Assessment of radiographic fracture healing in patients with operatively treated femoral neck fractures

Improving agreement in assessing subtrochanteric fracture healing among orthopedic surgeons using the Radiographic Union Score for Hip (RUSH)

BACKGROUND

Prompt identification of fracture healing is crucial for medical decision-making and clinical research. This study aims to assess the effectiveness of the Radiographic Union Score for Hip (RUSH) in subtrochanteric fractures and determine the optimal scoring threshold for fracture healing.

METHODS

We obtained 94 sets of X-ray films from the postoperative follow-up of 35 patients who underwent intramedullary nail fixation for subtrochanteric fractures. Six orthopedic trauma surgeons evaluated the imaging data and determined fracture healing based on subjective judgment. They then scored the X-ray images using the RUSH form. After four weeks, the same observers re-evaluated 47 randomly selected sets of radiographs. Subsequently, the observers and study designer conducted a consensus meeting where they agreed on whether the fractures had healed. We used Fleiss kappa to evaluate agreement among observers based on subjective impressions, and the intraclass correlation coefficient assessed RUSH score consistency. Regression analysis examined the relationship between scores and fracture healing consensus using a receiver operator characteristic (ROC) curve.

RESULTS

Based on overall impressions, the agreement level among orthopedic trauma surgeons for determining the healing status of subtrochanteric fractures was moderate (Kappa = 0.564, 95% CI: 0.511-0.616). However, utilizing the RUSH scoring system can improve the consistency to a substantial level of agreement (ICC = 0.748, 95% CI: 0.663-0.817). Regarding intraobserver reliability, there were significant differences among orthopedic trauma surgeons in judging fracture healing based on overall impressions. However, using the RUSH scoring form, the attending group achieved better intraobserver consistency than the resident group. Regression analysis and ROC curve analysis revealed a strong correlation between the RUSH total score, cortical bone score, cancellous bone score, and consensus on fracture healing. The AUC values are 0.769 (95% CI: 0.670-0.868), 0.779 (95% CI: 0.681-0.876), and 0.771 (95% CI: 0.674-0.867), respectively.

CONCLUSIONS

Our study highlights the effectiveness of the RUSH scoring system in enhancing interobserver agreement and intraobserver consistency when evaluating subtrochanteric fracture healing in orthopedic trauma surgeons. We propose setting 21 points as the threshold for the simplified RUSH scoring system to determine fracture healing. This system includes only eight items related to cortical bone, with a total score of 24 points.

Contralateral Neck-shaft Angle Lower Than 130° Is Associated With Clinical Failure in Nongeriatric Individuals: Analysis of the National Femoral Neck Fracture Database of 1066 Patients

BACKGROUND

Treatment of femoral neck fractures in patients who are nongeriatric (≤ 60 years) is challenging because of high failure rates. Anatomic parameters influence the biomechanical environment for fracture healing, but their associations with clinical prognosis remains unclear.

QUESTIONS/PURPOSES

(1) Which anatomic parameter that is identifiable on pelvic radiographs shows a statistical correlation with a higher risk of clinical failure defined as nonunion, avascular necrosis (AVN), reoperation, and functional failure (decrease in Harris hip score reaching the minimum clinically important difference) in the screw fixation of femoral neck fractures among nongeriatric patients? (2) How does the influence of anatomic parameters on clinical prognosis manifest: directly or mediated by additional mechanisms?

METHODS

This retrospective, multicenter study used a nationwide database in China. Between January 2014 and December 2020, we evaluated 1066 patients with femoral neck fractures with a median age of 53 years (interquartile range 46 to 56) and median follow-up period of 62 months. Anatomic parameters including femoral neck-shaft angle (NSA), femoral head radius, femoral neck width, femoral offset, acetabular center-edge angle, and acetabular sharp angle were variables of interest. The primary outcome was clinical failure including nonunion, AVN, reoperation, and functional failure (decrease in Harris hip score reaching the minimum clinically important difference). Risk factors for failure were first filtered using the Bayesian information criterion and then assessed with multiple regression adjusting for confounders. The mediation effect was further explored using model-based causal mediation analysis with a quasi-Bayesian Monte Carlo method.

RESULTS

Of all anatomic parameters we assessed, the contralateral NSA was associated with clinical failure, after adjusting for all potential covariates and confounding variables (adjusted odds ratio 0.92 [95% confidence interval 0.89 to 0.95]; p < 0.001). The optimal threshold for the NSA was 130°, with the highest Youden index of 0.27. Patients with an NSA < 130° (41% [441 of 1066]) demonstrated an increased occurrence of nonunion (15% [68 of 441] versus 5% [33 of 625]; p < 0.001), AVN (32% [141 of 441] versus 22% [136 of 625]; p < 0.001), functional failure (25% [110 of 441] versus 15% [93 of 625]), and reoperations (28% [122 of 441] versus 13% [79 of 625]). The impact of an NSA less than 130° on clinical failure was direct and substantially mediated by the type of displaced fracture (mediation proportion: 18.7%).

CONCLUSION

In our study of screw fixations for femoral neck fractures among nongeriatric patients, we identified that a contralateral NSA < 130° correlates with an increased risk of clinical failure including nonunion, AVN, functional failure, and reoperation. The effect is either direct or mediated through displaced fracture types. This is important for surgeons in order to recognize the elevated rate of clinical failure and nature of the challenging biomechanical environment, which should guide them in refining surgical details and selecting appropriate fixation and rehabilitation plans. Approaches to managing these fractures require further validation with large-scale clinical trials.

LEVEL OF EVIDENCE

Level III, prognostic study.

[Non-unions of the upper extremities]

The diagnosis and treatment of non-unions still represents an interdisciplinary challenge. Therefore, prevention, early detection and specific treatment are of great importance. Non-unions of the upper extremities, although less common than that of the lower extremities, requires special attention for successful treatment due to the central role of the shoulder girdle and arm in day to day activities. Successful treatment of non-unions requires a comprehensive evaluation of the patient's medical history, a thorough clinical examination and in particular radiological imaging. In order to effectively treat the pseudarthrosis it is crucial to distinguish between pseudarthroses that are suspected to be due to infections and those that are not. This article presents a treatment algorithm for managing both pseudarthrosis due to infection and pseudarthrosis without infection in the upper extremities.

