Development of a prognostic naive bayesian classifier for successful treatment of nonunions

Callus formation and bone remodeling in a tibial nonunion after minimal invasive percutaneous screw fixation followed by extracorporeal shockwave therapy 17-months after initial trauma - A case report

INTRODUCTION

The treatment of tibial nonunion is challenging and treatment may be conservative or surgical. Conservative strategies include functional braces and weight bearing, or focused extracorporeal shockwave therapy (fESWT).

CASE DESCRIPTION

A 45-year-old male patient sustained spiral tibial shaft fractures and was treated surgically within 24 hours after the initial accident with intramedullary nails. The tibial fracture was later classified as nonunion after 11 months. Radiologic evaluation 17 months after the initial trauma demonstrated clinical nonunion, and subsequently the patient was offered a conservative approach with fESWT to facilitate an increase in callus formation. The handpiece was fitted with a stand-off II (long), penetration depth of 15 mm. Three cycles were administered in month 17, 19 and 20 after baseline. Each cycle consisted of three treatments sessions spaced with 6-8 days apart, and consisted of 3000 to 4000 impulses each given at 0.25-0.84 mJ/mm2. The number of impulses and the power at the focus point varied according to the pain response.

OUTCOMES

The patient achieved union 23 months after fracture. A clinical important improvement was observed with both Lower Extremity Functional Scale (LEFS) (18-point difference) and Patient Specific Functional Scale (PSFS) (average: 4.7 points,) The "worst pain last 24 hours" was reduced by 5 points. These values express minimal clinically important difference (MCID) values in these functional patient-reported outcome measures.

CONCLUSION

This treatment strategy may be viable in a broader setting, including private practice physiotherapy thereby treating the patient in close proximity to the patient's everyday life.

Treatment of delayed union of the forearm with extracorporeal shockwave therapy: a case report and literature review

Compared to other long bones, forearm fractures are particularly challenging due to the high rate of complications. These include malunion, delayed/nonunion, wrist and elbow movement reduction, and pain. Surgical procedure is considered the gold standard for managing delayed union and nonunion of the long bones. However, in the last decades, extracorporeal shockwave therapy (ESWT) has emerged as an effective and less invasive approach to enhance bone regeneration and fracture healing, avoiding major complications of surgical procedures. In contrast to the broad literature reporting good clinical results of ESWT in the treatment of nonunions, there is currently limited evidence regarding the clinical application of shock waves on long bone delayed fractures, particularly those of the forearm. In the present paper, we report a case of delayed bone healing of the diaphyseal region of the ulna treated with focused ESWT. The successful case experienced bone healing at the fracture site in less than 3 months after initial ESWT treatment. Acknowledging the limitation of reporting a case report, however, the remarkable clinical results and the absence of side effects contribute valuable information in support of the use of ESWT as an effective alternative to standard surgery for forearm fractures.

Extracorporeal shock wave treatment for post‑surgical fracture nonunion: Insight into its mechanism, efficacy, safety and prognostic factors (Review)

Post-surgical fracture nonunion (PSFN) represents the failure to achieve cortical continuity at radiological examination after an orthopedic operation, which causes a considerable disease burden in patients with fractures. As one of the traditional treatment modalities, surgical therapy is associated with a high fracture union rate; however, post-surgical complications are not negligible. Therefore, less invasive therapies are needed to improve the prognosis of patients with PSFN. Extracorporeal shock wave treatment (ESWT) is a noninvasive method that presents a similar efficacy profile and favorable safety profile compared with surgical treatment. However, the application and detailed mechanism of ESWT in patients with PSFN remain unclear. The present review focuses on the mechanism, efficacy, safety and prognostic factors of ESWT in patients with PSFN, aiming to provide a theoretical basis for its application and improve the prognosis of these patients.

Applications of artificial intelligence in orthopaedic surgery

The practice of medicine is rapidly transforming as a result of technological breakthroughs. Artificial intelligence (AI) systems are becoming more and more relevant in medicine and orthopaedic surgery as a result of the nearly exponential growth in computer processing power, cloud based computing, and development, and refining of medical-task specific software algorithms. Because of the extensive role of technologies such as medical imaging that bring high sensitivity, specificity, and positive/negative prognostic value to management of orthopaedic disorders, the field is particularly ripe for the application of machine-based integration of imaging studies, among other applications. Through this review, we seek to promote awareness in the orthopaedics community of the current accomplishments and projected uses of AI and ML as described in the literature. We summarize the current state of the art in the use of ML and AI in five key orthopaedic disciplines: joint reconstruction, spine, orthopaedic oncology, trauma, and sports medicine.

