Low-intensity pulsed ultrasound for treatment of tibial fractures: an economic evaluation of the TRUST study

Opioid reduction and enhanced recovery in orthopaedic surgery (OREOS): a protocol for a feasibility randomised controlled trial in patients undergoing total knee arthroplasty

BACKGROUND

Knee arthritis is a leading cause of limited function and long-term disability in older adults. Despite a technically successful total knee arthroplasty (TKA), around 20% of patients continue to have persisting pain with reduced function, and low quality of life. Many of them continue using opioids for pain control, which puts them at risk for potential long-term adverse effects such as dependence, overdose and risk of falls. Although persisting pain and opioid use after TKA have been recognised to be important issues, individual strategies to decrease their burden have limitations and multi-component interventions, despite their potential, have not been well studied. In this study, we propose a multi-component pathway including personalized pain management, facilitated by a pain management coordinator. The objectives of this pilot trial are to evaluate feasibility (recruitment, retention, and adherence), along with opioid-free pain control at 8 weeks after TKA.

METHODS

This is a protocol for a multicentre pilot randomised controlled trial using a 2-arm parallel group design. Adult participants undergoing unilateral total knee arthroplasty will be considered for inclusion and randomised to control and intervention groups. Participants in the intervention group will receive support from a pain management coordinator who will facilitate a multicomponent pain management pathway including (1) preoperative education on pain and opioid use, (2) preoperative risk identification and mitigation, (3) personalized post-discharge analgesic prescriptions and (4) continued support for pain control and recovery up to 8 weeks post-op. Participants in the control group will undergo usual care. The primary outcomes of this pilot trial are to assess the feasibility of participant recruitment, retention, and adherence to the interventions, and key secondary outcomes are persisting pain and opioid use.

DISCUSSION

The results of this trial will determine the feasibility of conducting a definitive trial for the implementation of a multicomponent pain pathway to improve pain control and reduce harms using a coordinated approach, while keeping an emphasis on patient centred care and shared decision making.

TRIAL REGISTRATION

Prospectively registered in Clinicaltrials.gov (NCT04968132).

Cost analysis of photobiomodulation in tibia fracture in the Brazilian public health system

Managing tibial fractures requires substantial health resources, which costs the health system. This study aimed to describe the costs of photobiomodulation (PBM) with LEDs in the healing process of soft tissue lesions associated with tibial fracture compared to a placebo. Economic analysis was performed based on a randomized controlled clinical trial, with a simulation of the cost-effectiveness and incremental cost model. Adults (n = 27) hospitalized with tibia fracture awaiting definitive surgery were randomized into two distinct groups: the PBM Group (n = 13) and the Control Group with simulated phototherapy (n = 14). To simulate the cost-effectiveness and incremental cost model, the outcome was the evolution of wound resolution by the BATES-JENSEN scale and time of wound resolution in days. The total cost of treatment for the Control group was R$21,164.56, and a difference of R$7,527.10 more was observed when compared to the treatment of the PBM group. The proposed intervention did not present incremental cost since the difference in the costs to reduce measures between the groups was smaller for the PBM group. When analyzing the ICER (Incremental cost-effectiveness ratio), it would be possible to save R$3,500.98 with PBM and decrease by 2.15 points in the daily average on the BATES-JENSEN scale. It is concluded, therefore, that PBM can be a supportive therapy of clinical and economic interest in a hospital setting.

Osteogenesis Stimulator Devices Reduce Surgical Intervention, Opioid Utilization, and Overall Costs in Patients with Fracture Nonunions

Background

Approximately 10% of fractures result in delayed union or nonunion. These cases result in pain and disability as well as increased utilization of healthcare resources such as pain medication, physical therapy, and subsequent surgery. Osteogenesis stimulator devices are a safe and low-cost, non-invasive option to aid healing in nonunion cases.

Objective

Study objectives aimed to evaluate real-world data of osteogenesis stimulator device usage in a variety of healthcare utilization endpoints including surgical intervention for nonunion, pain medication use, and overall healthcare costs. Data were stratified into three groups: the Stim Device group and the No Stim and Surgical control groups.

Methods

A retrospective analysis of a large claims-based database was conducted. The database was queried for adult patients having a diagnosis of nonunion, with evidence of a prior fracture in the previous 180 days (n = 11,010). The osteogenesis stimulator group (Stim Device group, n = 1,628) was defined as those patients having at least one claim for an osteogenesis stimulator in the period 90 to 180 days following fracture and up to 60 days following the nonunion diagnosis. The control group (No Stim group, n = 9,382) had a nonunion diagnosis with evidence of a fracture in the prior 180 days but did not receive a device. A total of 1,751 patients from the No Stim group were sub-grouped into surgical/operative controls (No Stim - Surgical group).