Mechanical outcomes of the TFNA, InterTAN and IMHS intramedullary nailing systems for the fixation of proximal femur fractures

INTRODUCTION

Hip fractures have become a major public health priority due to their increasing incidence. Intramedullary (IM) nailing has gained popularity as a surgical technique for managing these fractures. However, comparative studies with extramedullary devices indicate potentially increased mechanical complications associated with IM nailing. Specifically, there have been recent reports of early implant fracture associated with the TFNA system. This study compares the rate of mechanical complications between 3 implants. Secondarily, we analysed the factors associated with implant fracture and all other mechanical complications.

METHODS

This retrospective study included 803 IM nails performed between 2008-2021 for the fixation of proximal femur fractures at a level 1 trauma centre. We recorded patient demographics, AO fracture classification, implant specification and intra-operative parameters such as tip-apex distance, Cleveland index, reduction quality, presence of medial calcar integrity, neck-shaft angle. The outcomes analysed included implant fracture, lag screw cut-out, >10 mm backing out, autodynamisation, periprosthetic fracture, non-union at 6 months and time to revision surgery.

RESULTS

The overall implant fracture rate was 3.1 % (25/803), with no statistically significant difference between the three devices (p = 0.51). The TFNA group included 183 patients with a median follow-up of 1.6 years. The TFNA fracture rate was 2.2 % (4/183) which occurred at 207 +/- 16.66 days post-operatively. The rate of all mechanical complications was 4.9 % in the TFNA group, 12.9 % in the InterTAN group and 17 % in the IMHS group. Non-union (p < 0.001) and increasing lag screw length (p < 0.02) were identified as risk factors for implant fracture and other mechanical complications. The reverse oblique fracture pattern (AO 31 A3.1) was associated with mechanical complications only (p < 0.01). The cumulative survival rates without revision for the TFNA, InterTAN, IMHS groups were 97.8 %, 95.5 % and 87.9 % respectively at 2.5 years.

DISCUSSION

The rates of implant fracture were comparable between the three nailing systems. The TFNA provides effective fixation for proximal femur fractures using a traditional screw without cement augmentation. The TFNA was associated with an overall reduction in mechanical complications compared to the InterTAN and IMHS. Previously reported mechanical complications associated with IM Nails may relate to older device designs.

Effectiveness of Weekly Teriparatide Injection in Postmenopausal Patients with Hip Fractures

Background

Teriparatide is an effective anabolic agent used in the treatment of severe osteoporosis. In addition, it is also used to promote fracture healing. The purpose of this double-blind randomized controlled trial was to evaluate the influence of weekly teriparatide administration on bone formation in hip fracture patients.

Methods

The control group (n = 41) was composed of patients treated with normal saline other than teriparatide, and the teriparatide group (n = 51) consisted of patients who received weekly teriparatide. Bone turnover markers, C-terminal telopeptide (CTx) and osteocalcin (OC), were assessed through blood tests at the initial hospital visit and 3-month, 6-month, and 1-year follow-ups. Dual-energy X-ray absorptiometry was performed 5 days postoperatively and at 1-year postoperative follow-up. The degree of fracture union was evaluated by comparing the radiographic union scoring system for hips using Radiographic Union Score for Hip (RUSH) scores between the two groups at 3 months, 6 months, and 1 year after surgery.

Results

Evaluation of the rate of change in bone mineral density over 1 year showed that the lumber bone mineral density increased by more than 7% in the experimental group. The control group did not show a difference between the CTx and OC at 6 months, but the difference between the CTx and OC values was large at 6 months in the experimental group. The mean RUSH score was significantly different between the control group and the experimental group: 12.105 and 15.476, respectively (p = 0.004), at 3 months and 18.571 and 22.389, respectively, at 6 months (p = 0.006).

Conclusions

Weekly use of teriparatide improved fracture healing, bone formation, and clinical outcomes at 1 year after hip fracture surgery by the anabolic window effect.

Fracture healing-orthobiologics: from basic science to clinical application

Orthopaedics as a field and a profession is fundamentally concerned with the treatment of musculoskeletal disease, in all of its many forms. Our collective understanding of the cellular mechanisms underlying musculoskeletal pathology resulting from injury continues to evolve, opening novel opportunities to develop orthobiologic treatments to improve care. It is a long path to move from an understanding of cellular pathology to development of successful clinical treatment, and this article proposes to discuss some of the challenges to achieving translational therapies in orthopaedics. The article will focus on challenges that clinicians will likely face in seeking to bring promising treatments forward to clinical practice and strategies for improving success in translational efforts.

Biophysical Stimulation in Delayed Fracture Healing of Hand Phalanx: A Radiographic Evaluation

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.

Role of Supplemental Teriparatide Therapy to Augment Functional and Radiological Outcomes in Osteoporotic Intertrochanteric Hip Fractures in the Elderly Population

With improved life expectancy and ever-increasing geriatric population with concomitant osteoporosis, there is increase in osteoporotic intertrochanteric hip fractures. Even the best surgical advances fail to provide satisfactory and early results. As a result, researchers' focus has lately shifted to developing a more integrated approach that combines the pharmacotherapeutic capabilities of teriparatide, a recombinant version of human parathyroid hormone (1-34), a new anabolic drug that enhances bone mass and strength by promoting osteoblastic activity and hastens fracture union in both human and animals. We attempted to evaluate the therapeutic efficiency of teriparatide therapy on outcomes of surgically managed Intertrochanteric hip fractures in osteoporotic patients. A total of 31 patients with established osteoporosis and Intertrochanteric fractures were selected and divided into two groups, managed surgically with proximal femur nailing, and then prospectively compared with one group receiving teriparatide therapy in addition to standard treatment after taking necessary consent and allocation into two groups based on the preference of patients to take additional teriparatide or not after understanding the benefits and risks involved. We aimed to assess the functional and radiological effects of teriparatide on bone mineral density, the time taken for fracture union, and other fracture-related postoperative complications such as weight bearing and residual bone pain. All patients were followed up at 6, 12, and 24 weeks. Time to fracture union was significantly shortened, with considerable improvement in bone density and functional outcome in the teriparatide group. Varus collapse, the rate of migration of the helical blade, and shortening of the femoral neck were also significantly less in the study group. From the assembled data, we can safely assume that with early union rates with better functional improvement with additional advantage of increased bone mass, we favor supplemental teriparatide therapy in the management of osteoporotic patients with femoral intertrochanteric fractures to augment healing. Further studies with a larger sample size are required to support our observation.

Subspecialty Fellowship Training Is Not Associated With Better Outcomes in Fixation of Low-Energy Femoral Neck Fractures-An Analysis of the Fixation Using Alternative Implants for the Treatment of Hip Fractures Database

OBJECTIVES

To compare risk of reoperation for femoral neck fracture patients undergoing fixation with cancellous screws (CSs) or sliding hip screws based on surgeon fellowship (trauma-fellowship-trained vs. non-trauma-fellowship-trained).