Extracorporeal Shockwave Therapy in the Treatment of Nonunion in Long Bones: A Systematic Review and Meta-Analysis

Background: Nonunion is one of the most challenging problems in the field of orthopedics. The aim of this study was to perform a systematic review of the literature to evaluate the effectiveness of extracorporeal shockwave therapy (ESWT) in the treatment of nonunion in long bones. Methods: We conducted a search of three databases (PubMed, Scopus, and Web of Science) and found 646 total publications, of which 23 met our inclusion criteria. Results: Out of 1200 total long bone nonunions, 876 (73%) healed after being treated with ESWT. Hypertrophic cases achieved 3-fold higher healing rates when compared to oligotrophic or atrophic cases (p = 0.003). Metatarsal bones were the most receptive to ESWT, achieving a healing rate of 90%, followed by tibiae (75.54%), femurs (66.9%) and humeri (63.9%). Short periods between injury and treatment lead to higher healing rates (p < 0.02). Conversely, 6 months of follow-up after the treatment appears to be too brief to evaluate the full healing potential of the treatment; several studies showed that healing rates continued to increase at follow-ups beyond 6 months after the last ESWT treatment (p < 0.01). Conclusions: ESWT is a promising approach for treating nonunions. At present, a wide range of treatment protocols are used, and more research is needed to determine which protocols are the most effective.

Addition of shock wave therapy to nail dynamization increases the chance of long-bone non-union healing

Background

Long-bone non-unions after intramedullary nailing can be treated by nail dynamization or focused high-energy extracorporal shock wave therapy (fESWT). The objective of this study was to assess the effect of the combination therapy of nail dynamization and fESWT on long-bone non-unions.

Materials and methods

49 patients with long-bone non-unions (femur and tibia) after nailing were treated with nail dynamization (group D, n = 15), fESWT (group S, n = 17) or nail dynamization in addition to fESWT (group DS, n = 17). Patients were followed up for 6 months retrospectively. Furthermore, age, sex, Non-Union Scoring System (NUSS) score, time intervals from primary and last surgery until intervention and smoking status were analysed for their correlations to bone union.

Results

Union rates were 60% for group D, 64.7% for group S and 88.2% for group DS, with a significant difference between group D and DS (p = 0.024). Successful treatment was correlated with high age (OR 1.131; 95% CI 1.009–1.268; p = 0.034), female gender (OR 0.009; 95% CI 0.000–0.89; p = 0.039), low NUSS score (OR 0.839; 95% CI 0.717–0.081; p = 0.028) and negative smoking status (OR 86.018; 95% CI 3.051–2425.038; p = 0.009).

Conclusions

Data from the present study indicate that the combination therapy of nail dynamization and fESWT leads to a higher union rate than dynamization or fESWT alone.

Level of evidence

Level 3.

The role of shockwaves in the enhancement of bone repair - from basic principles to clinical application

Extracorporeal shockwave therapy is a treatment modality, originally introduced into the clinic as lithotripsie, which has also been successfully used in the last two decades in the non-invasive treatment of delayed or non-healing fractures. Initially, the mechanism of action was attributed to microfracture-induced repair, but intensive basic research has now shown that the shockwave generates its effect in tissue via mechanotransduction. Numerous signal transduction pathways have already been demonstrated, which in their entirety trigger an endogenous regeneration process via cell proliferation, migration and differentiation. Clinically, these shockwave-conveyed biological signals support healing of acute, delayed and non-union fractures. The attainable outcome is comparable to surgery but avoiding an open approach with associated potential complications. These advantageous properties with a clearly positive cost-benefit ratio make shockwave therapy a first line treatment in delayed and non-union fractures.

[Extracorporeal magnetotransduction therapy (EMTT) and high-energetic focused extracorporeal shockwave therapy (ESWT) as bone stimulation therapy for metacarpal non-union - a case report]

This case report describes the combination of a high-energetic focused extracorporeal shockwave therapy (ESWT) with an extracorporeal magnetotransduction therapy (EMTT) in the treatment of a non-union of the metacarpal V improving bone healing within six weeks.

