The Radiographic Union Score for HUmeral fractures (RUSHU) predicts humeral shaft nonunion

Impact of osteoporosis and osteoporosis medications on fracture healing: a narrative review

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.

[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.

No Differences in Clinical, Functional, or Patient-Reported Outcomes Following Trial of Nonoperative Management Before Open Reduction and Internal Fixation of Humeral Shaft Fractures

OBJECTIVES

To test the hypothesis that primary osteosynthesis of humeral shaft fractures may lead to more favorable clinical, functional, and patient-reported outcomes than fixation following a trial of nonoperative management.

METHODS

DESIGN

Retrospective cohort review.

SETTING

Academic level I trauma center.

PATIENT SELECTION CRITERIA

Adult patients who presented with humeral shaft fractures and ultimately underwent open reduction and internal fixation (ORIF) from May 2011 to May 2021. Patients who underwent ORIF within 2 weeks of injury were grouped into the primary osteosynthesis cohort, and patients who underwent ORIF >4 weeks from the date of injury were grouped into the trial of nonoperative cohort.

OUTCOME MEASURES AND COMPARISONS

Postoperative complications, elbow arc of motion, time to radiographic union, and patient-reported outcomes were investigated and compared between the primary osteosynthesis and trial of nonoperative management cohorts.

RESULTS

One hundred twenty-seven patients fit the study criteria, 84 underwent primary osteosynthesis and 43 trialed initial nonoperative treatment. No differences were found in patient demographics between the primary osteosynthesis and trial of nonoperative management cohorts, including age (53 ± 19 vs. 57 ± 18; P = 0.25), sex (39% vs. 44% male, 61% vs. 56% female; P = 0.70), and Body Mass Index (BMI) (30 ± 6 vs. 32 ± 9; P = 0.38). The average time to operative intervention in the primary osteosynthesis group was 4 days (0-14 days) and 105 days (28-332 days) in the trial of nonoperative treatment group ( P < 0.01). No differences were found with regard to intraoperative blood loss, total operative time, time to radiographic union (determined using the Radiographic Union Scores for Humeral scoring system), or overall complication rates, including primary and secondary radial nerve injuries ( P = 0.23 and 0.86, respectively). Patients reported similar patient-reported outcomes measurement information system pain interference ( P = 0.73), depression (D) ( P = 0.99), and physical function ( P = 0.66) scores at their 6-month postsurgical follow-up visits.

CONCLUSIONS

Patients who attempted a trial of nonoperative management for humeral shaft fractures before ORIF had similar clinical, functional, and patient-reported outcomes as those who underwent primary osteosynthesis.

LEVEL OF EVIDENCE

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

Ultrasound assessment of humeral shaft nonunion risk: a feasibility and proof of concept study

PURPOSE

To determine the feasibility and reliability of ultrasound in the assessment of humeral shaft fracture healing and estimate the accuracy of 6wk ultrasound in predicting nonunion.

METHODS

Twelve adults with a non-operatively managed humeral shaft fracture were prospectively recruited and underwent ultrasound scanning at 6wks and 12wks post-injury. Seven blinded observers evaluated sonographic callus appearance to determine intra- and inter-observer reliability. Nonunion prediction accuracy was estimated by comparing images for patients that united (n = 10/12) with those that developed a nonunion (n = 2/12).

RESULTS

The mean scan duration was 8 min (5-12) and all patients tolerated the procedure. At 6wks and 12wks, sonographic callus (SC) was present in 11 patients (10 united, one nonunion) and sonographic bridging callus (SBC) in seven (all united). Ultrasound had substantial intra- (weighted kappa: 6wk 0.75; 12wk 0.75) and inter-observer reliability (intraclass correlation coefficient: 6wk 0.60; 12wk 0.76). At 6wks, the absence of SC demonstrated sensitivity 50%, specificity 100%, positive predictive value (PPV) 100% and negative predictive value (NPV) 91% in nonunion prediction (overall accuracy 92%). The absence of SBC demonstrated sensitivity 100%, specificity 70%, PPV 40% and NPV 100% in nonunion prediction (overall accuracy 75%). Of three patients at risk of nonunion (Radiographic Union Score for HUmeral fractures < 8), one had SBC on 6wk ultrasound (that subsequently united) and the others had non-bridging/absent SC (both developed nonunion).

CONCLUSIONS

Ultrasound assessment of humeral shaft fracture healing was feasible, reliable and may predict nonunion. Ultrasound could be useful in defining nonunion risk among patients with reduced radiographic callus formation.

Metacarpal and Phalangeal Nonunions

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.

The Radiographic Union Score for ulnar fractures (RUSU) predicts ulnar shaft nonunion

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.

HUMERAL SHAFT FRACTURE WITH AN INTACT WEDGE FRAGMENT: MIPO VS CONVENTIONAL PLATING

Objectives

Evaluate bone healing time, consolidation, and the complication rate between the minimally invasive plate osteosynthesis and open reduction with plate osteosynthesis in humeral diaphyseal fractures with an intact wedge (AO 12B2).