DESIGN

Retrospective review of Fixation using Alternative Implants for the Treatment of Hip fractures data.

SETTING

Eighty-one centers across 8 countries.

PATIENTS/PARTICIPANTS

Eight hundred nineteen patients ≥50 years old with low-energy hip fractures requiring surgical fixation.

INTERVENTION

Patients were randomized to CS or sliding hip screw group in the initial dataset.

MAIN OUTCOME MEASUREMENTS

The primary outcome was risk of reoperation. Secondary outcomes included death, serious adverse events, radiographic healing, discharge disposition, and use of ambulatory devices postoperatively.

RESULTS

There was no difference in risk of reoperation between the 2 surgeon groups (P > 0.05). Patients treated by orthopaedic trauma surgeons were more likely to be overweight/obese and have major medical comorbidities (P < 0.05). There was a higher risk of serious adverse events, higher likelihood of radiographic healing, and higher odds of discharge to a facility for patients treated by trauma-fellowship-trained surgeons (P < 0.05).

CONCLUSIONS

Based on these data, risk of reoperation for low-energy femoral neck fracture fixation is equivalent regardless of fellowship training. The higher likelihood of radiographic healing noted in the trauma-trained group does not seem to have a major clinical implication because it did not affect risk of reoperation between the 2 groups. Patient-specific factors present preinjury, such as body habitus and medical comorbidities, may account for the lower odds of discharge to home and higher risk of postoperative medical complications for patients treated by orthopaedic trauma surgeons.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Definition of long-bone nonunion: A scoping review of prospective clinical trials to evaluate current practice

AIM

Although nonunions are among the most common complications after long-bone fracture fixation, the definition of fracture nonunion remains controversial and varies widely. The aim of this study was to identify the definitions and diagnostic criteria used in the scientific literature to describe nonunions after long-bone fractures.

METHODS

A comprehensive literature search was performed in PubMed, Cochrane Library, Web of Science, and Embase. Prospective clinical studies, in which adult long-bone fracture nonunions were investigated as main subject, were included in this analysis. Data on nonunion definitions described in each study were extracted and collected in a database.

RESULTS

Although 148 studies met the inclusion criteria, only 50% (74/148) provided a definition for their main study subject. Nonunion was defined in these studies based on time-related criteria in 85% (63/74), on radiographic criteria in 62% (46/74), and on clinical criteria in 45% (33/74). A combination of clinical, radiographic and time-related criteria for definition was found in 38% (28/74). The time interval between fracture and the time point when authors defined an unhealed fracture as a nonunion showed considerable heterogeneity, ranging from three to twelve months.

CONCLUSION

In the current orthopaedic literature, we found a lack of consensus with regard to the definition of long-bone nonunions. Without valid and reliable definition criteria for nonunion, standardization of diagnostic and treatment algorithms as well as the comparison of clinical studies remains problematic. The lack of a clear definition emphasizes the need for a consensus-based approach to the diagnosis of fracture nonunion centred on clinical, radiographical and time-related criteria.

Short and long-term outcomes of three-dimensional printed surgical guides and virtual surgical planning versus conventional methods for fibula free flap reconstruction of the mandible: Decreased nonunion and complication rates

BACKGROUND

To determine whether virtual surgical planning and three-dimensional printed cutting guides (3D/VSP) improved radiographic bone union compared to conventional methods (CM) in fibula free flap (FFF) reconstruction of the mandibles.

METHODS

Retrospective study from the years 2000-2018 at a tertiary hospital. Osseous union was evaluated by a radiologist blinded to each patient's treatment.

RESULTS

Two hundred sixty patients who underwent FFF tissue transfer, 28 with VSP and 3D cutting guides. Bony union was not achieved in 46 (20%) patients who underwent CM compared to 1 (4%) of patients with VSP and guides (p = 0.036). FFF complication was significantly higher in CM with 87 patients (38%) compared to three patients (11%) in 3D/VSP (p = 0.005). Median time to bony union for patients who underwent CM was 1.4 years compared to 0.8 years in 3D/VSP.

CONCLUSIONS

3D/VSP reduced the rate of radiographic nonunion and flap-related complications in FFF reconstruction for mandibular defects.

Semi-quantitative CT scoring of nailed shaft fractures during normal healing and in non-unions: comparison with radiographic scoring

PURPOSE

To compare tomographic (TUS) with radiographic (RUS) union scores in nailed shaft fractures during normal healing and in non-unions.

METHODS

Two radiologists blinded to fracture age separately determined RUS and TUS in nailed femoral or tibial shaft fractures by analyzing the radiographic and CT examinations obtained in 47 patients during normal healing (early fracture group; 24 study participants, 17 men,19 tibias, mean fracture-CT delay 109 ± 57 days [42-204 days]) and in surgically proven non-united fractures (late fracture group, 23 patients, 14 men, 12 tibias, mean fracture-CT delay 565 ± 519 days[180-1983 days]). In both study groups, we determined the inter- and intra-observer agreement of RUS and TUS and compared TUS with RUS.

RESULTS

Intra- and inter-observer agreement of RUS and TUS was very good in the early fracture group and good in the late fracture group for both readers. TUS correlated with RUS substantially in the early fracture group and only weakly in the late fracture group. TUS was statistically significantly lower than RUS in study participants with RUS ≥ 8 or 9 for R2 only and ≥ 10 for both readers in the early fracture group and in patients with RUS ≥ 8, 9 or 10 in the late fracture group for both readers.

CONCLUSION

RUS and TUS of nailed shaft fractures during normal healing or in non-unions are both feasible and reproducible. They yield similar values in fractures with no or limited callus. TUS yields lower values than RUS in fractures with callus.

The Life of a Fracture: Biologic Progression, Healing Gone Awry, and Evaluation of Union

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.

Early Radiographic Union Score for Hip Is Predictive of Femoral Neck Fracture Complications Within 2 Years

OBJECTIVES

To determine if the Radiographic Union Score for Hip (RUSH) measured at 3 and 6 months after femoral neck fracture were predictive of reoperation for infection, nonunion, delayed union, avascular necrosis, or implant failure within 24 months of initial surgery.

DESIGN

Secondary analysis of a randomized controlled trial. Logistic regression was performed to investigate associations between lower RUSH and reoperation. Results were reported as odds ratios (OR), 95% confidence intervals (CIs), and associated P values. All tests were 2 tailed with alpha = 0.05.