Biomedical research models in the science of fracture healing - Pitfalls & promises

Development of intervention strategies to stimulate fracture healing has long been a focus of musculoskeletal research. Considerable investment in empirical research has led to the discovery of several genes and signaling pathways that are involved in skeletal development and regeneration. However, there are currently very few biologic interventions that can efficiently be used to enhance fracture healing in clinical practice. This translational barrier is due in part to experimental barriers to mechanism discovery. Animal models, biomechanical models, finite element models, and mathematical models are a few examples of models that aid in the discovery of mechanisms. Understanding the advantages, limitations, and specialized uses of each model type is critical to our ability to interpret mechanistic insights from such research and to help bridge the translation gap between pre-clinical research and clinical practice. In this review, we look at specific modeling methods used in the study of the fracture healing mechanism. We also discuss the strength and limitations to translation of each method, hopefully leading to a better understanding of how we can use models to advance the study of fracture healing.

Extracorporal shock wave therapy for the treatment of arthrodesis non-unions

INTRODUCTION

Non-union is a regular complication of arthrodeses. Standard treatment includes revision surgery with frequent need for re-revision due to persistent non-union. Particularly patients with concomitant diseases are at risk of secondary complications. There is a need for evaluation of alternative treatment options. The aim of this study is to provide first evidence on union-rate and pain course after focussed extracorporeal shock-wave therapy of arthrodesis non-unions.

PATIENTS AND METHODS

In a retrospective single-centre study, 25 patients with non-union following arthrodesis received one session of focussed extracorporeal shock-wave therapy (energy flux density 0.36 mJ/mm², 3000 impulses, 23 kV, 4 Hz). Radiographic and clinical results were recorded 6, 12 and 24 weeks after treatment.

RESULTS

24 patients were followed-up. After 24 weeks arthrodeses of the hand healed in 80%, of the upper ankle in 50%, of subtalar joint in 27.2% and of the midfoot in 0% of the cases. Pain decreased from 4.8 (± 2.8) points on the visual analogue scale to 3.4 (± 2.3), 2.9 (± 2.5) and 2.4 (± 2.8) points after 6, 12 and 24 weeks, respectively (p < 0.0001).

CONCLUSION

Our data indicate that the effect of focussed, high-energy shock wave therapy depends on body region and is effective for the treatment of non-unions of the hand as well as for pain relief.

LEVEL OF EVIDENCE

Level IV.

Extracorporeal shock wave therapy accelerates endochondral ossification and fracture healing in a rat femur delayed-union model

Extracorporeal shock wave therapy (ESWT) has been demonstrated to accelerate bone healing; however, the mechanism underlying ESWT-induced bone regeneration has not been fully elucidated. This study aimed to examine the effects of ESWT and the process of fracture healing. A rat model of femur delayed-union was established by cauterizing the periosteum. ESWT treatment at the fracture site was performed 2 weeks after the operation and the site was radiographically and histologically evaluated at weeks 4, 6, and 8. The bone union rate and radiographic score of the ESWT group were significantly higher than those of the control group at 8 weeks. Histological evaluation revealed enhanced endochondral ossification at the fracture site. The effects of ESWT on ATDC5 cells were examined in vitro. ESWT promoted chondrogenic differentiation without inhibiting the proliferation of ATDC5 cells. ESWT may induce significant bone healing by promoting endochondral ossification at the fracture site.

The effects of shockwave therapy on musculoskeletal conditions based on changes in imaging: a systematic review and meta-analysis with meta-regression

BACKGROUND

Shockwave therapy (SWT) is a commonly used intervention for a number of musculoskeletal conditions with varying clinical outcomes. However, the capacity of SWT to influence pathophysiological processes and the morphology of affected tissues remains unclear. The objective of the current review is to evaluate changes in imaging outcomes of musculoskeletal conditions following SWT.

METHODS

A comprehensive search of Medline, Embase, Cochrane Controlled Trials Register, CINAHL and SportDiscus was conducted from inception to October 2018. Prospective clinical trials evaluating the effectiveness of SWT based on changes in imaging outcomes were eligible for inclusion. Articles were evaluated independently for risk of bias using the Cochrane Risk of Bias list and the Methodological Index for Non-Randomized Studies. Random-effects meta-analysis and meta-regression with a priori determined covariates was conducted for each condition to determine potential predictors of SWT effects.

