465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 10/06/2020] [Indexed: 11/21/2022] Open
Abstract
Objectives
This study aims to evaluate the reliability of the radiographic union scale in tibial (RUST) fractures and modified RUST (mRUST) fractures in pediatric forearm fractures treated with elastic stable intramedullary nail (ESIN) and to investigate the effect of the experience of surgeon, thresholds for union, and delayed union decisions. Patients and methods
In this retrospective study, radiographic images of 20 patients (10 males, 10 females; mean age 8.6±4.3; range, 4 to 11 years) with forearm fractures treated using ESIN between January 2013 and December 2018 were scored by 20 observers based on the RUST and mRUST scores. The observers scored the radiographs at immediate postoperative period, and at 4-, 8-, and 12-week follow-up. Intra- and interobserver agreement for each cortex, RUST, and mRUST were evaluated using intraclass correlation coefficient (ICC). The Fleiss’ kappa (k) coefficient was used in the agreement between evaluators regarding union decision. Receiver operating curves were created to determine the thresholds for radiographic union and delayed union. Results
Intra- and interobserver reliability of the mRUST score (ICC: 0.84 and 0.79) were slightly higher than that of the RUST score (ICC: 0.80 and 0.72). Pediatric orthopedic and trauma surgeons had slightly higher agreement than the residents and general orthopedists for the total mRUST and RUST scores of the eight-week radiographs. Mean RUST and mRUST scores at the union for all fractures were 10.2±3.4 and 13.0±2.1, respectively. Kappa value for union was moderate (0.74). The total mRUST score had a higher predictive value for union than the total RUST score (area under the curve: 0.986 vs. 0.889). A mRUST score of ≥12 and RUST score of ≥9 were considered as the predictors of union. In addition, a mRUST score of ≤7 and RUST score of <9 were considered as the predictors of delayed union. Conclusion
A moderate agreement for both RUST and mRUST scores was found. However, the agreement for mRUST was found to be slightly higher. Healing and union of forearm fractures treated with ESIN can be reliably assessed using RUST and mRUST.
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Abstract
OBJECTIVES To establish the reliability of 2 radiographic union scoring systems for nonoperative humeral shaft fractures. DESIGN Retrospective medical record review. Patients identified had humeral shaft fractures and radiographs at various follow-up time points, which were graded according to the both the standard (RUST) and modified radiographic union scoring systems (mRUST). SETTING A single North American Level-1 Trauma center in Connecticut, including emergency department and clinic follow-up visits. PATIENTS/PARTICIPANTS Forty-five adult patients (162 image sets) met the following inclusion criteria: diaphyseal humerus fracture, initial nonoperative management, and greater than 2 weeks of follow-up with imaging. INTERVENTION All 162 image sets of anterior-posterior and lateral radiographs were scored and divided into 4 tiers based on increasing score. Anterior-posterior and lateral image sets were randomly selected from each tier for a total of 50 that were then scored by 7 different reviewers using both the RUST and mRUST systems. MAIN OUTCOME MEASURES The intraclass correlation coefficients for the cortical and system scores for the RUST and mRUST systems. RESULTS Interobserver reliability was 0.795 for the RUST system and 0.801 for mRUST. Intraobserver reliability was 0.909 for RUST and 0.949 for mRUST. For mRUST, 92% of values were within ± 1 point from each other. CONCLUSIONS The RUST and mRUST systems can be applied to humeral shaft fractures with excellent reliability. They have the potential to assist in the diagnosis of humeral shaft union by providing an objective and standardized method to assess healing of bone over time.
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Christiano AV, Goch AM, Burke CJ, Leucht P, Konda SR, Egol KA. Radiographic Humerus Union Measurement (RHUM) Demonstrates High Inter- and Intraobserver Reliability in Assessing Humeral Shaft Fracture Healing. HSS J 2020; 16:216-220. [PMID: 33380949 PMCID: PMC7749905 DOI: 10.1007/s11420-019-09680-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 02/27/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Orthopedic surgeons use radiographs to determine degrees of fracture healing, guide progression of clinical care, and assist in determining weight bearing and removal of immobilization. However, no gold standard exists to determine the progression of healing of humeral shaft fractures treated non-operatively. PURPOSE The purpose of this study was to determine whether a scale comparable to the modified Radiographic Union Score for Tibial (RUST) fractures applied to non-operatively treated humeral shaft fractures can increase interobserver reliability in determining fracture healing. METHODS A retrospective review was undertaken by three orthopedic traumatologists and one musculoskeletal radiologist, who evaluated 50 sets of anteroposterior and lateral radiographs, presented at random, of non-operatively treated humeral shaft fractures at various stages of healing from 17 patients. The radiographs were scored using a modified RUST scale called the Radiographic Humerus Union Measurement (RHUM). Observers were blinded to the time from injury. After a 4-week washout period, observers again scored the same radiographs. Observers classified each fracture as either healed or not healed based on the combination of radiographs. Inter- and intraobserver reliability of the RHUM were determined using an intraclass correlation coefficient (ICC). Interobserver reliability of determining a healed fracture was calculated using Cohen's kappa (κ) statistics. A receiver operator characteristic curve was conducted to determine the RHUM score predictive of a fracture being considered healed. RESULTS ICC demonstrated almost perfect interobserver reliability (ICC, 0.838; ICC 95% CI, 0.765 to 0.896) and intraobserver reliability (ICC range, 0.822 to 0.948) of the RHUM. κ demonstrated substantial agreement between observers in considering a fracture healed (κ = 0.647). Receiver operating characteristic (ROC) curve demonstrated that a RHUM of 10 or higher is an excellent predictor of the observer considering the fracture healed (area under the ROC curve = 0.946, specificity = 0.957, 95% CI specificity, 0.916 to 0.979). CONCLUSIONS This cortical scoring system has excellent interobserver reliability in humeral shaft fractures treated non-operatively. Consistent with previous cortical scoring systems, a RHUM score of 10 or above can be considered radiographically healed.