SETTING

Eighty-one clinical sites across 8 countries.

PATIENTS/PARTICIPANTS

Data from 734 of the clinical trial participants with radiographs at 3 and 6 months after fracture fixation were included.

INTERVENTION

A reviewer blinded to patients' outcomes independently assigned a RUSH at each follow-up time point.

MAIN OUTCOME MEASURES

Revision surgery rate related to intervention.

RESULTS

Lower RUSH at 3 and 6 months were associated with increased odds of reoperation within 24 months of fracture fixation. For every 2-point decrease in RUSH at 3 months, there was a 16% increase in the odds of a patient experiencing a re-operation (OR, 1.16; 95% CI, 1.10-1.22; P < 0.0001). A similar association was observed at the 6-month assessment for every 2-point decrease (OR = 1.05; 95% CI, 1.01-1.09; P = 0.005).

CONCLUSIONS

Decreased radiographic healing as early as 3 months post fracture fixation is associated with developing patient important femoral neck fracture reoperations. This relationship may guide early treatment decisions, suggesting that 3- and 6-month RUSH are a useful surrogate measure of reoperations within 24 months of fracture fixation.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Radiographic evaluations: Which are most effective to follow fracture healing?

The assessment of fracture healing is an imperative and fundamental clinical aspect within orthopaedics. Despite that, there have historically been non-reliable methods utilized to assess for fracture union and nonunion. In recent years, a number of radiographic assessment tools such as the Radiographic Union Score for Tibial fractures (RUST) and Radiographic Union Score for Hip fracture (RUSH) have been developed in order to improve the reliability of fracture assessment for union. These scores have not only increased the reliability of assessments but have also provided thresholds to aid in predicting nonunion as well as union. The nonunion risk determination (NURD) Score was also created to prognosticate these clinical presentations. With the large burdens of cost, lower quality of life and morbidity associated with fracture nonunion, these evaluation methods have provided orthopaedic surgeons with an improved ability to predict nonunion and assist in the management of patients. This review outlines the development, reliability testing as well as biomechanical validity testing associated with these scoring systems.

A Randomized, Placebo-Controlled Study of Romosozumab for the Treatment of Hip Fractures

BACKGROUND

Romosozumab is a bone-forming antibody that increases bone formation and decreases bone resorption. We conducted a double-blinded, randomized, phase-2, dose-finding trial to evaluate the effect of romosozumab on the clinical outcomes of open reduction and internal fixation of intertrochanteric or femoral neck hip fractures.

METHODS

Patients (55 to 94 years old) were randomized 2:3:3:3 to receive 3 subcutaneous injections of romosozumab (70, 140, or 210 mg) or a placebo postoperatively on day 1 and weeks 2, 6, and 12. The primary end point was the difference in the mean timed "Up & Go" (TUG) score over weeks 6 to 20 for romosozumab versus placebo. Additional end points included the time to radiographic evidence of healing and the score on the Radiographic Union Scale for Hip (RUSH).

RESULTS

A total of 332 patients were randomized: 243 to receive romosozumab (70 mg, n = 60; 140 mg, n = 93; and 210 mg, n = 90) and 89 to receive a placebo. Although TUG scores improved during the study, they did not differ significantly between the romosozumab and placebo groups over weeks 6 to 20 (p = 0.198). The median time to radiographic evidence of healing was 16.4 to 16.9 weeks across treatment groups. The RUSH scores improved over time across treatment groups but did not differ significantly between the romosozumab and placebo groups. The overall safety and tolerability profile of romosozumab was comparable with that of the placebo.

CONCLUSIONS

Romosozumab did not improve the fracture-healing-related clinical and radiographic outcomes in the study population.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Interobserver Reliability in Imaging-Based Fracture Union Assessment-Two Systematic Reviews

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.

Carbon/PEEK nails: a case-control study of 22 cases

BACKGROUND

Interest around carbon/PEEK plates and nails has been raising. The elastic modulus close to the bone, the high load-carrying capacity and radiolucency make CFR/PEEK materials a potential breakthrough. In the literature, there are abundant data about CFR/PEEK plates in the treatment of proximal humerus, distal radius and distal fibula fractures. In patients affected by bone metastasis, CFR/PEEK nails were proved effective and safe with 12 months of follow-up. Very little is known about performances of CFR/PEEK nails in patients affected by other pathologies.

PURPOSES

The aim of the study was to evaluate safety and efficacy of CFR/PEEK nails in the treatment of various pathological conditions. It was also investigated whatever radiolucency of this nails could lead to a more objective evaluation of bone callus or disease site.

PATIENTS AND METHODS

In the study group were included 20 patients (22 bone segments) who underwent CFR/PEEK nail implantation (eight humerus, one tibia, nine femur and four knee arthrodesis). They were affected by pathological fractures, and in four cases, they required an arthrodesis of the knee. They were retrospectively evaluated considering nail failures and bone callus or disease progression (RUSH scores). Mean follow-up time was 11 months (min 6.8-max 20.3). In the control group were included patients treated with titanium nails in the same institution for the same pathologies. An interclass correlation coefficient (ICC) analysis was performed in both groups considering RUSH scores by two expert surgeon from two institution to assess whether radiolucency could lead to a more objective evaluation of disease or bone callus site.

RESULTS

The ICC of mean values between RUSH scores was 0.882 (IC 95%: 0.702-0.953) in the CFR/PEEK group, while it was 0.778 (IC 95%: 0.41-0.91) in the titanium group. Observers' evaluation showed a significantly higher obscuration by titanium nails than by CFR/PEEK nails. No osteosynthesis failures were reported in both groups.

CONCLUSIONS

Our results confirm the safety of CFR/PEEK nails in the short-medium term. The radiolucency of these materials led our observers to perform more objective evaluations of bone callus formation or disease progression compared to the titanium group given the higher ICC.

LEVEL OF EVIDENCE

III Case-control therapeutic study.

Radiologic evaluation of fracture healing

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.