RESULTS

Sixty-three studies were included, with data from 27 studies available for effect size pooling. Meta-analyses and meta-regression on imaging outcomes were performed for rotator cuff calcific tendinitis (n = 11), plantar fasciitis (n = 7) and osteonecrosis of the femoral head (n = 9). There was an overall reduction in the size of measured lesion following SWT (MD 8.44 mm (95%CI -4.30, 12.57), p < 0.001) for calcium deposit diameter, (MD 0.92 mm (95%CI -0.03, 1.81), p = 0.04) for plantar fascia thickness and (MD 4.84% (95%CI -0.06, 9.75), p = 0.05) for lesion size in femoral head osteonecrosis. Meta-regression showed no influence of SWT dosage parameters, however, baseline lesion size was an independent predictor for changes in imaging outcomes.

CONCLUSIONS

SWT altered the morphology of musculoskeletal conditions, potentially reflecting changes in underlying pathophysiological processes. The parameters of SWT dosage are not significant predictors of changes in imaging outcomes. Lack of adequate reporting of imaging outcomes limited the conclusions that could be drawn from the current review. Registration number: PROSPERO CRD42018091140.

Prediction of mortality at one year after surgery for pertrochanteric fracture in the elderly via a Bayesian belief network

BACKGROUND

Pertrochanteric fractures in the elderly are common and associated with considerable mortality and disability. However, the predictors of the fracture mortality have been somewhat controversial. The aim of this study was to use univariate, multivariate analyses and a Bayesian belief network (BBN) model, which are graphic and intuitive to the clinician, to understand of the prognosis of pertrochanteric fractures.

METHODS

Records of patients undergoing surgery at our hospital between January 2013 and June 2018 were retrospectively reviewed. Univariate and multivariate regression as well as a machine-learned BBN model were used to estimate mortality at one year after surgery for pertrochanteric fracture in the elderly.

RESULTS

Complete data were available for 448 surgically treated patients who were followed up for 12 months (age ≥60 years). Multivariate regression analysis revealed that hypertension, diabetes mellitus, chronic obstructive pulmonary disease, albumin, serum potassium, blood urea nitrogen and blood lactate were independent risk factors for death in surgical treatment patients (P < 0.05). First-degree predictors of mortality following surgery were established: the number of comorbid diseases, serum albumin, blood lactate and blood urea nitrogen. Following cross-validation, the area under the ROC curve was 0.85 (95% CI: 0.76-0.91) for the one-year probability of postoperative mortality.

CONCLUSION

We believe cohesive models such as the Bayesian belief network can be useful as clinical decision-support tools and provide clinicians with information to the treatment of old pertrochanteric fracture. This method warrants further development and must be externally validated in other patient populations.

Artificial Intelligence and Machine Learning: A New Disruptive Force in Orthopaedics

Orthopaedics as a surgical discipline requires a combination of good clinical acumen, good surgical skill, a reasonable physical strength and most of all, good understanding of technology. The last few decades have seen rapid adoption of new technologies into orthopaedic practice, power tools, new implants, CAD-CAM design, 3-D printing, additive manufacturing just to name a few. The new disruption in orthopaedics in the current time and era is undoubtedly the advent of artificial intelligence and robotics. As these technologies take root and innovative applications continue to be incorporated into the main-stream orthopedics, as we know it today, it is imperative to look at and understand the basics of artificial intelligence and what work is being done in the field today. This article takes the form of a loosely structured narrative review and will introduce the reader to key concepts in the field of artificial intelligence as well as some of the directions in application of the same in orthopaedics. Some of the recent work has been summarised and we present our viewpoint at the conclusion as to why we must consider artificial intelligence as a disrupting positive influence on orthopaedic surgery.

[Extracorporal shock wave therapy for the treatment of pseudarthrosis : New experiences with an old technology]

BACKGROUND

Between 5 and 10 % of all fractures show disturbed healing or nonunion formation. Extracorporeal shock wave therapy (ESWT) has been described as a non-surgical treatment option. Even though the outcome has shown promising results, the procedure is not commonly used in clinical practice. The purpose of this study was to analyze the union rate of pseudarthrosis and the cost savings after ESWT.

METHODS

In this study 42 nonunions were treated with shock waves (LithSpaceOrtho, JenaMedtech). The follow up examinations were performed over a period of six months. Outcome measurement included radiological fracture union and pain (VAS). The study group contained 39 pseudarthrosis in the six-week follow-up (93 %), 41 after three months (98 %) and 41 after six months (98 %).

RESULTS

After six weeks, 13 % of patients showed fracture union. After three months 61 % and after six months 73 % of the fractures were completely healed. The fracture healing was significantly lower in older nonunions. All patients presented significantly lower pain levels six weeks after ESWT. Shock wave treatment of all 42 pseudarthrosis made up less than one quarter of the overall operative costs.