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Affiliation(s)
- Anthony V. Christiano
- grid.59734.3c0000 0001 0670 2351Department of Orthopaedic Surgery, Mount Sinai School of Medicine, 5 E. 98th Street, Box 1188, New York, NY 10029-6504 USA
| | - Abraham M. Goch
- grid.240283.f0000 0001 2152 0791Montefiore Medical Center, Bronx, NY USA
| | - Christopher J. Burke
- grid.137628.90000 0004 1936 8753NYU Langone Orthopedic Hospital, New York, NY USA
| | - Philipp Leucht
- grid.137628.90000 0004 1936 8753NYU Langone Orthopedic Hospital, New York, NY USA
| | - Sanjit R. Konda
- grid.137628.90000 0004 1936 8753NYU Langone Orthopedic Hospital, New York, NY USA ,grid.414915.c0000 0004 0414 4052Jamaica Hospital Medical Center, Queens, NY USA
| | - Kenneth A. Egol
- grid.137628.90000 0004 1936 8753NYU Langone Orthopedic Hospital, New York, NY USA
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Kaneko A, Naito K, Obata H, Nagura N, Sugiyama Y, Goto K, Kawakita S, Iwase Y, Kaneko K. Influence of Smoking in the Clinical Outcomes of Distal Radius Fractures. J Hand Microsurg 2020; 14:212-215. [DOI: 10.1055/s-0040-1715425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Abstract
Introduction There are various studies that reviewed the effect of cigarette smoking in fracture healing process. Nonunion, delayed union, and residual pain are the significant risk factors associated with smoking and fracture healing. Little has been known about the impact of smoking in distal radius fracture healing. We intend to explore in brief the effect of smoking in distal radius fracture healing and comparing it with nonsmokers having the same fracture fixation and analyze the outcomes with respect to fracture healing and return of function.
Materials and Methods Of the total 186 patients, 92 were included in the study with (n = male: 31, female: 61) mean age of 60.2 years. They were divided into two groups: smoking (n = 43) and nonsmoking (n = 49). All had surgical fixation of the distal radius with volar locking plate and started on early mobilization. The range of motion of the wrist, grip, visual analog scale, quick disabilities of the arm and shoulder and hand score, Mayo wrist score, and bone healing period were noted between these two groups and compared with statistical analysis.
Results The mean follow-up period was 8.7 months. There was a significant association of young age and male patients having distal radius fractures in the smoking group (p < 0.05). All fractures healed well in both groups without complications. There was no significant difference between these two groups in terms of range of motion, grasp, bone healing period, and functional outcomes.
Conclusion Despite the well-known fact that, smoking has negative implications in the fracture healing process, we found group of patients (smoking and nonsmoking) with distal radius fractures treated by volar locking plates healed well with good radiological union and excellent functional outcome There is no significant influence of smoking in distal radius fracture fixation.
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Affiliation(s)
- Ayaka Kaneko
- Department of Orthopaedics, Juntendo University School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Kiyohito Naito
- Department of Orthopaedics, Juntendo University School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Hiroyuki Obata
- Department of Orthopaedics, Juntendo University School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Nana Nagura
- Department of Orthopaedics, Juntendo University School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Yoichi Sugiyama
- Department of Orthopaedics, Juntendo University School of Medicine, Bunkyo-ku, Tokyo, Japan
- Department of Orthopaedic Surgery, Juntendo Tokyo Koto Geriatric Medical Center, Koto-ku, Tokyo, Japan
| | - Kenji Goto
- Department of Orthopaedics, Juntendo University School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - So Kawakita
- Department of Orthopaedics, Juntendo University School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Yoshiyuki Iwase
- Department of Orthopaedic Surgery, Juntendo Tokyo Koto Geriatric Medical Center, Koto-ku, Tokyo, Japan
| | - Kazuo Kaneko
- Department of Orthopaedics, Juntendo University School of Medicine, Bunkyo-ku, Tokyo, Japan
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Hellwinkel JE, Miclau T, Provencher MT, Bahney CS, Working ZM. The Life of a Fracture: Biologic Progression, Healing Gone Awry, and Evaluation of Union. JBJS Rev 2020; 8:e1900221. [PMID: 32796195 PMCID: PMC11147169 DOI: 10.2106/jbjs.rvw.19.00221] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
New knowledge about the molecular biology of fracture-healing provides opportunities for intervention and reduction of risk for specific phases that are affected by disease and medications. Modifiable and nonmodifiable risk factors can prolong healing, and the informed clinician should optimize each patient to provide the best chance for union. Techniques to monitor progression of fracture-healing have not changed substantially over time; new objective modalities are needed.
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Affiliation(s)
- Justin E Hellwinkel
- Department of Orthopedic Surgery, New York Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
- Center for Regenerative Sports Medicine, The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colorado
| | - Theodore Miclau
- Orthopaedic Trauma Institute, University of California, San Francisco (UCSF) and Zuckerberg San Francisco General Hospital (ZSFG), San Francisco, California
| | - Matthew T Provencher
- Center for Regenerative Sports Medicine, The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colorado
| | - Chelsea S Bahney
- Center for Regenerative Sports Medicine, The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colorado
- Orthopaedic Trauma Institute, University of California, San Francisco (UCSF) and Zuckerberg San Francisco General Hospital (ZSFG), San Francisco, California
| | - Zachary M Working
- Orthopaedic Trauma Institute, University of California, San Francisco (UCSF) and Zuckerberg San Francisco General Hospital (ZSFG), San Francisco, California
- Oregon Health & Science University, Portland, Oregon
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Chloros GD, Howard A, Giordano V, Giannoudis PV. Radiographic Long Bone Fracture Healing Scores: Can they predict non-union? Injury 2020; 51:1693-1695. [PMID: 32718464 DOI: 10.1016/j.injury.2020.07.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- George D Chloros
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom
| | - Anthony Howard
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom; NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, United Kingdom
| | - Vincenzo Giordano
- Hospital Municipal Miguel Couto, Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro - Rio de Janeiro - RJ - Brasil
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom; NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, United Kingdom.