Radiostereometric analysis of the initial stability of internally fixed femoral neck fractures under differential loading

We examined the feasibility of radiostereometric analysis (RSA) in the assessment of the initial stability of internally fixed femoral neck fractures. The study included 16 patients (mean age 73 years). During surgery, multiple RSA-beads were inserted on both sides of the fracture. Radiographs for RSA were taken in the supine position within the first 3 days and 6, 12, 24, and 52 weeks after surgery. To detect any inducible motion at the fracture-site, radiographs for RSA were taken with the patient resting or applying a load through the fracture. Fracture loading was achieved by the patient pressing the ipsilateral foot as much as tolerated on a force plate while providing a counterforce through both hands. Micromotion exceeding the precision values of RSA (≥0.3 mm for the translation vector and/or ≥1.2 degrees for the rotation vector) was considered significant. Permanent three-dimensional fracture-site displacement was also recorded. Voluntary loading induced fracture-site micromotion, which exhibited a dichotomous distribution. In patients with uncomplicated fracture union, inducible micromotion was detectable only at baseline-if at all. Conversely, fractures that developed a nonunion were characterized by the continuation of inducible micromotion beyond baseline. Permanent fracture-site displacement was, on average, nearly an order of magnitude greater than the inducible micromotion. Fracture unions were characterized by the cessation of permanent fracture-site displacement by 12 weeks. Nonunions presented as outliers in permanent fracture-site displacement. Large-scale studies are warranted to evaluate whether the detection of inducible micromotion beyond baseline could serve as an indicator of insufficient fixation stability. © 2018 The Authors. Journal of Orthopaedic Research® Published by Wiley Periodicals, Inc. on behalf of the Orthopaedic Research Society.

Effects of Zoledronic Acid Treatment on Fracture Healing, Morbidity and Mortality in Elderly Patients with Osteoporotic Hip Fractures

Background

In this study, the effects of zoledronic acid (ZolA) administered at different times to patients undergoing surgical treatment for hip fracture were investigated.

Materials and methods

Ninety patients who underwent surgical treatment for osteoporotic (OP) hip fractures between February 2013 and September 2016 in our hospital were included in the study. After surgical treatment, patients were allocated into three groups: group I—patients who had osteosynthesis using proximal femoral nail (PFN) for an intertrochanteric fracture of the femur were given ZolA within 1 week after fracture and before discharge; group II—patients who had osteosynthesis using the PFN for an intertrochanteric fracture of the femur were given ZolA within 1 month after fracture post-discharge; group III—patients in the same age group who had a hemiarthroplasty (HA) for an intertrochanteric fracture of the femur were administered ZolA before discharge. In addition, all patients were given daily oral calcium and vitamin D3. The Radiographic Union Score for Hip (RUSH), Harris Hip Score (HHS), and bone mineral density (BMD) were used at the follow-up as evaluation criteria, and complications were noted.

Results

There were no significant differences between groups in terms of demographic data and laboratory outcomes (p > 0.05). Radiographic Union Score for Hip scores were similar between groups I and II (p > 0.05). Fracture union occurred by the sixth month in all patients whose results were evaluated. No statistically significant difference was found between three groups (p > 0.05). There was no difference between the three groups in the hip and vertebrae BMD and t scores (p > 0.05). When t and BMD scores before treatment were compared with those at 1 year after treatment, a benefit from ZolA treatment was observed in all three groups (p < 0.05).

Conclusion

This study shows that the timing of ZolA administration has no effect on fracture healing and complication incidence in elderly patients with hip fractures. In addition, ZolA was found to be beneficial in increasing BMD of both femur and vertebra in all groups, but there was no significant difference between the groups.

Clinical significance

The study demonstrated that ZolA may be used early in the treatment of osteoporotic hip fractures with PFN.

How to cite this article

Sargin S, Konya MN, Gulcu A, et al. Effects of Zoledronic Acid Treatment on Fracture Healing, Morbidity and Mortality in Elderly Patients with Osteoporotic Hip Fractures. Strategies Trauma Limb Reconstr 2019;14(3):126–131.

Complications After Tibial Tuberosity Osteotomy: Association With Screw Size and Concomitant Distalization

Background:

Tibial tuberosity osteotomy (TTO) is a versatile procedure commonly used to treat patellar instability as well as to unload cartilage lesions. TTO with concomitant distalization (TTO-d) may be performed in patients with patella alta to stabilize the patella by helping it to engage in the trochlea earlier during flexion.

Purpose:

To identify and compare perioperative complications in patients who underwent TTO and those who underwent TTO-d and to analyze risk factors associated with these complications.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

We retrospectively identified perioperative complications and associated factors from medical records for 240 patients who underwent TTO with or without distalization performed by 2 surgeons at 2 institutions between 2009 and 2015. A musculoskeletal radiologist at each institution determined osteotomy union using a published grading system. Significance was set at P < .01.

Results:

Of the 240 patients, 153 (122 TTO, 31 TTO-d) had clinical and radiographic follow-up of at least 90 days or evidence of osseous union. Eighty-eight complications were identified in 71 of 153 (46%) patients: delayed union (n = 35); painful hardware (n = 32); deep vein thrombosis (n = 4); clinical nonunion, delayed range of motion, sensory deficit, and wound breakdown (n = 3 each); and broken screw, fascial hernia, hematoma, quadriceps dysfunction, and tibial fracture (n = 1 each). Thirteen of 35 delayed unions occurred in the TTO-d group (P = .005). Painful hardware was more frequent in patients who received 4.5-mm screws (31/115) than in those who received 3.5-mm screws (1/38) (P = .001). A reoperation was required in 38 of 153 patients (37 patients using 4.5-mm screws vs 1 patient using 3.5-mm screws; P < .001), primarily for screw removal (32/38).

Conclusion:

Minor complications, including delayed union and painful hardware, were common, but major complications such as tibial fracture, deep vein thrombosis, and clinical nonunion were rare. Delayed union was more frequent in the TTO-d group. The 3.5-mm screws were less painful and less likely to need removal than the 4.5-mm screws.

Fracture healing: A review of clinical, imaging and laboratory diagnostic options

A fundamental issue in clinical orthopaedics is the determination of when a fracture is united. However, there are no established "gold standards," nor standardized methods for assessing union, which has resulted in significant disagreement among orthopaedic surgeons in both clinical practice and research. A great deal of investigative work has been directed to addressing this problem, with a number of exciting new techniques described. This review provides a brief summary of the burden of nonunion fractures and addresses some of the challenges related to the assessment of fracture healing. The tools currently available to determine union are discussed, including various imaging modalities, biomechanical testing methods, and laboratory and clinical assessments. The evaluation of fracture healing in the setting of both patient care and clinical research is integral to the orthopaedic practice. Weighted integration of several available metrics must be considered to create a composite outcome measure of patient prognosis.