Methods

A retrospective study was carried out between 2016 and 2020. The medical records and radiographs of 18 patients were analyzed, and data were collected regarding the time of consolidation, age, sex, plate size, number of screws, complications such as iatrogenic injury damage to the radial nerve, material failure, and postoperative infection.

Results

No statistically significant differences were observed in the variables of age, sex, plate size, and number of screws used or in the RUSHU index (Radiographic Union Score for Humeral fractures). There were no postoperative infections, material failure, or need for reoperation, nor cases of secondary radial nerve injury. After one year, all patients had a consolidation index analyzed by RUSHU >11.

Conclusion

both techniques showed similar results, with a high consolidation rate and low rates of complications or iatrogenic damage to the radial nerve. Evidence level III; Retrospective comparative study .

Validation of the Radiographic Union Score for HUmeral fractures (RUSHU): A retrospective study in an independent centre

Background

Early diagnosis and fixation of fractures unlikely to unite can prevent months of morbidity. The Radiographic Union Score for Humeral fractures (RUSHU) is a summative scoring system developed to aid identification of patients at higher risk of developing humeral shaft non-union. Plain radiographs taken six weeks after injury are given a score between four and 12 based on signs of union. Our aim was to assess the validity of the RUSHU prognostic model in an external population.

Methods

The radiographs of fifty-seven patients were scored independently according to RUSHU methodology by three reviewers (blinded to patient outcome). Interobserver intraclass correlation (ICC) was calculated.

Results

Of the cohort, six (10.5%) progressed to non-union after six months. We observed an interobserver ICC co-efficient of 0.89 (95%CI0.84,0.93) in RUSHU score at six weeks. Median score was significantly higher in the union cohort (10v5 p < 0.001). Using the score of < 8 to predict non-union gave an area under the ROC curve of 0.87 (95%CI 0.83,0.90).

Conclusions

In this retrospective single-centre study, we have demonstrated good inter-rater reliability. We would suggest that the RUSHU model be assessed in further external validation studies. RUSHU has the potential to reduce morbidity of delayed treatment of non-union.

Initial Displacement of Humeral Shaft Fractures Is Associated With Failure of Nonoperative Management

OBJECTIVES

To determine whether the initial radiographic displacement of humeral shaft fractures is associated with failure of nonoperative management.

DESIGN

Retrospective cohort study.

SETTING

Urban level 1 trauma center.

PATIENTS/PARTICIPANTS

106 patients with humeral shaft fractures (OTA/AO 12) initially managed nonoperatively.

INTERVENTION

Functional bracing.

MAIN OUTCOME MEASUREMENTS

Failure of nonoperative management, defined as conversion to surgery, malunion, and delayed union/nonunion.

RESULTS

Nonoperative management failed in 33 (31%) of 106 included patients with 27 patients (25%) requiring surgery. On multivariate analysis, female sex [odds ratio (OR): 3.50, 95% confidence interval (CI): 1.09 to 11.21], American Society of Anesthesiologist classification >1 (OR: 7.16, CI: 1.95 to 26.29), initial fracture medial/lateral (ML) translation (OR: 1.09, CI: 1.01 to 1.17, per unit change), and initial fracture anterior-posterior (AP) angulation (OR: 1.09, CI: 1.02 to 1.15, per unit change) were independently associated with failure of nonoperative management. Initial fracture displacement values that maximized the sensitivity (SN) and specificity (SP) for failure included an AP angulation >11 degrees (SN 75%, SP 64%) and ML translation >12 mm (SN 55%, SP 75%). The failure rate in patients with none, 1, or both of these fracture parameters was 3.1% (1/32), 35.6% (20/56), and 66.6% (12/18), respectively.

CONCLUSIONS

Nearly one-third of patients experienced failure of initial nonoperative management. Failure was found to be associated with greater initial fracture AP angulation and ML translation. Fracture displacement cut-off values were established that may be used by surgeons to counsel patients with these injuries.

LEVEL OF EVIDENCE

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

Aseptic humeral shaft nonunion

Aseptic humeral shaft nonunions are rare lesions, with less than 700 cases per year in France. This low frequency explains why they are difficult to manage. They can be hypertrophic or atrophic, with or without a defect. The diagnosis is made based on radiographs and/or CT scan images. Nonunion is suspected early on when a patient presents with abnormal motion at the fracture site 6 weeks after the initial injury event in the context of conservative treatment or has large residual displacement after initial treatment or an open fracture. The treatment for hypertrophic nonunion consists in applying stable, rigid fixation, most often using a large-fragment plate with 4.5 mm screws, combined with cancellous autograft. When combined with the osteoperiosteal decortication first described by Judet, it produces union in 98% of cases. Intramedullary (IM) nail fixation with an autograft is another possibility. In atrophic nonunions, resecting the ends and ensuring the soft tissues have good vitality will generally lead to fracture union. Nonunions with critical size defects (larger than 5 cm), which have a high risk of infection, are a treatment challenge that requires stable fixation and recourse to more complex treatments like the two-step induced membrane technique or vascularized fibular graft. In all cases, to avoid complex repeat revision, internal fixation with plate or IM nail must be combined with a bone graft in situ to maximize the chances of union.