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Chang FS, Chen CH, Lee CH, Lee KT, Cho YC. Evaluating the necessity of bone augmentation for distal radius fracture fixed with a volar locking plate: a retrospective study. BMC Musculoskelet Disord 2020; 21:180. [PMID: 32192479 PMCID: PMC7082908 DOI: 10.1186/s12891-020-03203-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 03/11/2020] [Indexed: 12/05/2022] Open
Abstract
Background Multiple approaches for fixation of distal radius fractures exist; nonetheless, there is no consensus on the optimal treatment for these injuries. Although using volar locking plates has become increasingly common as a surgical intervention, the usefulness of bone augmentation remains debatable. Therefore, this study aimed to evaluate the necessity of bone augmentation for distal radius fractures fixed with a volar locking plate. Methods This retrospective study enrolled patients with a single distal radius fracture treated with a volar locking plate between January 2014 and December 2016. Overall, 105 fractures were included and divided into two groups (non-bone augmentation: group 1, n = 88; bone augmentation: group 2, n = 17). Images were reviewed, and dorsal cortex collapse, volar tilting, and radial height and inclination were measured immediately after surgery and at the 6-month follow-up. Results Both groups exhibited significant differences in dorsal collapse (p < 0.001 and p = 0.001, respectively) and radial height shortening (p < 0.001 and p = 0.039, respectively); volar tilting and radial inclination did not differ significantly. There was no difference in the degree of dorsal collapse (p = 0.715) and radial height shortening (p = 0.651) between the two groups. Of the 105 fractures, 54 were identified as comminuted type according to the AO classification (A3, C2, and C3), and similar radiographic outcomes were noted. Conclusions Volar locking plates for the treatment of distal radius fractures with or without bone augmentation do not affect the radiographic outcomes. In comminuted fractures, additional bone augmentation is unnecessary if intraoperative anatomical reduction and fixation are performed when possible.
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Affiliation(s)
- Feng-Shuo Chang
- Department of Orthopedics, Taichung Veterans General Hospital, 1650, Taiwan Boulevard Sect. 4, Taichung, 40705, Taiwan
| | - Chih-Hui Chen
- Department of Orthopedics, Taichung Veterans General Hospital, 1650, Taiwan Boulevard Sect. 4, Taichung, 40705, Taiwan. .,School of Medicine, National Yang-Ming University, No.155, Sec. 2, Li-Nong Street, Pei-Tou District, Taipei City 112, Taiwan.
| | - Cheng-Hung Lee
- Department of Orthopedics, Taichung Veterans General Hospital, 1650, Taiwan Boulevard Sect. 4, Taichung, 40705, Taiwan.,Department of Food Science and Technology, Hung Kuang University, Taichung, Taiwan
| | - Kun-Tsan Lee
- Department of Orthopedics, Taichung Veterans General Hospital, 1650, Taiwan Boulevard Sect. 4, Taichung, 40705, Taiwan.,Department of Veterinary Medicine, College of Veterinary Medicine, National Chung-Hsing University, Taichung, Taiwan
| | - Yi-Cheng Cho
- Department of Orthopedics, Taichung Veterans General Hospital, 1650, Taiwan Boulevard Sect. 4, Taichung, 40705, Taiwan
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30
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Scoring of radiographic cortical healing with the radiographic humerus union measurement predicts union in humeral shaft fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 30:835-838. [PMID: 32034464 DOI: 10.1007/s00590-020-02635-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 01/27/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE The purpose of this study is to determine if the radiographic humerus union measurement (RHUM) is predictive of union in humeral shaft fractures treated nonoperatively. METHODS All patients with long bone fracture nonunion presenting to a single surgeon were enrolled in a prospective registry. This registry was queried to identify patients with humeral shaft fractures treated nonoperatively and developed nonunion. The nonunion cohort was matched to a three to one gender- and age-matched control group that were treated nonoperatively for a humeral shaft fracture and achieved union. Two fellowship-trained orthopedic traumatologists blinded to eventual union scored radiographs obtained 12 weeks after injury using the RHUM. A binomial logistic regression determined the effect of the RHUM on the likelihood of developing union. RESULTS Nine patients with humeral shaft fractures treated nonoperatively with radiographs 12 weeks after injury that developed nonunion were identified. These patients were matched to 27 controls. Logistic regression demonstrated the RHUM was a significant predictor of healing 12 weeks after humeral shaft fracture treated nonoperatively (p = 0.014, odds ratio 9.434, 95% CI for OR 1.586-56.098). All patients with RHUM below 7 went on to nonunion. All patients with RHUM above 8 healed. Three of seven patients (43%) with RHUM of 7 or 8 healed. CONCLUSION The RHUM demonstrated an increased likelihood of achieving union 12 weeks after injury. Orthopedic surgeons can counsel patients that fractures with RHUM scores of 6 or below are in danger of developing nonunion and can target interventions appropriately.