CONCLUSION

We established the ESWT as an important treatment option for fracture nonunion in our clinic. Considering the selection of patients in this study with a high mean time from injury to ESWT and multiple prior operations, the fracture healing rate of 73 % after ESWT is comparable with operative healing rates of nonunions. Further prospective, randomized and controlled studies are needed to show the effectiveness of ESWT in the treatment of nonunions on a higher level of evidence and to identify pseudarthrosis that particularly responds to the EWST.

Extracorporeal Shock Wave Treatment for Delayed Union and Nonunion Fractures: A Systematic Review

OBJECTIVES

Nonunions after bone fractures are usually treated surgically with risk of infections and failure of osteosynthesis. A noninvasive alternative is extracorporeal shock wave treatment (ESWT), which potentially stimulates bone regeneration. Therefore this review investigates whether ESWT is an effective and safe treatment for delayed unions and nonunions.

DATA SOURCES

Embase.com, MEDLINE ovid, Cochrane, Web of Science, PubMed publisher, and Google Scholar were systematically searched.

STUDY SELECTION

Inclusion criteria included studies with patients with delayed union or nonunion treated with ESWT; inclusion of ≥10 patients; and follow-up period ≥6 weeks.

DATA EXTRACTION

Assessment for risk of bias was conducted by 2 authors using the Cochrane tool. Union rates and adverse events were extracted from the studies.

DATA SYNTHESIS

Two RCTs and 28 nonrandomized studies were included. One RCT was assessed at medium risk of bias and reported similar union rates between ESWT-treated patients (71%) and surgery-treated patients (74%). The remaining 29 studies were at high risk of bias due to poor description of randomization (n = 1), nonrandomized allocation to control groups (n = 2), or absence of control groups (n = 26). The average union rate after ESWT in delayed unions was 86%, in nonunions 73%, and in nonunions after surgery 81%. Only minor adverse events were reported after ESWT.

CONCLUSIONS

ESWT seems to be effective for the treatment of delayed unions and nonunions. However, the quality of most studies is poor. Therefore, we strongly encourage conducting well-designed RCTs to prove the effectiveness of ESWT and potentially improve the treatment of nonunions because ESWT might be as effective as surgery but safer.

LEVEL OF EVIDENCE

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

Radiographic union score for tibia fractures predicts success with operative treatment of tibial nonunion

BACKGROUND

The purpose of this study is to evaluate the ability of preoperative and postoperative radiographic union scores for tibia fractures (RUST) to predict treatment success of tibia fracture nonunion.

MATERIALS AND METHODS

Patients presenting for operative treatment of tibia fracture nonunion were enrolled in a prospective data registry. Enrolled patients were followed at regular intervals for 12 months. Preoperative and 12 week postoperative radiographs were reviewed and scored using the RUST criteria. Postoperative time to union was determined by clinical and radiographic measures. Multivariate regressions were conducted to predict time to union using preoperative and postoperative RUST while controlling for treatment method. Receiver operating characteristic (ROC) curve was conducted to determine the accuracy of preoperative RUST in predicting failure of treatment.

RESULTS

Sixty-eight patients with aseptic tibia fracture nonunion treated operatively were identified. Sixty-one patients achieved union. Mean preoperative RUST was 7.5 (SD 1.4). Mean postoperative RUST was 9.2 (SD 1.4). Multivariate linear regressions demonstrated that preoperative (p = 0.043) and postoperative (p = 0.007) RUST are significant predictors of time to union after tibia fracture nonunion surgery. ROC curve demonstrated preoperative RUST below 7 was a good predictor of developing persistent tibia fracture nonunion (AUC = 0.83, Sensitivity = 1.000, Specificity = 0.745).

CONCLUSIONS

RUST preoperatively and postoperatively predicts outcome after nonunion surgery. RUST can be used as part of the complete clinical picture to shape patient expectations and guide treatment.

A novel bimodal approach for treating atrophic bone non-unions with extracorporeal shockwaves and autologous mesenchymal stem cell transplant

We propose a novel approach for the treatment of atrophic bone non-unions via parallel applications of extracorporeal shock wave therapy (ESWT) and an autologous mesenchymal stem cell transplant. The hypothesis resides on the potentiality of shock waves (SWs) to act as a tool for manipulating the patient's mesenchymal stem cells (MSCs). In addition to the conventional physical stimulus achieved by delivering SWs at the site of non-union to stimulate the well-known trophic effects on bone tissue, a series of concomitant ESWT would be administered in tandem at a bone marrow donor site, such as the iliac crest, to precondition resident bone marrow stromal cells (BMSCs) in vivo, priming resident MSCs by enlarging and conditioning their population prior to bone marrow aspiration. The resulting sample could then be treated to further augment cell concentration and injected, under fluoroscopic control, into the non-union site through a percutaneous approach.