Surgical Versus Nonsurgical Management of Humeral Shaft Fractures: A Systematic Review and Meta-Analysis of Randomized Trials

INTRODUCTION

The aim was to compare surgical and nonsurgical management for adults with humeral shaft fractures in terms of patient-reported upper limb function, health-related quality of life, radiographic outcomes, and complications.

METHODS

MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, PubMed, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, International Clinical Trials Registry, and OpenGrey (Repository for Grey Literature in Europe) were searched in September 2021. All published prospective randomized trials comparing surgical and nonsurgical management of humeral shaft fractures in adults were included. Of 715 studies identified, five were included in the systematic review and four in the meta-analysis. Data were extracted by two independent reviewers according to the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. Methodological quality was assessed using the revised Cochrane risk-of-bias tool for randomized trials. Pooled data were analyzed using a random-effects model.

RESULTS

The meta-analysis comprised 292 patients (mean age 41 [18 to 83] years, 67% male). Surgery was associated with superior Disabilities of the Arm, Shoulder and Hand (DASH) and Constant-Murley scores at 6 months (mean DASH difference 7.6, P = 0.01; mean Constant-Murley difference 8.0, P = 0.003), but there was no difference at 1 year (DASH, P = 0.30; Constant-Murley, P = 0.33). No differences in health-related quality of life or pain scores were found. Surgery was associated with a lower risk of nonunion (0.7% versus 15.7%; odds ratio [OR] 0.13, P = 0.004). The number needed to treat with surgery to avoid one nonunion was 7. Surgery was associated with a higher risk of transient radial nerve palsy (17.4% versus 0.7%; OR 8.23, P = 0.01) but not infection (OR 3.57, P = 0.13). Surgery was also associated with a lower risk of reintervention (1.4% versus 19.3%; OR 0.14, P = 0.04).

CONCLUSIONS

Surgery may confer an early functional advantage to adults with humeral shaft fractures, but this is not sustained beyond 6 months. The lower risk of nonunion should be balanced against the higher risk of transient radial nerve palsy.

LEVEL OF EVIDENCE

Level I.

Clinical Assessments of Fracture Healing and Basic Science Correlates: Is There Room for Convergence?

PURPOSE OF REVIEW

The purpose of this review is to summarize the clinical and basic science methods used to assess fracture healing and propose a framework to improve the translational possibilities.

RECENT FINDINGS

Mainstays of fracture healing assessment include clinical examination, various imaging modalities, and assessment of function. Pre-clinical studies have yielded insight into biomechanical progression as well as the genetic, molecular, and cellular processes of fracture healing. Efforts are emerging to identify early markers to predict impaired healing and possibly early intervention to alter these processes. Despite of the differences in clinical and preclinical research, opportunities exist to unify and improve the translational efforts between these arenas to develop and optimize our ability to assess and predict fracture healing, thereby improving the clinical care of these patients.

Intra-Observational and Inter-Observer Agreement of The Radiographic Humerus Union Measurement (RHUM) in Patients Treated with Dynamic Compression Plate for Humeral Shaft Nonunion

BACKGROUND

It is important for orthopedic surgeons to follow the union of the fracture after surgery. This becomes even more important after nonunion surgery. The radiological union scale is popular in the follow-up of unions. However, the intraobserver and interobserver agreement of this scale in humeral nonunion surgery is still not found in the literature.

OBJECTIVE

This study aimed to reveal the intra/interobserver agreement of the Radiographic Union scale (RHUM) for the humerus as well as the relationship between this agreement, plate placement characteristics, and the number of plates in cases where plates were used for surgical treatment of humeral diaphysis nonunion.

MATERIALS AND METHODS

Twenty patients who received surgical treatment for aseptic humeral nonunion at our hospital between 2010-2019 were studied retrospectively. According to RHUM, two observers scored the patients' anteroposterior and lateral radiographs in the postoperative 12th week. The data obtained were statistically analyzed.

RESULTS

The mean age was 52.05±15.88 years. While a single plate was used in 14 cases, a double plate was used in 6 cases. Interobserver agreement was fair-moderate. The interobserver agreement values of the single plate group were significantly higher than those of the double plate group (p<0.05). Interobserver agreement in cases with a lateral plate was significantly higher than in the group where the lateral + posterior plate was applied (p:0.01).