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Schurko BM, Lechtig A, Chen NC, Earp BE, Kanj WW, Harper CM, Rozental TD. Outcomes and Complications Following Volar and Dorsal Osteotomy for Symptomatic Distal Radius Malunions: A Comparative Study. J Hand Surg Am 2020; 45:158.e1-158.e8. [PMID: 31421937 DOI: 10.1016/j.jhsa.2019.05.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 03/27/2019] [Accepted: 05/10/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare patient-reported outcomes, functional outcomes, radiographic alignment, and complications of volar versus dorsal corrective osteotomies as the treatment for symptomatic distal radius malunions. METHODS We performed a retrospective review of all patients who underwent a distal radius corrective osteotomy with either a volar or dorsal approach and plating at 1 of 3 institutions between 2005 and 2017. Demographic data, type of surgical treatment, and radiographs were examined. Outcomes were Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) function scores and radius union scoring system as well as major and minor complications. RESULTS We included 53 cases (37 volar osteotomies and 16 dorsal osteotomies). Postoperative follow-up from the time of surgery to last QuickDASH score was 84.6 months (range, 12-169.4 months). Compared with the dorsal osteotomy group, the volar osteotomy group demonstrated a better postoperative flexion-extension arc (94.9° vs 72.9°, respectively), pronation-supination arc (146.2° vs 124.9°, respectively), and last QuickDASH scores (6.65 vs 12.87), respectively. Radiographically, there was no difference noted in radial height, radial inclination, or volar tilt in the immediate postoperative and last radiographs. There was a higher rate of complications in the dorsal osteotomy group (8 cases [50% of patients]) compared with the volar osteotomy group (7 cases [18.9% of patients]), including a higher rate of hardware removal. CONCLUSIONS For patients with symptomatic malunions of the distal radius, the volar and dorsal approaches both resulted in improvement in QuickDASH scores and range of motion. Volar plating resulted in slightly better QuickDASH scores and fewer complications compared with dorsal plating. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Brian M Schurko
- Department of Orthopaedic Surgery, Harvard Medical School, Beth Israel Deaconess Medical Center
| | - Aron Lechtig
- Department of Orthopaedic Surgery, Harvard Medical School, Beth Israel Deaconess Medical Center
| | - Neal C Chen
- Department of Orthopaedic Sugery, Harvard Medical School, Massachusetts General Hospital
| | - Brandon E Earp
- Department of Orthopaedic Surgery, Harvard Medical School, Brigham and Women's Hospital
| | | | - Carl M Harper
- Department of Orthopaedic Surgery, Harvard Medical School, Beth Israel Deaconess Medical Center
| | - Tamara D Rozental
- Department of Orthopaedic Surgery, Harvard Medical School, Beth Israel Deaconess Medical Center.
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Abstract
OBJECTIVES (A) To investigate the specialty of observers involved in imaging-based assessment of bone fracture union in recent orthopaedic trials and (B) to provide a general overview of observer differences (in terms of interobserver reliability) in radiologic fracture union assessment that have been reported between surgeons and radiologists. DATA SOURCES Two separate systematic reviews (A, B) of English-, German-, and French-language articles in MEDLINE and Embase databases using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were done, with the following time frames: (A) January 2016-August 2017 and (B) through November 2017. STUDY SELECTION (A) Clinical trials of surgical fracture treatment evaluating radiologic (non) union. (B) Interobserver studies reporting kappa-values or intraclass correlation coefficients as reliability coefficient for radiologic fracture union assessment. Inclusion criteria for both reviews were fractures of the appendicular skeleton and the use of radiographs or computed tomography. DATA EXTRACTION Data were independently retrieved by 2 reviewers. DATA SYNTHESIS Descriptive statistics and percentages were reported. RESULTS (A) Forty-eight trials were included, whereof 33 (68%) did not report the observer's specialty. Six trials (13%) reported surgeon observers only, and 6 (13%) reported radiologist observers only. The median number of observers is 1 (interquartile range, 1-2). (B) Thirty-one interobserver studies were included, whereof 11 (35%) included at least 1 surgeon and 1 radiologist. Interobserver reliability varied considerably across the various fracture types studied and outcome scale used and was often unsatisfactory (kappa or intraclass correlation coefficients of <0.7). CONCLUSIONS In most trials providing observer's characteristics, radiologic fracture union was either rated by 1 surgeon or 1 radiologist. As interobserver reliability can be unsatisfactory, we recommend surgeons and radiologists to further intensify collaboration and trials to include at least 2 observers and associated reliability statistics.
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Hall MJ, Ostergaard PJ, Dowlatshahi AS, Harper CM, Earp BE, Rozental TD. The Impact of Obesity and Smoking on Outcomes After Volar Plate Fixation of Distal Radius Fractures. J Hand Surg Am 2019; 44:1037-1049. [PMID: 31677908 DOI: 10.1016/j.jhsa.2019.08.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 08/26/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE Distal radius fractures are common fractures of the upper extremity. Whereas surgical outcomes have been extensively investigated, the impact of risk factors such as body mass index (BMI) and smoking on patient outcomes has not been explored. We hypothesized that obesity and smoking would have a negative impact on the functional and radiographic outcomes of surgically treated patients with distal radius fractures. METHODS We performed a retrospective analysis of patients surgically treated for a distal radius fracture between 2006 and 2017 at 2 level 1 trauma centers. Patients were divided into obese (BMI ≥ 30) and nonobese (BMI < 30) groups according to the World Health Organization BMI Classification. Patients were also divided into current, former, and never smokers based on reported cigarette use. Primary outcomes included patient-reported outcome measures (Quick Disabilities of the Arm, Shoulder, and Hand [QuickDASH]), range of motion (ROM) arc (flexion-extension, pronation-supination), radiographic union (Radiographic Union Scoring System [RUSS] score), and change in radiographic alignment (radial height, radial inclination, volar tilt) between first and last follow-up. Multivariable models corrected for age, sex, comorbidities, fracture complexity, osteoporosis, and time to surgery. RESULTS Two hundred patients were identified, 39 with BMI of 30 or greater and 161 with BMI less than 30. Obese patients had more comorbidities but similar fracture types. At 3-month and 1-year follow-up, both groups achieved acceptable QuickDASH scores, close to those of the general population (21 vs 18, 14 vs 2, respectively). The 2 groups were similar in regard to motion, RUSS score, and alignment. There were 148 never smokers, 32 former smokers, and 20 current smokers. At 3 months, smokers demonstrated higher QuickDASH scores (42 vs 21-24) and a lower percentage of radiographically healed fractures (40% vs 69%-82%). At final follow-up, smokers reported small differences in patient-reported outcomes (QuickDASH 18 vs 9-13) whereas ROM, fracture healing, and complication rates were similar. CONCLUSIONS Both obese and nonobese patients can achieve excellent outcomes following surgical treatment of distal radius fracture with similar self-reported outcomes, motion, RUSS score, and alignment. Despite slower healing in the early postoperative period, smokers had similar QuickDASH scores, ROM, and union rates to past smokers and never smokers at final follow-up, with a similar complication profile. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.