Sources and quality of literature addressing femoroacetabular impingement: a scoping review 2011-2015

A systematic review was performed to explore the current trends over the last 5 years in femoroacetabular impingement (FAI) literature and compare the quality and sources of publications in the literature to that published previously. We identified 1066 relevant studies including 186,572 patients. The number of publications increased during the reviewed time period with the most dramatic increase from 2011 to 2013. Seventy-three percent (N = 786) of all studies were of levels 4 and 5 quality evidence. The percent of publications which were levels 1, 2 and 3 increased by almost twofold from 16.1 % (N = 26) to 28.7 % (N = 51) between 2011 and 2015. In comparison to previous work, there has been 3.5-fold increase in the number of publications over the past 5 years with a shift towards improving the level of evidence available guiding the arthroscopic management of FAI.

LEVEL OF EVIDENCE

IV-Systematic Review.

The Radiographic Union Score for Hip (RUSH) Identifies Radiographic Nonunion of Femoral Neck Fractures

BACKGROUND

The Radiographic Union Score for Hip (RUSH) is a previously validated outcome instrument designed to improve intra- and interobserver reliability when describing the radiographic healing of femoral neck fractures. The ability to identify fractures that have not healed is important for defining nonunion in clinical trials and predicting patients who will likely require additional surgery to promote fracture healing. We sought to investigate the utility of the RUSH score to define femoral neck fracture nonunion.

QUESTIONS/PURPOSES

(1) What RUSH score threshold yields at least 98% specificity to diagnose nonunion at 6 months postinjury? (2) Using the threshold identified, are patients below this threshold at greater risk of reoperation for nonunion and for other indications?

METHODS

A representative sample of 250 out of a cohort of 725 patients with adequate 6-month hip radiographs was analyzed from a multinational elderly hip fracture trial (FAITH). All patients had a femoral neck fracture and were treated with either multiple cancellous screws or a sliding hip screw. Two reviewers independently determined the RUSH score based on the 6-month postinjury radiographs and interrater reliability was assessed with the interclass correlation coefficient (ICC). There was substantial reliability between the reviewers assigning the RUSH scores (ICC, 0.81; 95% confidence interval [CI], 0.76-0.85). The RUSH score is a checklist-based system that quantifies four measures of healing: cortical bridging, cortical fracture disappearance, trabecular consolidation, and trabecular fracture disappearance.. Fracture healing was determined by two independent methods: (1) concurrently by the treating surgeon using both clinical and radiographic assessments as per routine clinical care; and (2) retrospectively by a Central Adjudication Committee using complete obliteration of the fracture line on radiographs alone. Receiver operating characteristic tables were used to define a RUSH threshold score that was > 98% specific for fracture nonunion.

RESULTS

A threshold score of < 18 was associated with a 100% specificity (95% CI, 97%-100%) and a positive predictive value of 100% (95% CI, 73%-100%) for radiographic nonunion. In contrast, using the fracture healing assessments of the treating surgeons failed to identify a useful discriminatory nonunion threshold and the highest positive predictive value was 43%. With respect to complications, patients with RUSH scores below 18 had greater risk of undergoing reoperation for nonunion (reoperation when < 18: six of 13 [46%]; reoperation when ≥ 18: 11 of 237 [54%]; relative risk [RR], 9.9 [95% CI, 4.4-22.7]; p < 0.001) and for all indications (reoperation when < 18: eight of 13 [62%]; reoperation when ≥ 18: 54 of 237 [38%]; RR, 2.7 [95% CI, 1.7-4.4]; p = 0.004).

CONCLUSIONS

The 6-month RUSH score is a reliable method for assessing radiographic healing. Our results highlight the discordance between radiographic determinations and clinician assessments of fracture healing and stress the need for clinical data to be incorporated in research studies evaluating fracture healing.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Determination of Radiographic Healing: An Assessment of Consistency Using RUST and Modified RUST in Metadiaphyseal Fractures

OBJECTIVE

To determine the reliability of the Radiographic Union Scale for Tibia (RUST) score and a new modified RUST score in quantifying healing and to define a value for radiographic union in a large series of metadiaphyseal fractures treated with plates or intramedullary nails.

DESIGN

Healing was evaluated using 2 methods: (1) evaluation of interrater agreement in a series of radiographs and (2) analysis of prospectively gathered data from 2 previous large multicenter trials to define thresholds for radiographic union.

INTERVENTION

Part 1: 12 orthopedic trauma surgeons evaluated a series of radiographs of 27 distal femur fractures treated with either plate or retrograde nail fixation at various stages of healing in random order using a modified RUST score. For each radiographic set, the reviewer indicated if the fracture was radiographically healed. Part 2: The radiographic results of 2 multicenter randomized trials comparing plate versus nail fixation of 81 distal femur and 46 proximal tibia fractures were reviewed. Orthopaedic surgeons at 24 trauma centers scored radiographs at 3, 6, and 12 months postoperatively using the modified RUST score above. Additionally, investigators indicated if the fracture was healed or not healed.

MAIN OUTCOME MEASURES

The intraclass correlation coefficient (ICC) with 95% confidence intervals was determined for each cortex, the standard and modified RUST score, and the assignment of union for part 1 data. The RUST and modified RUST that defined "union" were determined for both parts of the study.

RESULTS

ICC: The modified RUST score demonstrated slightly higher ICCs than the standard RUST (0.68 vs. 0.63). Nails had substantial agreement, whereas plates had moderate agreement using both modified and standard RUST (0.74 and 0.67 vs. 0.59 and 0.53).

UNION

The average standard and modified RUST at union among all fractures was 8.5 and 11.4. Nails had higher standard and modified RUST scores than plates at union. The ICC for union was 0.53 (nails: 0.58; plates: 0.51), which indicates moderate agreement. However, the majority of reviewers assigned union for a standard RUST of 9 and a modified RUST of 11, and >90% considered a score of 10 on the RUST and 13 on the modified RUST united.

CONCLUSIONS

The ICC for the modified RUST is slightly higher than the standard RUST in metadiaphyseal fractures and had substantial agreement. The ICC for the assessment of union was moderate agreement; however, definite union would be 10 and 13 with over 90% of reviewers assigning union. These are the first data-driven estimates of radiographic union for these scores.

Relationship between the alpha and beta angles in diagnosing CAM-type femoroacetabular impingement on frog-leg lateral radiographs

PURPOSE

Alpha and beta angles are commonly used radiographic measures to assess the sphericity of the proximal femur and distance between the pathologic head-neck junction and the acetabular rim, respectively. The aim of this study was to explore the relationship between these two measurements on frog-leg lateral hip radiographs.

METHODS

Fifty frog-leg lateral hip radiographs were evaluated by two orthopaedic surgeons and two radiologists. Each reviewer measured the alpha and beta angles on two separate occasions to determine the relationship between positive alpha and beta angles and the inter- and intra-observer reliability of these measurements.