CONCLUSION

In humeral diaphyseal fracture nonunion cases, the number and location of the plate following surgery negatively impact the evaluation of RHUM scores. Given the importance of the union's follow-up and the decision to proceed with additional treatment in these cases, it may be necessary to develop a new method for determining and monitoring the union if a plate was used in the surgical treatment of humeral nonunion.

Radiographic Scoring of Humeral Shaft Fractures Helps Identify Patients at Risk of Surgery for Delayed Union

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.

The epidemiology and direct healthcare costs of aseptic nonunions in Germany - a descriptive report

Aims

This observational cross-sectional study aimed to answer the following questions: 1) how has nonunion incidence developed from 2009 to 2019 in a nationwide cohort; 2) what is the age and sex distribution of nonunions for distinct anatomical nonunion localizations; and 3) how high were the costs for surgical nonunion treatment in a level 1 trauma centre in Germany?

Methods

Data consisting of annual International Classification of Diseases (ICD)-10 diagnosis codes from German medical institutions from 2009 to 2019, provided by the Federal Statistical Office of Germany (Destatis), were analyzed. Nonunion incidence was calculated for anatomical localization, sex, and age groups. Incidence rate ratios (IRRs) were determined and compared with a two-sample z-test. Diagnosis-related group (DRG)-reimbursement and length of hospital stay were retrospectively retrieved for each anatomical localization, considering 210 patients.

Results

In 2019, a total of 11,840 nonunion cases (17.4/100,000 inhabitants) were treated. In comparison to 2018, the incidence of nonunion increased by 3% (IRR 1.03, 95% confidence interval (CI) 0.53 to 1.99, p = 0.935). The incidence was higher for male cases (IRR female/male: 0.79, 95% CI 0.76 to 0.82, p = 0.484). Most nonunions occurred at the pelvic and hip region (3.6/100,000 inhabitants, 95% CI 3.5 to 3.8), followed by the ankle and foot as well as the hand (2.9/100,000 inhabitants each). Mean estimated DRG reimbursement for in-hospital treatment of nonunions was highest for nonunions at the pelvic and hip region (€8,319 (SD 2,410), p < 0.001).

Conclusion

Despite attempts to improve fracture treatment in recent years, nonunions remain a problem for orthopaedic and trauma surgery, with a stable incidence throughout the last decade.

Cite this article: Bone Joint Res 2022;11(8):541–547.

Routine fixation of humeral shaft fractures is cost-effective

Aims

The primary aim was to estimate the cost-effectiveness of routine operative fixation for all patients with humeral shaft fractures. The secondary aim was to estimate the health economic implications of using a Radiographic Union Score for HUmeral fractures (RUSHU) of < 8 to facilitate selective fixation for patients at risk of nonunion.

Methods

From 2008 to 2017, 215 patients (mean age 57 yrs (17 to 18), 61% female (n = 130/215)) with a nonoperatively managed humeral diaphyseal fracture were retrospectively identified. Union was achieved in 77% (n = 165/215) after initial nonoperative management, with 23% (n = 50/215) uniting after surgery for nonunion. The EuroQol five-dimension three-level health index (EQ-5D-3L) was obtained via postal survey. Multiple regression was used to determine the independent influence of patient, injury, and management factors upon the EQ-5D-3L. An incremental cost-effectiveness ratio (ICER) of < £20,000 per quality-adjusted life-year (QALY) gained was considered cost-effective.

Results

At a mean of 5.4 yrs (1.2 to 11.0), the mean EQ-5D-3L was 0.736 (95% confidence interval (CI) 0.697 to 0.775). Adjusted analysis demonstrated the EQ-5D-3L was inferior among patients who united after nonunion surgery (β = 0.103; p = 0.032). Offering routine fixation to all patients to reduce the rate of nonunion would be associated with increased treatment costs of £1,542/patient, but would confer a potential EQ-5D-3L benefit of 0.120/patient over the study period. The ICER of routine fixation was £12,850/QALY gained. Selective fixation based on a RUSHU < 8 at six weeks post-injury would be associated with reduced treatment costs (£415/patient), and would confer a potential EQ-5D-3L benefit of 0.335 per ‘at-risk patient’.

Conclusion

Routine fixation for patients with humeral shaft fractures to reduce the rate of nonunion observed after nonoperative management appears to be a cost-effective intervention at five years post-injury. Selective fixation for patients at risk of nonunion based on their RUSHU may confer even greater cost-effectiveness, given the potential savings and improvement in health-related quality of life. Cite this article: Bone Jt Open 2022;3(7):566–572.

Surgical versus non-surgical treatment of humeral SHAFT fractures compared by a patient-reported outcome: the Scandinavian Humeral diAphyseal Fracture Trial (SHAFT)-a study protocol for a pragmatic randomized controlled trial

BACKGROUND

The outcome of non-surgical treatment is generally good, but the treatment course can be long and painful with approximately a quarter of the patients acquiring a nonunion. Both surgical and non-surgical treatment can have disabling consequences such as nerve injury, infection, and nonunion. The purpose of the study is to compare patient-reported outcomes after surgical and non-surgical treatment for humeral shaft fractures.