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Affiliation(s)
- Matthew J Hall
- Harvard Combined Orthopaedic Residency Program, Boston, MA
| | | | - Arriyan S Dowlatshahi
- Division of Hand and Upper Extremity Surgery, Department of Orthopedics, Beth Israel Deaconess Medical Center, Boston, MA
| | - Carl M Harper
- Division of Hand and Upper Extremity Surgery, Department of Orthopedics, Beth Israel Deaconess Medical Center, Boston, MA
| | - Brandon E Earp
- Division of Hand and Upper Extremity Surgery, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Tamara D Rozental
- Division of Hand and Upper Extremity Surgery, Department of Orthopedics, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Combined Orthopaedic Residency Program, Boston, MA.
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Oliver WM, Smith TJ, Nicholson JA, Molyneux SG, White TO, Clement ND, Duckworth AD. The Radiographic Union Score for HUmeral fractures (RUSHU) predicts humeral shaft nonunion. Bone Joint J 2019; 101-B:1300-1306. [PMID: 31564159 DOI: 10.1302/0301-620x.101b10.bjj-2019-0304.r1] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The primary aim of this study was to develop a reliable, effective radiological score to assess the healing of humeral shaft fractures, the Radiographic Union Score for HUmeral fractures (RUSHU). The secondary aim was to assess whether the six-week RUSHU was predictive of nonunion at six months after the injury. PATIENTS AND METHODS Initially, 20 patients with radiographs six weeks following a humeral shaft fracture were selected at random from a trauma database and scored by three observers, based on the Radiographic Union Scale for Tibial fractures system. After refinement of the RUSHU criteria, a second group of 60 patients with radiographs six weeks after injury, 40 with fractures that united and 20 with fractures that developed nonunion, were scored by two blinded observers. RESULTS After refinement, the interobserver intraclass correlation coefficient (ICC) was 0.79 (95% confidence interval (CI) 0.67 to 0.87), indicating substantial agreement. At six weeks after injury, patients whose fractures united had a significantly higher median score than those who developed nonunion (10 vs 7; p < 0.001). A receiver operating characteristic curve determined that a RUSHU cut-off of < 8 was predictive of nonunion (area under the curve = 0.84, 95% CI 0.74 to 0.94). The sensitivity was 75% and specificity 80% with a positive predictive value (PPV) of 65% and a negative predictive value of 86%. Patients with a RUSHU < 8 (n = 23) were more likely to develop nonunion than those with a RUSHU ≥ 8 (n = 37, odds ratio 12.0, 95% CI 3.4 to 42.9). Based on a PPV of 65%, if all patients with a RUSHU < 8 underwent fixation, the number of procedures needed to avoid one nonunion would be 1.5. CONCLUSION The RUSHU is reliable and effective in identifying patients at risk of nonunion of a humeral shaft fracture at six weeks after injury. This tool requires external validation but could potentially reduce the morbidity associated with delayed treatment of an established nonunion. Cite this article: Bone Joint J 2019;101-B:1300-1306.
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Affiliation(s)
- William M Oliver
- Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Thomas J Smith
- Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Jamie A Nicholson
- Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Sam G Molyneux
- Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Tim O White
- Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Nick D Clement
- Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Andrew D Duckworth
- Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, UK
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Duckworth AD, McQueen MM, Tuck CE, Tobias JH, Wilkinson JM, Biant LC, Pulford EC, Aldridge S, Edwards C, Roberts CP, Ramachandran M, McAndrew AR, Cheng KC, Johnston P, Shah NH, Mathew P, Harvie J, Hanusch BC, Harkess R, Rodriguez A, Murray GD, Ralston SH. Effect of Alendronic Acid on Fracture Healing: A Multicenter Randomized Placebo-Controlled Trial. J Bone Miner Res 2019; 34:1025-1032. [PMID: 30845365 DOI: 10.1002/jbmr.3679] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 01/07/2019] [Accepted: 01/19/2019] [Indexed: 11/06/2022]
Abstract
There is a concern that bisphosphonates may impair fracture healing because of their inhibitory effects on bone turnover. Here we evaluated the effects of early bisphosphonate therapy on fracture healing and functional outcome following a fracture of the distal radius. The fracture and bisphosphonates (FAB) trial was a double-blind, randomized, placebo-controlled trial involving 15 trauma centers in the United Kingdom. We enrolled 421 bisphosphonate-naive patients aged ≥50 years with a radiographically confirmed fracture of the distal radius and randomized them in a 1:1 ratio to receive alendronic acid 70 mg once weekly (n = 215) or placebo (n = 206) within 14 days of the fracture. The primary outcome measure was the proportion of fractures that had radiologically united at 4 weeks as assessed by an observer, blinded to treatment allocation. Secondary outcomes included the Disabilities of the Arm Shoulder and Hand (DASH) questionnaire, range of wrist movement and grip strength, pain and analgesia requirements, and the rate of malunion. The mean ± SD age of participants was 63 ± 8.5 years and 362 (86%) were female. At 4 weeks, 48 of 202 (23.8%) fractures had united in the alendronic acid group compared with 52 of 187 (27.8%) in the placebo group (observed absolute proportion difference 4.0%; 95% CI, -4.7% to 12.8%; p = 0.36). The absolute proportion difference between groups based on imputed data was 4.5% (95% CI, -4.7% to 13.8%; p = 0.30). There was no significant difference in the proportion of fractures that had united at any other time point and no differences in the DASH score, pain at the fracture site, grip strength, or any other clinical outcome. We conclude that among patients aged 50 years and above with a distal radius fracture, early administration of alendronic acid does not adversely affect fracture union or clinical outcome. These findings suggest bisphosphonate therapy can be safely commenced early after fracture if clinically indicated. © 2019 American Society for Bone and Mineral Research.