RESULTS

There was no significant association between positive alpha and beta angles, [kappa range -0.043 (95 % CI -0.17 to 0.086) to 0.54 (95 % CI 0.33-0.75)]. Intra-observer reliability was high [alpha angle intra-class correlation coefficient (ICC) range 0.74 (95 % CI 0.58-0.84) to 0.99 (95 % CI 0.98-0.99) and beta angle ICC range 0.86 (95 % CI 0.76-0.92) to 0.97 (95 % CI 0.95-0.98)].

CONCLUSIONS

There is no statistical or functional relationship between readings of positive alpha and beta angles. The radiographic measurements resulted in high intra-observer and fair-to-moderate inter-observer reliability. Results of this study suggest that the presence of a CAM lesion on lateral radiographs as suggested by a positive alpha angle does not necessitate a decrease in clearance between the femoral head and acetabular rim as measured by the beta angle and thus may not be the best measure of functional impingement. Understanding the relationship between these two aspects of femoroacetabular impingement improves a surgeon's ability to anticipate potential operative management.

Atlantoaxial instability in acute odontoid fractures is associated with nonunion and mortality

BACKGROUND CONTEXT

Odontoid fractures are the most common geriatric cervical spine fractures. Nonunion rates have been reported to be up to 40% and mortality up to 35%, and poor functional outcomes are common. Atlantoaxial instability (AAI) is a plausible prognostic factor, but its role has not been previously examined.

PURPOSE

To determine the effect of severe AAI on the outcomes of nonunion and mortality in patients with acute odontoid fractures.

STUDY DESIGN

Retrospective cohort/single institution.

PATIENT SAMPLE

One hundred twenty-four consecutive patients with acute odontoid fractures.

OUTCOME MEASURES

Rates of nonunion and mortality.

METHODS

Two independent blinded reviewers measured AAI using postinjury computed tomography scans. Patients were classified as having "severe" or "minimal" AAI on the basis of greater versus less than or equal to 50% mean subluxation across each C1-C2 facet joint. Rates of nonunion and mortality were compared using independent samples t tests and adjusted for age, displacement, and subtype using binary logistic regression.

RESULTS

One hundred seven patients had minimal AAI and 17 had severe AAI. Mean follow-up was 4.4 months (standard deviation=4.6). Patients with severe AAI were more likely to experience nonunion (29% vs. 10%, respectively; p=.03) and mortality (35% vs. 14%, respectively; p=.03) regardless of treatment modality. Fracture displacement correlated with AAI (r(2)=0.65). When adjusted for patient age, the odds ratio of nonunion with severe AAI approached significance at 3.3 (95% confidence interval [CI]: 0.9-11.7). Mortality prediction with AAI approached a twofold increased risk (odds ratio=2.1; 95% CI: 0.6-6.8). In patients with Type-II fractures, the odds of mortality with severe AAI approached a threefold higher risk (odds ratio=3.3; 95% CI: 0.9-12.3).

CONCLUSIONS

Patients with acute odontoid fractures and severe AAI may be more likely to experience nonunion and mortality, suggesting the possibility that aggressive management could be warranted. Further investigation with a large prospective study including patient-important functional outcomes is justified.

Posterior pedicle screw fixation for complex atlantoaxial fractures with atlanto-dental interval of ≥ 5 mm or C2-C3 angulation of ≥ 11°

Objective

Previous studies have demonstrated that the posterior pedicle screw fixation is an effective and safe method to treat atlantoaxial fractures. However, no report focuses on only the complex atlantoaxial fractures with atlanto-dental interval (ADI) of ≥5 mm or C2-C3 angulation of ≥11°.

Methods

This study was to retrospectively evaluate the outcome of 15 patients (six females and nine males; age, 27–55 years) who underwent posterior pedicle screw fixation for the above complex atlantoaxial fractures between July 2006 and March 2011. Fracture combinations included three Jefferson-type II odontoid, four anterior ring-type II odontoid, two posterior ring-type II odontoid, one lateral mass-type II odontoid, one Jefferson-hangman’s fracture, three anterior ring-hangman’s fracture, and one lateral mass-hangman’s fracture. Fracture healing and bone fusion were determined on X-ray scan. Upper limbs, lower limbs, and sphincter functions were assessed using the Japanese Orthopaedic Association (JOA) score. The Frankel grading system was used to determine the neurological situation.

Results

The mean operative time, blood loss, and hospital stays were 108.9 ± 25.8 min, 508.0 ± 209.6 ml, and 13.3 ± 2.0 days. Fracture healing and graft fusion were obtained in all patients within 9 months. The ADI or C2-C3 angulation was reduced to ≤5 mm or ≤11°. The JOA score was significantly improved from 7.27 ± 1.10 preoperatively to 15.7 ± 2.1 postoperatively (P <0.001), with 88.1 ± 18.3% recovery rate and 93.3% excellent and good rate. The neurological situation was improved in all patients by at least 1 grade in the Frankel scale. After a mean of 36.5 months of follow-up (range, 18 to 58 months), no operative complications (spinal cord injury, vertebral artery injury, or cerebrospinal fluid leakage) were observed.

Conclusion

Posterior pedicle screw fixation is a reliable, effective, and minimally invasive procedure for patients suffering from complex atlantoaxial fractures.

Current Options for Determining Fracture Union

Determining whether a bone fracture is healed is one of the most important and fundamental clinical determinations made in orthopaedics. However, there are currently no standardized methods of assessing fracture union, which in turn has created significant disagreement among orthopaedic surgeons in both clinical and research settings. An extensive amount of research has been dedicated to finding novel and reliable ways of determining healing with some promising results. Recent advancements in imaging techniques and introduction of new radiographic scores have helped decrease the amount of disagreement on this topic among physicians. The knowledge gained from biomechanical studies of bone healing has helped us refine our tools and create more efficient and practical research instruments. Additionally, a deeper understanding of the molecular pathways involved in the bone healing process has led to emergence of serologic markers as possible candidates in assessment of fracture union. In addition to our current physician centered methods, patient-centered approaches assessing quality of life and function are gaining popularity in assessment of fracture union. Despite these advances, assessment of union remains an imperfect practice in the clinical setting. Therefore, clinicians need to draw on multiple modalities that directly and indirectly measure or correlate with bone healing when counseling patients.