METHODS

A pragmatic randomized controlled trial (RCT) is planned with two study groups (SHAFT-Young and SHAFT-Elderly). A total of 287 eligible acute humeral shaft fractures are scheduled to be recruited and randomly allocated to surgical or non-surgical treatment with the option of early crossover due to delayed union. The surgical method within the allocation is decided by the surgeon. The primary outcome is the Disability of Arm, Shoulder, and Hand (DASH) score at 52 weeks, and is assessor blinded. The secondary outcomes are DASH score, EQ-5D-5L, pain assessed by visual analog score, Constant-Murley score including elbow range of motion, and anchor questions collected at all timepoints throughout the trial. All complications will be reported including; infection, nerve or vascular injury, surgical revisions (implant malpositioning, hardware failure, aseptic loosening, and peri-implant fracture), major adverse cardiovascular events, and mortality.

DISCUSSION

The SHAFT trial is a pragmatic multicenter RCT, that will compare the effectiveness of the main strategies in humeral shaft fracture treatment. This will include a variety of fracture morphologies, while taking the dilemmas within the population into account by splitting the population by age and providing the orthopedic society with an interval for early crossover surgery.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04574336 . Registered on 5 October 2020.

A comparative study of 6-week and 12-week Radiographic Union Scores for HUmeral fractures (RUSHU) as a predictor of humeral shaft non-union

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.

Factors Associated with Patient-Reported Outcomes Following a Humeral Shaft Fracture: Nonunion Results in a Poorer Outcome Despite Union after Surgical Fixation

OBJECTIVES

The primary aim was to assess patient-reported outcomes ≥1 year following a humeral diaphyseal fracture. The secondary aim was to compare outcomes of patients who united after initial management (operative/nonoperative) with those who united after nonunion fixation (NU-ORIF).

DESIGN

Retrospective.

SETTING

University teaching hospital.

PATIENTS AND INTERVENTION

From 2008 to 2017, 291 patients [mean age, 55 years (17-86 years), 58% (n = 168/291) female] were available to complete an outcomes survey. Sixty-four (22%) were initially managed operatively and 227 (78%) nonoperatively. After initial management, 227 (78%) united (n = 62 operative, n = 165 nonoperative), 2 had a delayed union (both nonoperative), and 62 (21%) had a nonunion (n = 2 operative, n = 60 nonoperative). Fifty-two patients (93%, n = 52/56) united after NU-ORIF.

MAIN OUTCOME MEASURES

QuickDASH, EuroQol-5 Dimension (EQ-5D)/EuroQol-Visual Analogue Scale (EQ-VAS), 12-item Short Form Physical (PCS) and Mental Component Summary (MCS).

RESULTS

At a mean of 5.5 years (range, 1.2-11.0 years) postinjury, the mean QuickDASH was 20.8, EQ-5D was 0.730, EQ-VAS was 74, PCS was 44.8 and MCS was 50.2. Patients who united after NU-ORIF reported worse function (QuickDASH, 27.9 vs. 17.6; P = 0.003) and health-related quality of life (HRQoL; EQ-5D, 0.639 vs. 0.766; P = 0.008; EQ-VAS, 66 vs. 76; P = 0.036; PCS, 41.8 vs. 46.1; P = 0.036) than those who united primarily. Adjusting for confounders, union after NU-ORIF was independently associated with a poorer QuickDASH (difference, 8.1; P = 0.019) and EQ-5D (difference, -0.102; P = 0.028).

CONCLUSIONS

Humeral diaphyseal union after NU-ORIF resulted in poorer patient-reported outcomes compared with union after initial management. Targeting early operative intervention to at-risk patients may mitigate the potential impact of nonunion on longer-term outcome.

LEVEL OF EVIDENCE

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

Humeral Shaft Fractures: A Literature Review on Current Treatment Methods

In this review, we aim to provide a concise yet comprehensive summation of the assessment and management of humeral shaft fractures. These are uncommon but prevalent enough that they are part of any trauma surgeon's scope of practice. They have historically been treated using non-operative methods, including braces and casts, supported by published excellent results in the rate of the bone union. However, recently published studies challenge these results and suggest the outcomes might be better with surgery, but the complications of an operation such as infection and nerve injury can not be overlooked. In summary, non-surgical treatment is still the gold standard in the treatment of these fractures, but the indications for surgical management are now clearer and include early signs of delayed union and patients who are unable to have a brace fitted or are uncompliant. It is likely that these new developments will start to change practice, and therefore the treatment of humeral shaft fractures should be a topic of interest of any clinician who deals with them.