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Affiliation(s)
- Andrew D Duckworth
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Margaret M McQueen
- Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Christopher E Tuck
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Jonathan H Tobias
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Leela C Biant
- Trauma & Orthopaedic Surgery, University of Manchester, Manchester, UK
| | - Elizabeth Claire Pulford
- Oxford University Hospitals National Health Service (NHS) Foundation Trust, Headington, Oxford, UK
| | - Stephen Aldridge
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Claire Edwards
- Norfolk and Norwich University Hospital Foundation Trust, Norwich, UK
| | | | | | | | | | - Phillip Johnston
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Nasir H Shah
- Warrington & Halton Hospitals NHS Foundation Trust, Warrington, UK
| | | | | | | | - Ronnie Harkess
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Aryelly Rodriguez
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Gordon D Murray
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Stuart H Ralston
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Centre for Genomic and Experimental Medicine, MRC Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
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36
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Fisher JS, Kazam JJ, Fufa D, Bartolotta RJ. Radiologic evaluation of fracture healing. Skeletal Radiol 2019; 48:349-361. [PMID: 30238139 DOI: 10.1007/s00256-018-3051-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/13/2018] [Accepted: 08/20/2018] [Indexed: 02/06/2023]
Abstract
While assessment of fracture healing is a common task for both orthopedic surgeons and radiologists, it remains challenging due to a lack of consensus on imaging and clinical criteria as well as the lack of a true gold standard. Further complicating this evaluation are the wide variations between patients, specific fracture sites, and fracture patterns. Research into the mechanical properties of bone and the process of bone healing has helped to guide the evaluation of fracture union. Development of standardized scoring systems and identification of specific radiologic signs have further clarified the radiologist's role in this process. This article reviews these scoring systems and signs with regard to the biomechanical basis of fracture healing. We present the utility and limitations of current techniques used to assess fracture union as well as newer methods and potential future directions for this field.
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Affiliation(s)
- Jessica S Fisher
- Weill Cornell Medical College, 1300 York Avenue, New York, NY, 10021, USA.,Department of Radiology, New York-Presbyterian Hospital, 525 E. 68th Street, New York, NY, 10065, USA
| | - J Jacob Kazam
- Weill Cornell Medical College, 1300 York Avenue, New York, NY, 10021, USA.,Department of Radiology, New York-Presbyterian Hospital, 525 E. 68th Street, New York, NY, 10065, USA
| | - Duretti Fufa
- Weill Cornell Medical College, 1300 York Avenue, New York, NY, 10021, USA.,Hand and Upper Extremity Surgery, Hospital for Special Surgery, 535 E. 70th Street, New York, NY, 10021, USA
| | - Roger J Bartolotta
- Weill Cornell Medical College, 1300 York Avenue, New York, NY, 10021, USA. .,Department of Radiology, New York-Presbyterian Hospital, 525 E. 68th Street, New York, NY, 10065, USA.
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Cooke ME, Hussein AI, Lybrand KE, Wulff A, Simmons E, Choi JH, Litrenta J, Ricci WM, Nascone JW, O’Toole RV, Morgan EF, Gerstenfeld LC, Tornetta P. Correlation between RUST assessments of fracture healing to structural and biomechanical properties. J Orthop Res 2018; 36:945-953. [PMID: 28833572 PMCID: PMC5823715 DOI: 10.1002/jor.23710] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 08/19/2017] [Indexed: 02/04/2023]
Abstract
Radiographic Union Score for Tibia (RUST) and modified RUST (mRUST) are radiographic tools for quantitatively evaluating fracture healing using a cortical scoring system. This tool has high intra-class correlation coefficients (ICCs); however, little evidence has evaluated the scores against the physical properties of bone healing. Closed, stabilized fractures were made in the femora of C3H/HeJ male mice (8-12 week-old) of two dietary groups: A control and a phosphate restricted diet group. Micro-computed tomography (µCT) and torsion testing were carried out at post-operative days (POD) 14, 21, 35, and 42 (n = 10-16) per group time-point. Anteroposterior and lateral radiographic views were constructed from the µCT scans and scored by five raters. The raters also indicated if the fracture were healed. ICCs were 0.71 (mRUST) and 0.63 (RUST). Both RUST scores were positively correlated with callus bone mineral density (BMD) (r = 0.85 and 0.80, p < 0.001) and bone volume fraction (BV/TV) (r = 0.86 and 0.80, p < 0.001). Both RUST scores positively correlated with callus strength (r = 0.35 and 0.26, p < 0.012) and rigidity (r = 0.50 and 0.39, p < 0.001). Radiographically healed calluses had a mRUST ≥13 and a RUST ≥10 and had excellent relationship to structural and biomechanical metrics. Effect of delayed healing due to phosphate dietary restrictions was found at later time points with all mechanical properties (p < 0.011), however no differences found in the RUST scores (p > 0.318). Clinical relevance of this study is both RUST scores showed high correlation to physical properties of healing and generally distinguished healed vs. non-healed fractures. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:945-953, 2018.