Results

Stim Device patients showed lower rates of surgical intervention for their bone nonunion compared to the No Stim patients (214/1,628, 13.1% vs. 1,751/9,382, 18.7%, p < 0.001). Stim Device patients had lower rates of opioid utilization post-index compared to No Stim patients (948/1,628, 58.2% vs. 6,359/9,382, 67.8%, p < 0.001). Overall healthcare costs were significantly reduced in the Stim Device group ($21,654) compared with No Stim ($29,101; p < 0.001) and Surgical ($35,914; p < 0.001) control groups.

Conclusion

The results show that bone growth stimulator devices have a positive individual and societal impact on treating patients with fracture nonunions.

Ultrasound and shockwave therapy for acute fractures in adults

BACKGROUND

The morbidity and socioeconomic costs of fractures are considerable. The length of time to healing is an important factor in determining a person's recovery after a fracture. Ultrasound may have a therapeutic role in reducing the time to union after fracture by stimulating osteoblasts and other bone-forming proteins. This is an update of a review previously published in February 2014.   OBJECTIVES: To assess the effects of low-intensity ultrasound (LIPUS), high-intensity focused ultrasound (HIFUS) and extracorporeal shockwave therapies (ECSW) as part of the treatment of acute fractures in adults.  SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase (1980 to March 2022), Orthopaedic Proceedings, trial registers and reference lists of articles.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs including participants over 18 years of age with acute fractures (complete or stress fractures) treated with either LIPUS, HIFUS or ECSW versus a control or placebo-control.

DATA COLLECTION AND ANALYSIS

We used standard methodology expected by Cochrane. We collected data for the following critical outcomes: participant-reported quality of life, quantitative functional improvement, time to return to normal activities, time to fracture union, pain, delayed or non-union of fracture. We also collected data for treatment-related adverse events. We collected data in the short term (up to three months after surgery) and in the medium term (later than three months after surgery).   MAIN RESULTS: We included 21 studies, involving 1543 fractures in 1517 participants; two studies were quasi-RCTs. Twenty studies tested LIPUS and one trial tested ECSW; no studies tested HIFUS. Four studies did not report any of the critical outcomes. All studies had unclear or high risk of bias in at least one domain. The certainty of the evidence was downgraded for imprecision, risk of bias and inconsistency. LIPUS versus control (20 studies, 1459 participants) We found very low-certainty evidence for the effect of LIPUS on Health-related quality of life (HRQoL) measured by SF-36 at up to one year after surgery for lower limb fractures (mean difference (MD) 0.06, 95% confidence interval (CI) -3.85 to 3.97, favours LIPUS; 3 studies, 393 participants). This result was compatible with a clinically important difference of 3 units with both LIPUS or control. There may be little to no difference in time to return to work after people had complete fractures of the upper or lower limbs (MD 1.96 days, 95% CI -2.13 to 6.04, favours control; 2 studies, 370 participants; low-certainty evidence).  There is probably little or no difference in delayed union or non-union up to 12 months after surgery (RR 1.25, 95% CI 0.50 to 3.09, favours control; 7 studies, 746 participants; moderate-certainty evidence). Although data for delayed and non-union included both upper and lower limbs, we noted that there were no incidences of delayed or non-union in upper limb fractures. We did not pool data for time to fracture union (11 studies, 887 participants; very low-certainty evidence) because of substantial statistical heterogeneity which we could not explain. In upper limb fractures, MDs ranged from 0.32 to 40 fewer days to fracture union with LIPUS. In lower limb fractures, MDs ranged from 88 fewer days to 30 more days to fracture union. We also did not pool data for pain experienced at one month after surgery in people with upper limb fractures (2 studies, 148 participants; very low-certainty evidence) because of substantial unexplained statistical heterogeneity. Using a 10-point visual analogue scale, one study reported less pain with LIPUS (MD -1.7, 95% CI -3.03 to -0.37; 47 participants), and the effect was less precise in the other study (MD -0.4, 95% CI -0.61 to 0.53; 101 participants). We found little or no difference in skin irritation (a possible treatment-related adverse event) between groups but judged the certainty of the evidence from this small study to be very low (RR 0.94, 95% CI 0.06 to 14.65; 1 study, 101 participants). No studies reported data for functional recovery. Data for treatment adherence were inconsistently reported across studies, but was generally described to be good. Data for costs were reported for one study, with higher direct costs, as well as combined direct and indirect costs, for LIPUS use. ECSW versus control (1 study, 56 participants) We are uncertain whether ECSW reduces pain at 12 months after surgery in fractures of the lower limb (MD -0.62, 95% CI -0.97 to -0.27, favours ECSW); the difference between pain scores was unlikely to be clinically important, and the certainty of the evidence was very low. We are also uncertain of the effect of ECSW on delayed or non-union at 12 months because the certainty of this evidence is very low (RR 0.56, 95% CI 0.15 to 2.01; 1 study, 57 participants). There were no treatment-related adverse events. This study reported no data for HRQoL, functional recovery, time to return to normal activities, or time to fracture union. In addition, no data were available for adherence or cost.