Approach to Humeral Shaft Nonunion: Evaluation and Surgical Techniques

Humeral shaft fractures account for 1% to 3% of all fractures. Traditional nonsurgical treatment with a functional brace is still the standard treatment of these fractures; however, modern studies have reported that nonunion rates may be as high as 33%. Recent information suggests that the development of nonunion after nonsurgical treatment may be identified as early as 6 to 8 weeks postinjury. Even with surgical treatment, nonunion rates as high as 10% have been reported. Regardless of the original treatment method, nonunion results in poor quality of life for the patient and therefore should be addressed. A thorough preoperative evaluation is important to identify any metabolic or infectious factors that may contribute to the nonunion. In most cases, surgical intervention should consist of compression plating with or without bone graft. Although most patients will achieve union with standard surgical intervention, some patients may require specialized techniques such as cortical struts or vascularized fibular grafts. Successful treatment of humeral shaft nonunion improves function, reduces disability, and improves the quality of life for patients. In this article, we outline our approach to the treatment of humeral shaft nonunion in a variety of clinical settings.

Predicting the Behavior of Humeral Shaft Fractures: An Independent Validation Study of the Radiographic Union Score for HUmeral Fractures and Value of Assessing Fracture Mobility

OBJECTIVES

To externally validate the Radiographic Union Score for HUmeral fractures (RUSHU) and to quantify the predictive relationship of fracture motion on physical examination to nonunion.

DESIGN

Retrospective cohort study.

SETTING

Single institutional center (University teaching hospital).

PATIENTS

Ninety-two consecutive patients undergoing nonoperative treatment of a diaphyseal humeral shaft fracture were identified over a 4-year period. The average age of the population was 62 years and 42% of the cohort was men.

INTERVENTION

Clinical examination for fracture stability was routinely performed on patients by the treating physicians. Radiographic assessment of fracture callus (RUSHU score) at 6 weeks was retrospectively determined. Patients were followed up until union.

MAIN OUTCOME MEASUREMENTS

Stability was graded as motion at the fracture site or the humerus moving as a single functional unit.

RESULTS

Fractures with a RUSHU score ≤7 were 14 times more likely to proceed to nonunion at 6 months (78% sensitivity, 80% specificity). The time to union was 49 weeks for a RUSHU score of ≤7 versus 16 weeks for a RUSHU score of ≥8. The number of operations needed to avoid one nonunion was 1.7. Fractures mobile at 6 weeks were 6.5 times more likely to proceed to nonunion at 6 months (77% specificity, 67% sensitivity). Mobile fractures had a longer time to union (41 weeks) than nonmobile fractures (17 weeks).

CONCLUSION

The RUSHU score and clinical assessment of fracture mobility are effective and valid tools in identifying patients at risk of developing nonunion of humeral shaft fractures and can enhance early decision making in fracture management.

LEVEL OF EVIDENCE

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

Radiographic union score for tibia (RUST) scoring system in adult diaphyseal femoral fractures treated with intramedullary nailing: an assessment of interobserver and intraobserver reliability

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.

Factors associated with humeral shaft nonunion

BACKGROUND

The primary aim was to identify patient and injury factors independently associated with humeral diaphyseal fracture nonunion after nonoperative management. The secondary aim was to determine the effect of management (operative/nonoperative) on nonunion.

METHODS

From 2008-2017, a total of 734 humeral shaft fractures (732 consecutive skeletally mature patients) were retrospectively identified from a trauma database. Follow-up was available for 663 fractures (662 patients, 90%) that formed the study cohort. Patient and injury characteristics were recorded. There were 523 patients (79%) managed nonoperatively and 139 (21%) managed operatively. Outcome (union/nonunion) was determined from medical records and radiographs.

RESULTS

The median age at injury was 57 (range 16-96) years and 54% (n = 359/662) were female. Median follow-up was 5 (1.2-74) months. Nonunion occurred in 22.7% (n = 119/524) of nonoperatively managed injuries. Multivariate analysis demonstrated preinjury nonsteroidal anti-inflammatory drugs (NSAIDs; odds ratio [OR] 20.58, 95% confidence interval [CI] 2.12-199.48; P = .009) and glenohumeral arthritis (OR 2.44, 95% CI 1.03-5.77; P = .043) were independently associated with an increased risk of nonunion. Operative fixation was independently associated with a lower risk of nonunion (2.9%, n = 4/139) compared with nonoperative management (OR for nonoperative/operative management 9.91, 95% CI 3.25-30.23; P < .001). Based on these findings, 5 patients would need to undergo primary operative fixation in order to avoid 1 nonunion.

CONCLUSIONS

Preinjury NSAIDs and glenohumeral arthritis were independently associated with nonunion following nonoperative management of a humeral diaphyseal fracture. Operative fixation was the independent factor most strongly associated with a lower risk of nonunion. Targeting early operative fixation to at-risk patients may reduce the rate of nonunion and the morbidity associated with delayed definitive management.