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Affiliation(s)
- Margaret E Cooke
- Department of Orthopaedic Surgery, Boston University, Boston, MA
| | - Amira I Hussein
- Department of Orthopaedic Surgery, Boston University, Boston, MA
| | - Kyle E Lybrand
- Department of Orthopaedic Surgery, Boston University, Boston, MA
| | - Alexander Wulff
- Department of Orthopaedic Surgery, Boston University, Boston, MA
| | - Erin Simmons
- Department of Orthopaedic Surgery, Boston University, Boston, MA
| | - Jeffrey H Choi
- Department of Orthopaedic Surgery, Boston University, Boston, MA
| | - Jody Litrenta
- Department of Orthopaedic Surgery, Boston University, Boston, MA
| | - William M Ricci
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO
| | - Jason W Nascone
- Department of Orthopaedic Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Robert V O’Toole
- Department of Orthopaedic Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Elise F Morgan
- Department of Mechanical Engineering, Boston University, Boston, MA
| | | | - Paul Tornetta
- Department of Orthopaedic Surgery, Boston University, Boston, MA
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38
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Shoji KE, Earp BE, Rozental TD. The Effect of Bisphosphonates on the Clinical and Radiographic Outcomes of Distal Radius Fractures in Women. J Hand Surg Am 2018; 43:115-122. [PMID: 29054355 DOI: 10.1016/j.jhsa.2017.09.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Revised: 07/31/2017] [Accepted: 09/06/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare clinical and radiographic outcomes of distal radius fractures (DRF) treated with nonsurgical management in female postmenopausal patients receiving bisphosphonate (BP) therapy at the time of injury with those not receiving BP therapy. METHODS We prospectively enrolled 33 female postmenopausal patients with 35 DRF between December 2010 and January 2014 at 2 Level I tertiary care centers. Eleven patients with 12 DRF were currently receiving BP at the time of injury (BP group) and were compared with 22 controls with 23 DRF (CONT group) who were not receiving BP at the time of injury. All were postmenopausal women with fragility fractures managed nonsurgically. Primary outcomes were radiographic healing measured by the Radius Union Scoring System (RUSS) score and clinical and functional outcomes. Radiographs, range of motion, pinch and grip strength, Patient-Rated Wrist Evaluation scores, and Disability of the Arm, Shoulder, and Hand scores were determined at 6, 9, and 12 weeks and 1 year from time of injury and compared between groups. RESULTS The BP and CONT groups were similar in terms of age, comorbidities, and fracture severity. Both groups had progressively improving RUSS scores from the time of injury throughout subsequent evaluation, and all patients achieved radiographic union. Fracture healing was similar in both groups at 6, 9, and 12 weeks after injury. The RUSS scores were slightly better in the CONT group at 1 year. There were no differences in wrist range of motion, pinch, grip, Patient-Rated Wrist Evaluation, or Disability of the Arm, Shoulder, and Hand scores at any time point after injury. CONCLUSIONS Patients receiving BP at the time of DRF had clinical outcomes similar to those not receiving antiresorptive treatment. Although there was a small difference in RUSS scores at 1 year after injury, this was not clinically relevant and all fractures united in a similar time frame with no healing complications. These results suggest that BP may be continued throughout nonsurgical management of DRF without detrimental effects on healing or function. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic II.
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Affiliation(s)
| | - Brandon E Earp
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Tamara D Rozental
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Perlepe V, Cerato A, Putineanu D, Bugli C, Heynen G, Omoumi P, Berg BV. Value of a radiographic score for the assessment of healing of nailed femoral and tibial shaft fractures: A retrospective preliminary study. Eur J Radiol 2017; 98:36-40. [PMID: 29279168 DOI: 10.1016/j.ejrad.2017.10.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 10/21/2017] [Accepted: 10/24/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To assess the value of a radiographic score for the detection of delayed union in nailed fractures. METHODS The modified radiographic union score (mRUS) values were determined by three separate radiologists on 259 radiographic sets of 58 nailed tibial or femoral fractures obtained at different timepoints after fracture (mean of 4.5 radiographic sets per fracture). A surgeon determined fracture outcome (normal or delayed union) at a mean of 192days after injury. Mean radiographic scores obtained at different timepoints after fracture were compared between fractures with normal or abnormal healing at follow-up. RESULTS The mean score values increased significantly over time for fractures with normal healing for all readers (p<0.001). The mean score values determined 11-14 weeks after injury were higher in fractures with normal healing than in fractures with delayed union at follow-up (p<0.05). Scoring of radiographs obtained at about 3 months after injury or later enabled detection of fractures with delayed union with a sensitivity of 0.63-0.77 and a specificity of 1.0 (area under curve: 0.77- 0.88). CONCLUSIONS The mRUS score can contribute to the detection of delayed union at a delay of about 3 months after injury in nailed shaft fractures.
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Affiliation(s)
- Vasiliki Perlepe
- Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium.
| | - Andrea Cerato
- Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Dan Putineanu
- Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Celine Bugli
- Plateforme technologique de Support en Méthodologie et Calcul Statistique (SMCS), 20, voie du Roman Pays - B-1348 Louvain-la-Neuve, Belgium
| | - Guy Heynen
- Bone Therapeutics, Avenue Auguste Piccard 37, 6041 Gosselies, Belgium
| | - Patrick Omoumi
- Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium; University Hospital of Lausanne, Bugnon 46 CH-1011 Lausanne, Switzerland
| | - Bruno Vande Berg
- Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium
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Eltorai AEM, Sobel AD, Thomas NP, Daniels AH, Born CT. Current Trends in the Management of Distal Radius Fractures. Orthopedics 2017; 40:145-152. [PMID: 28112784 DOI: 10.3928/01477447-20170117-08] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 07/28/2016] [Indexed: 02/03/2023]
Abstract
This article discusses recent reports on distal radius fractures. The keyword "distal radius fracture" was used to query the PubMed database of the US National Library of Medicine. From the resulting list, articles published in the Journal of Hand Surgery (American Volume), the Journal of Hand Surgery (European Volume), and the Journal of Orthopaedic Trauma from April 2014 through December 2015 were reviewed. Related commentaries were also evaluated. Case series of fewer than 5 patients were excluded. The 65 studies and commentaries identified are categorized and summarized. [Orthopedics. 2017; 40(3):145-152.].