Outcomes of surgery for unstable odontoid fractures combined with instability of adjacent segments

BACKGROUND

At present, traumatic atlantoaxial dislocation or C2-3 instability complicating odontoid fractures remains rarely reported. The aim of this study was to further investigate the surgical treatment strategies and curative effects for odontoid fractures combined with instability of adjacent segments.

METHODS

This is a retrospective study of 12 patients (5 females and 7 males; age, 21-65 years) who underwent internal fixation for odontoid fractures (type II and shallow type III) and atlantoaxial instability in 6 cases, C2-3 instability in 4 cases, simultaneous C1-2 and C2-3 instability in 2 cases between January 2005 and June 2012. Accordingly, individualized surgeries were performed. Fracture healing and bone fusion were determined on X-ray scan. Upper limbs, lower limbs and sphincter functions were assessed using the Japanese Orthopaedic Association (JOA) score. Frankel grading system was used for the evaluation of neurological situation.

RESULTS

Mean follow-up time of all 12 cases was 16.4 months (range, 12 to 48 months). Odontoid fracture healing was obtained in all patients within 9 months, and graft fusion was achieved within 6 months. JOA score was significantly improved from 6.3 ± 3.1 preoperatively to 11.1 ± 4.6 at 12 months after operation (P = 0.007), with 50.5 ± 25.7% recovery rate and 66.7% excellent and good rate. Except one patient still had Frankel grade B neurological injury at 12 months after surgery, the other patients improved their neurological situation (at 1 grade in Frankel scale). One patient developed wound fat liquefaction which resolved by changing the dressing. Cerebrospinal fluid leakage occurred in three patients, which resolved after the continuous drainage for 2 days.

CONCLUSIONS

According to the characteristics of odontoid fractures, the individualized operative procedure should be performed, resulting in high fracture healing rate, function recovery rate, and less, transient complications.

Radiographic scoring system to evaluate union of distal radius fractures

PURPOSE

To evaluate the intra- and interobserver reliability of a scoring system for distal radius fracture union based on specific radiographic parameters obtainable from x-rays.

METHODS

Two sets of 35 anteroposterior and lateral x-rays were obtained by retrospective review of consecutive patients with distal radius fractures (AO types A and C) treated by a single surgeon in 2009. One set was assembled for those patients treated nonsurgically and 1 set for those treated with open reduction and internal fixation (ORIF) with volar plating. Radius union scoring system (RUSS) scores were compiled from a 5-person review panel consisting of hand surgeons and musculoskeletal radiologists. Union of each of the 4 cortices was graded on a 3-point scale (0, fracture line visible with no callus; 1, callus formation but fracture line present; 2, cortical bridging without clear fracture line). Reviewers also recorded their overall impression of fracture union (united or not united). Each set of radiographs was reviewed twice by the 5 reviewers, 2 weeks apart. Inter- and intraobserver reliability were determined using intraclass correlation coefficients.

RESULTS

For nonsurgically treated fractures, substantial agreement in union scores was found with regard to both intra- and interobserver reliability. For fractures treated with ORIF, substantial agreement was found in union scores with regard to intraobserver reliability and moderate agreement with regard to interobserver reliability. In addition, when using the reviewers' overall assessment of union as a reference standard, RUSS had a statistically significant predictive value in being able to differentiate between united and not united fractures.

CONCLUSIONS

This radiographic union tool demonstrated substantial intra- and interobserver reliability for the determination of fracture union in the distal radius. The RUSS is a simple method for a standardized assessment of radiographic union of DRF treated nonsurgically or with ORIF.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic/decision analysis IV.

Design and execution of clinical trials in orthopaedic surgery

High-quality randomised controlled trials (RCTs) evaluating surgical therapies are fundamental to the delivery of evidence-based orthopaedics. Orthopaedic clinical trials have unique challenges; however, when these challenges are overcome, evidence from trials can be definitive in its impact on surgical practice. In this review, we highlight several issues that pose potential challenges to orthopaedic investigators aiming to perform surgical randomised controlled trials. We begin with a discussion on trial design issues, including the ethics of sham surgery, the importance of sample size, the need for patient-important outcomes, and overcoming expertise bias. We then explore features surrounding the execution of surgical randomised trials, including ethics review boards, the importance of organisational frameworks, and obtaining adequate funding. Cite this article: Bone Joint Res 2014;3:161-8.

Radiographic union score for hip substantially improves agreement between surgeons and radiologists

Background

Despite the prominence of hip fractures in orthopedic trauma, the assessment of fracture healing using radiographs remains subjective. The variability in the assessment of fracture healing has important implications for both clinical research and patient care. With little existing literature regarding reliable consensus on hip fracture healing, this study was conducted to determine inter-rater reliability between orthopedic surgeons and radiologists on healing assessments using sequential radiographs in patients with hip fractures. Secondary objectives included evaluating a checklist designed to assess hip fracture healing and determining whether agreement improved when reviewers were aware of the timing of the x-rays in relation to the patients’ surgery.

Methods

A panel of six reviewers (three orthopedic surgeons and three radiologists) independently assessed fracture healing using sequential radiographs from 100 patients with femoral neck fractures and 100 patients with intertrochanteric fractures. During their independent review they also completed a previously developed radiographic checklist (Radiographic Union Score for Hip (RUSH)). Inter and intra-rater reliability scores were calculated. Data from the current study was compared to the findings from a previously conducted study where the same reviewers, unaware of the timing of the x-rays, completed the RUSH score.

Results

The agreement between surgeons and radiologists for fracture healing was moderate for “general impression of fracture healing” in both femoral neck (ICC = 0.60, 95% CI: 0.42-0.71) and intertrochanteric fractures (0.50, 95% CI: 0.33-0.62). Using a standardized checklist (RUSH), agreement was almost perfect in both femoral neck (ICC = 0.85, 95% CI: 0.82-0.87) and intertrochanteric fractures (0.88, 95% CI: 0.86-0.90). We also found a high degree of correlation between healing and the total RUSH score using a Receiver Operating Characteristic (ROC) analysis, there was an area under the curve of 0.993 for femoral neck cases and 0.989 for intertrochanteric cases. Agreement within the radiologist group and within the surgeon group did not significantly differ in our analyses. In all cases, radiographs in which the time from surgery was known resulted in higher agreement scores compared to those from the previous study in which reviewers were unaware of the time the radiograph was obtained.

Conclusions

Agreement in hip fracture radiographic healing may be improved with the use of a standardized checklist and appears highly influenced by the timing of the radiograph. These findings should be considered when evaluating patient outcomes and in clinical studies involving patients with hip fractures. Future research initiatives are required to further evaluate the RUSH checklist.