Non-union bone fractures

The human skeleton has remarkable regenerative properties, being one of the few structures in the body that can heal by recreating its normal cellular composition, orientation and mechanical strength. When the healing process of a fractured bone fails owing to inadequate immobilization, failed surgical intervention, insufficient biological response or infection, the outcome after a prolonged period of no healing is defined as non-union. Non-union represents a chronic medical condition not only affecting function but also potentially impacting the individual's psychosocial and economic well-being. This Primer provides the reader with an in-depth understanding of our contemporary knowledge regarding the important features to be considered when faced with non-union. The normal mechanisms involved in bone healing and the factors that disrupt the normal signalling mechanisms are addressed. Epidemiological considerations and advances in the diagnosis and surgical therapy of non-union are highlighted and the need for greater efforts in basic, translational and clinical research are identified.

Fracture nonunion in long bones: A literature review of risk factors and surgical management

Nonunion following a long bone fracture causes considerable morbidity when it occurs. Risk factors depend on specific fractures but there is a complex interplay of injury severity, comorbidities, patient medication and infection. The majority of nonunions occur after long bone fractures with the tibia, femur, forearm, humerus and clavicle predominating. Despite interest in the biological augmentation of fracture healing, the majority of nonunions can be effectively managed with conventional surgical techniques. In this review we present a review of risk factors for nonunion and the outcome following surgical management.

Monitoring of fracture healing. Update on current and future imaging modalities to predict union

Fracture nonunion causes considerable patient morbidity and an associated burden to society. Traditional reliance on radiographs to monitor union has limitations as bridging callus of long bone fractures can take three or more months to occur. Computed Tomographic (CT) scanning is becoming increasingly popular and can evaluate bridging callus in the late stages of healing to confirm union. The use of dynamic contrast enhanced Magnetic Resonance Imaging (MRI) and advances in nuclear imaging may yield benefits in the assessment of the infected nonunion. Emerging evidence supports the use of ultrasound to detect bridging callus prior to radiographic confirmation and it may be of use to predict patients at high risk of nonunion. This paper is part of a Supplement supported by The Osteosynthesis and Trauma Care Foundation (OTCF).

Risk factors associated with delayed and aseptic nonunion following tibial diaphyseal fractures managed with intramedullary nailing

Aims

The primary aim of this study was to identify independent predictors associated with nonunion and delayed union of tibial diaphyseal fractures treated with intramedullary nailing. The secondary aim was to assess the Radiological Union Scale for Tibial fractures (RUST) score as an early predictor of tibial fracture nonunion.

Methods

A consecutive series of 647 patients who underwent intramedullary nailing for tibial diaphyseal fractures were identified from a trauma database. Demographic data, comorbidities, smoking status, alcohol consumption, use of non-steroidal anti-inflammatory drugs (NSAIDs), and steroid use were documented. Details regarding mechanism of injury, fracture classification, complications, and further surgery were recorded. Nonunion was defined as the requirement for revision surgery to achieve union. Delayed union was defined as a RUST score < 10 at six months postoperatively.

Results

There were 41 nonunions (6.3%), of which 13 were infected (31.7%), and 77 delayed unions (11.9%). There were 127 open fractures (19.6%). Adjusting for confounding variables, NSAID use (odds ratio (OR) 3.50; p = 0.042), superficial infection (OR 3.00; p = 0.026), open fractures (OR 5.44; p < 0.001), and high-energy mechanism (OR 2.51; p = 0.040) were independently associated with nonunion. Smoking (OR 1.76; p = 0.034), open fracture (OR 2.82; p = 0.001), and high-energy mechanism (OR 1.81; p = 0.030) were independent predictors associated with delayed union. The RUST score at six-week follow-up was highly predictive of nonunion (sensitivity and specificity of 75%).

Conclusion

NSAID use, high-energy mechanisms, open fractures, and superficial infection were independently associated with nonunion in patients with tibial diaphyseal fractures treated with intramedullary nailing. The six-week RUST score may be useful in identifying patients at risk of nonunion.

Cite this article: Bone Jt Open 2021;2(4):227–235.

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.

Fractures of the proximal- and middle-thirds of the humeral shaft should be considered as fragility fractures

Aims

The aim of this study was to determine the current incidence and epidemiology of humeral diaphyseal fractures. The secondary aim was to explore variation in patient and injury characteristics by fracture location within the humeral diaphysis.

Methods

Over ten years (2008 to 2017), all adult patients (aged ≥ 16 years) sustaining an acute fracture of the humeral diaphysis managed at the study centre were retrospectively identified from a trauma database. Patient age, sex, medical/social background, injury mechanism, fracture classification, and associated injuries were recorded and analyzed.