AUTHORS' CONCLUSIONS

We were uncertain of the effectiveness of ultrasound and shock wave therapy for acute fractures in terms of patient-reported outcome measures (PROMS), for which few studies reported data. It is probable that LIPUS makes little or no difference to delayed union or non-union. Future trials should be double-blind, randomised, placebo-controlled trials recording validated PROMs and following up all trial participants. Whilst time to union is difficult to measure, the proportion of participants achieving clinical and radiographic union at each follow-up point should be ascertained, alongside adherence with the study protocol and cost of treatment in order to better inform clinical practice.

Review on experimental study and clinical application of low-intensity pulsed ultrasound in inflammation

Low-intensity pulsed ultrasound (LIPUS), as physical therapy, is widely used in both research and clinical settings. It induces multiple bioeffects, such as alleviating pain, promoting tissue repair, and shortening disease duration. LIPUS can also mediate inflammation. This paper reviews the application of LIPUS in inflammation and discusses the underlying mechanism. In basic experiments, LIPUS can regulate inflammatory responses at the cellular level by affecting some signaling pathways. In a clinical trial, LIPUS has been shown to alleviate inflammatory responses efficiently. As a cheap, safe, and convenient physical method, LIPUS is promising as anti-inflammatory therapy.

Ultrasound Therapy: Experiences and Perspectives for Regenerative Medicine

Ultrasound has emerged as a novel tool for clinical applications, particularly in the context of regenerative medicine. Due to its unique physico-mechanical properties, low-intensity ultrasound (LIUS) has been approved for accelerated fracture healing and for the treatment of established non-union, but its utility has extended beyond tissue engineering to other fields, including cell regeneration. Cells and tissues respond to acoustic ultrasound by switching on genetic repair circuits, triggering a cascade of molecular signals that promote cell proliferation, adhesion, migration, differentiation, and extracellular matrix production. LIUS also induces angiogenesis and tissue regeneration and has anti-inflammatory and anti-degenerative effects. Accordingly, the potential application of ultrasound for tissue repair/regeneration has been tested in several studies as a stand-alone treatment and, more recently, as an adjunct to cell-based therapies. For example, ultrasound has been proposed to improve stem cell homing to target tissues due to its ability to create a transitional and local gradient of cytokines and chemokines. In this review, we provide an overview of the many applications of ultrasound in clinical medicine, with a focus on its value as an adjunct to cell-based interventions. Finally, we discuss the various preclinical and clinical studies that have investigated the potential of ultrasound for regenerative medicine.

The top three unanswered questions in the management of open fractures

Despite improvements in treatment strategies and emphasis on preventative measures, the management of open fractures continues to be a challenging endeavor for orthopaedic surgeons. Deep infections, delayed healing, and nonunion continue to be problematic complications associated with these devastating injuries. There remain many unanswered clinical questions regarding the management of these injuries and how the various aspects of care can be further optimized. There continues to be a paucity of evidence regarding how infection can best be treated and prevented, how to reliability predict bone healing/nonunion, and how bone healing can be best augmented in the setting of open fractures and their potential nonunions. This review aims to assess the current literature on these top unanswered questions and discuss the gaps in evidence that may be filled with future studies.

Topical cutaneous application of carbon dioxide via a hydrogel for improved fracture repair: results of phase I clinical safety trial

Background

Clinicians have very limited options to improve fracture repair. Therefore, it is critical to develop a new clinically available therapeutic option to assist fracture repair biologically. We previously reported that the topical cutaneous application of carbon dioxide (CO₂) via a CO₂ absorption-enhancing hydrogel accelerates fracture repair in rats by increasing blood flow and angiogenesis and promoting endochondral ossification. The aim of this study was to assess the safety and efficacy of CO₂ therapy in patients with fractures.

Methods

Patients with fractures of the femur and tibia were prospectively enrolled into this study with ethical approval and informed consent. The CO₂ absorption-enhancing hydrogel was applied to the fractured lower limbs of patients, and then 100% CO₂ was administered daily into a sealed space for 20 min over 4 weeks postoperatively. Safety was assessed based on vital signs, blood parameters, adverse events, and arterial and expired gas analyses. As the efficacy outcome, blood flow at the level of the fracture site and at a site 5 cm from the fracture in the affected limb was measured using a laser Doppler blood flow meter.