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Ballal A, Sadasivan AK, Hegde A, Shetty A. Open Reduction and Volar Plate Fixation of Dorsally Displaced Distal Radius Fractures: A Prospective Study of Functional and Radiological Outcomes. J Clin Diagn Res 2017; 10:RC01-RC04. [PMID: 28208953 DOI: 10.7860/jcdr/2016/23187.8944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 08/29/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The fractures of the distal radius have always posed a unique challenge to the orthopaedic fraternity. The complex ligamentous and bony anatomy offers a wide variety of fractures to be dealt with around this zone. Over the years these injuries have become common especially in the elderly age group as well as the implants and surgical techniques have improved. AIM To assess the radiological and functional outcome after fixation of intra-articular dorsally displaced distal radius fractures with open reduction and volar Locking Compression Plate fixation (LCP). To study the complications occurring with this technique. MATERIALS AND METHODS A prospective study was conducted in the Department of Orthopaedics at ARS Hospital, Tirupur, Tamil Nadu, from June 2015 to June 2016. A total of 20 skeletally mature patients with Lidstrom class 2D and 2E fresh closed distal radius fractures were enrolled in the study. All the patients underwent open reduction with locking compression plating with titanium LCPs using the volar approach. The patients were reviewed regularly at three, six, 12 and 24 weeks. Final assessment of radiographic fracture union was done and scored as per the 'Radiographic Scoring System to Evaluate Union of Distal Radius Fractures {Radius Union Scoring System (RUSS)}' and the functional assessment of the wrist was done using the Mayo wrist score. The final results were tabulated and calculated statistically using 'frequency and proportions' and 'Chi-square tests' were used to assess the test of association. RESULTS Of the 20 patients reviewed, one patient had excellent Mayo wrist score, five had good scores, 12 had satisfactory and two patients had poor results. Seven patients had a RUSS score less than five points and four patients had RUSS score of five points, four patients had six points, two patients had seven points and three patients had eight points. One patient was noted to have dorsal collapse of the fracture during the final review. But, no evident of cosmetic deformity or any diminution in functional outcome of wrist was noted. CONCLUSION Open reduction and internal fixation with volar plating of dorsally displaced intra-articular distal radius fractures is an excellent technique with acceptable radiological fracture union and satisfactory functional outcome of the wrist.
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Affiliation(s)
- Arjun Ballal
- Registrar, Department of Orthopaedics, ARS Hospital , Tirupur, Tamil Nadu, India
| | - Anand Kumar Sadasivan
- Consultant and Chief Orthopaedic Surgeon, Department of Orthopaedics, ARS Hospital, Tirupur , Tamil Nadu, India
| | - Anoop Hegde
- Registrar, Department of Orthopaedics, ARS Hospital , Tirupur, Tamil Nadu, India
| | - Ashwin Shetty
- Associate Professor, Department of Orthopaedics, K.S. Hegde Medical Academy , Mangalore, Karnataka, India
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Liuni FM, Rugiero C, Feola M, Rao C, Pistillo P, Terracciano C, Giganti MG, Tarantino U. Impaired healing of fragility fractures in type 2 diabetes: clinical and radiographic assessments and serum cytokine levels. Aging Clin Exp Res 2015. [PMID: 26197718 DOI: 10.1007/s40520-015-0422-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Diabetes induces bone alterations accompanied by altered cytokine expression patterns. These alterations lead to modified fracture healing, contributing to musculoskeletal fragility in the elderly. AIMS We evaluated the inflammatory immune response in diabetic patients during fracture healing relative to clinical and radiographic assessments. METHODS Fifty patients of both sexes with fragility fractures were studied: 30 diabetics (group A, mean age 73.4 ± 11.2 years) and 20 normoglycemic controls (group B, mean age 75.1 ± 16.9 years). Two subgroups comprised those with hip or wrist fragility fractures (25 and 16 patients, respectively). We evaluated serum concentrations of tumor necrosis factor α, interleukins 4 and 8, monocyte chemotactic protein-1 (MCP-1), vascular endothelial growth factor, and epidermal growth factor (EGF) before and at 4 and 8 weeks after surgery. We also determined the Radiographic Union Score for Hips and the Radius Union Scoring System score and applied the Physical Activity Scale for the Elderly test at the same time points. Each patient underwent bone densitometry. RESULTS MCP-1 and EGF levels were higher in group A than in group B at 4 weeks after surgery (p > 0.05). Radiographic evaluation showed lower scores in group A (p < 0.05). The main difference between the groups was evident 4 weeks after surgery. Changes in the serum concentrations of chemotactic and angiogenic factors could explain the radiographically proved impaired fracture healing in diabetic patients. CONCLUSIONS Fragility fracture healing is impaired in diabetic patients. Radiographic and molecular patterns confirmed that the most compromised fracture-healing phase is at 4 weeks after surgery, during callus mineralization.
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Letter regarding Patel SP, Anthony SG, Zurakowski D, et al. Radiographic scoring system to evaluate union of distal radius fractures. J Hand Surg Am. 2014;39(8):1471-1479. J Hand Surg Am 2015; 40:635. [PMID: 25708444 DOI: 10.1016/j.jhsa.2015.01.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 01/09/2015] [Accepted: 01/10/2015] [Indexed: 02/02/2023]
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