Results

A total of 900 fractures (typical 88.9%, n = 800/900; pathological 8.3%, n = 75/900; periprosthetic 2.8%, n = 25/900) were identified in 898 patients (mean age 57 years (16 to 97), 55.5% (n = 498/898) female). Overall fracture incidence was 12.6/100,000/year. For patients with a typical fracture (n = 798, mean age 56 years (16 to 96), 55.1% (n = 440/798) female), there was a bimodal distribution in men and unimodal distribution in older women (Type G). A fall from standing was the most common injury mechanism (72.6%, n = 581/800). The majority of fractures involved the middle-third of the diaphysis (47.6%, n = 381/800) followed by the proximal- (30.5%, n = 244/800) and distal-thirds (n = 175/800, 21.9%). In all, 18 injuries (2.3%) were open and a radial nerve palsy occurred in 6.7% (n = 53/795). Fractures involving the proximal- and middle-thirds were more likely to occur in older (p < 0.001), female patients (p < 0.001) with comorbidities (p < 0.001) after a fall from standing (p < 0.001). Proximal-third fractures were also more likely to occur in patients with alcohol excess (p = 0.003) and to be classified as AO-Orthopaedic Trauma Association type B or C injuries (p < 0.001).

Conclusion

This study updates the incidence and epidemiology of humeral diaphyseal fractures. Important differences in patient and injury characteristics were observed based upon fracture location. Injuries involving the proximal- and middle-thirds of the humeral diaphysis should be considered as fragility fractures. Cite this article: Bone Joint J 2020;102-B(11):1475–1483.

Lipoteichoic Acid Accelerates Bone Healing by Enhancing Osteoblast Differentiation and Inhibiting Osteoclast Activation in a Mouse Model of Femoral Defects

Lipoteichoic acid (LTA) is a cell wall component of Gram-positive bacteria. Limited data suggest that LTA is beneficial for bone regeneration in vitro. Thus, we used a mouse model of femoral defects to explore the effects of LTA on bone healing in vivo. Micro-computed tomography analysis and double-fluorochrome labeling were utilized to examine whether LTA can accelerate dynamic bone formation in vivo. The effects of LTA on osteoblastogenesis and osteoclastogenesis were also studied in vitro. LTA treatment induced prompt bone bridge formation, rapid endochondral ossification, and accelerated healing of fractures in mice with femoral bone defects. In vitro, LTA directly enhanced indicators of osteogenic factor-induced MC3T3-E1 cell differentiation, including alkaline phosphatase activity, calcium deposition and osteopontin expression. LTA also inhibited osteoclast activation induced by receptor activator of nuclear factor-kappa B ligand. We identified six molecules that may be associated with LTA-accelerated bone healing: monocyte chemoattractant protein 1, chemokine (C-X-C motif) ligand 1, cystatin C, growth/differentiation factor 15, endostatin and neutrophil gelatinase-associated lipocalin. Finally, double-fluorochrome, dynamic-labeling data indicated that LTA significantly enhanced bone-formation rates in vivo. In conclusion, our findings suggest that LTA has promising bone-regeneration properties.

Epidemiology, Clinical Assessments, and Current Treatments of Nonunions

PURPOSE OF REVIEW

The failure of bony union following a fracture, termed a fracture nonunion, has severe patient morbidity and economic consequences. This review describes current consensuses and future directions of investigation for determining why, detecting when, and effective treatment if this complication occurs.

RECENT FINDINGS

Current nonunion investigation is emphasizing an expanded understanding of the biology of healing. This has led to assessments of the immune environment, multiple cytokines and morphogenetic factors, and the role of skeletogenic stem cells in the development of nonunion. Detecting biological markers and other objective diagnostic criteria is also a current objective of nonunion research. Treatment approaches in the near future will likely be dominated by the development of specific adjunct therapies to the nonunion surgical management, which will be informed by an expanded mechanistic understanding of nonunion biology. Current consensus among orthopedists is that improved diagnosis and treatment of nonunion hinges first on discoveries at the bench side with later translation to the clinic.

Imaging Modalities to Assess Fracture Healing

PURPOSE OF REVIEW

This review discusses imaging modalities for fracture repair assessment, with an emphasis on pragmatic clinical and translational use, best practices for implementation, and challenges and opportunities for continuing research.

RECENT FINDINGS

Semiquantitative radiographic union scoring remains the clinical gold standard, but has questionable reliability as a surrogate indicator of structural bone healing, particularly in early-stage, complex, or compromised healing scenarios. Alternatively, computed tomography (CT) scanning enables quantitative assessment of callus morphometry and mechanics through the use of patient-specific finite-element models. Dual-energy X-ray absorptiometry (DXA) scanning and radiostereometric analysis (RSA) are also quantitative, but technically challenging. Nonionizing magnetic resonance (MR) and ultrasound imaging are of high interest, but require development to enable quantification of 3D mineralized structures. Emerging image-based methods for quantitative assessment of bone healing may transform clinical research design by displacing binary outcomes classification (union/nonunion) and ultimately enhance clinical care by enabling early nonunion detection.