Results

Nineteen patients were subjected to complete analysis. No adverse events were observed. Arterial and expired gas analyses revealed no adverse systemic effects including hypercapnia. The mean ratio of blood flow 20 min after CO₂ therapy compared with the pre-treatment level increased by approximately 2-fold in a time-dependent manner.

Conclusions

The findings of the present study revealed that CO₂ therapy is safe to apply to human patients and that it can enhance blood flow in the fractured limbs.

Trial registration

This study has been registered in the UMIN Clinical Trials Registry (Registration number: UMIN000013641, Date of registration: July 1, 2014).

Regulation of exosomes secretion by low-intensity pulsed ultrasound in lung cancer cells

Low-intensity pulsed ultrasound (LIPUS) is a noninvasive therapeutic method which gradually being used in clinic including cancers. Exosomes mediate intercellular communication functions in disease development and the potential clinical applications in diagnosis and therapy. However, few studies have discussed the relationship between LIPUS and exosomes. Herein, we show that low intensity (0.6-2.1 W/cm² or 0.6-3.4 W/cm²) LIPUS promoted exosomes secretion whereas higher intensity (3.4-5.0 W/cm² or 5.0 W/cm²) LIPUS inhibited exosomes secretion, and this phenomenon is associated with autophagy. Pretreatment with 3-MA or down-regulation of LC3 potentiated low intensity LIPUS's promotion of exosomes secretion and conferred resistance to higher intensity LIPUS's effects on exosomes secretion. Furthermore, pretreatment with PP242 attenuated LIPUS-influenced exosomes secretion while expression of constitutively active Akt (Ad-myr-Akt) elevated LIPUS-influenced exosomes secretion, implying mTOR-dependent mechanism involved. The findings indicate that LIPUS influences exosomes secretion by targeting mTOR-mediated LC3 signaling in SPC-A1 and SPC-A1-BM cells. Our data provided initial evidence to connect LIPUS and secretion of exosomes, and highlight that LIPUS may be exploited in exosome-related diseases.

A consensus exercise identifying priorities for research into clinical effectiveness among children's orthopaedic surgeons in the United Kingdom

Aims

High-quality clinical research in children's orthopaedic surgery has lagged behind other surgical subspecialties. This study used a consensus-based approach to identify research priorities for clinical trials in children's orthopaedics.

Methods

A modified Delphi technique was used, which involved an initial scoping survey, a two-round Delphi process and an expert panel formed of members of the British Society of Children's Orthopaedic Surgery. The survey was conducted amongst orthopaedic surgeons treating children in the United Kingdom and Ireland.

Results

A total of 86 clinicians contributed to both rounds of the Delphi process, scoring priorities from one (low priority) to five (high priority). Elective topics were ranked higher than those relating to trauma, with the top ten elective research questions scoring higher than the top question for trauma. Ten elective, and five trauma research priorities were identified, with the three highest ranked questions relating to the treatment of slipped capital femoral epiphysis (mean score 4.6/ 5), Perthes' disease (4.5) and bone infection (4.5).

Conclusion

This consensus-based research agenda will guide surgeons, academics and funders to improve the evidence in children's orthopaedic surgery and encourage the development of multicentre clinical trials. Cite this article: Bone Joint J 2018;100-B:680-4.

Effect of Low-Frequency Pulsed Ultrasound on Drug Delivery, Antibacterial Efficacy, and Bone Cement Degradation in Vancomycin-Loaded Calcium Phosphate Cement

Background

Calcium phosphate cement (CPC) has been applied as a biodegradable antibiotic carrier in osteomyelitis. However, the drug delivery, antibacterial efficacy, and degradation rate of CPC are insufficient and require further improvement in clinical application.

Material/Methods

Vancomycin-loaded CPC columns were prepared, and eluted in simulated body fluid. The drug delivery was assessed in the ultrasound group and control group by fluorescence polarization immunoassay. The antibacterial efficacy of vancomycin in the ultrasound group and control groups was investigated by standard plate count method. Low-frequency pulsed ultrasound (46.5 kHz, 900 mW/cm²) was used to produce a sinusoidal wave in the ultrasound groups. The percentage of residual weight was evaluated to assess the degradation of CPC.

Results

The concentration and cumulatively released percentage of vancomycin in the ultrasound group were higher than that in the control group at each time point (p<0.05). The duration of vancomycin concentration over the level of minimum inhibitory concentration was significantly prolonged in the ultrasound group (p<0.05). Antibacterial efficacy of vancomycin in the ultrasound group was significantly greater than that in the control group with same concentration of vancomycin (p<0.05). The percentage of residual weight in the ultrasound group was significantly less than that in the control group (p<0.05).

Conclusions

Low-frequency pulsed ultrasound can enhance vancomycin release, prolong the duration of vancomycin concentration at high levels, and accelerate the degradation rate of vancomycin-loaded CPC.