Radial extracorporeal shock wave therapy is efficient and safe in the treatment of fracture nonunions of superficial bones: a retrospective case series

BACKGROUND

A substantial body of evidence supports the use of focused extracorporeal shock wave therapy (fESWT) in the non-invasive treatment of fracture nonunions. On the other hand, virtually no studies exist on the use of radial extracorporeal shock wave therapy (rESWT) for this indication.

METHODS

We retrospectively analyzed 22 patients treated with rESWT for fracture nonunions of superficial bones that failed to heal despite initial surgical fixation in most cases. Radial extracorporeal shock wave therapy was applied without anesthesia in three rESWT sessions on average, with one rESWT session per week and 3000 radial extracorporeal shock waves at an energy flux density of 0.18 mJ/mm² per session. Treatment success was monitored with radiographs and clinical examinations.

RESULTS

Six months after rESWT radiographic union was confirmed in 16 out of 22 patients (73%), which is similar to the success rate achieved in comparable studies using fESWT. There were no side effects. The tibia was the most common treatment site (10/22) and 70% of tibia nonunions healed within 6 months after rESWT. Overall, successfully treated patients showed a mean time interval of 8.8 ± 0.8 (mean ± standard error of the mean) months between initial fracture and commencement of rESWT whereas in unsuccessfully treated patients the mean interval was 26.0 ± 10.1 months (p < 0.05). In unsuccessful tibia cases, the mean interval was 43.3 ± 13.9 months.

CONCLUSIONS

Radial extracorporeal shock wave therapy appears to be an effective and safe alternative in the management of fracture nonunions of superficial bones if diagnosed early and no fESWT device is available. The promising preliminary results of the present case series should encourage the implementation of randomized controlled trials for the early use of rESWT in fracture nonunions.

Prediction of Postoperative Clinical Recovery of Drop Foot Attributable to Lumbar Degenerative Diseases, via a Bayesian Network

BACKGROUND

Drop foot resulting from degenerative lumbar diseases can impair activities of daily living. Therefore, predictors of recovery of this symptom have been investigated using univariate or/and multivariate analyses. However, the conclusions have been somewhat controversial. Bayesian network models, which are graphic and intuitive to the clinician, may facilitate understanding of the prognosis of drop foot resulting from degenerative lumbar diseases.

QUESTIONS/PURPOSES

(1) To show a layered correlation among predictors of recovery from drop foot resulting from degenerative lumbar diseases; and (2) to develop support tools for clinical decisions to treat drop foot resulting from lumbar degenerative diseases.

METHODS

Between 1993 and 2013, we treated 141 patients with decompressive lumbar spine surgery who presented with drop foot attributable to degenerative diseases. Of those, 102 (72%) were included in this retrospective study because they had drop foot of recent development and had no diseases develop that affect evaluation of drop foot after surgery. Specifically, 28 (20%) patients could not be analyzed because their records were not available at a minimum of 2 years followup after surgery and 11 (8%) were lost owing to postoperative conditions that affect the muscle strength evaluation. Eight candidate variables were sex, age, herniated soft disc, duration of the neurologic injury (duration), preoperative tibialis anterior muscle strength (pretibialis anterior), leg pain, cauda equina syndrome, and number of involved levels. Manual muscle testing was used to assess the tibialis anterior muscle strength. Drop foot was defined as a tibialis anterior muscle strength score of less than 3 of 5 (5 = movement against gravity and full resistance, 4 = movement against gravity and moderate resistance, 3 = movement against gravity through full ROM, 3- = movement against gravity through partial ROM, 2 = movement with gravity eliminated through full ROM, 1 = slight contraction but no movement, and 0 = no contraction). The two outcomes of interest were postoperative tibialis anterior muscle strength (posttibialis anterior) of 3 or greater and posttibialis anterior strength of 4 or greater at 2 years after surgery. We developed two separate Bayesian network models with outcomes of interest for posttibialis anterior strength of 3 or greater and posttibialis anterior strength of 4 or greater. The two outcomes correspond to "good" and "excellent" results based on previous reports, respectively. Direct predictors are defined as variables that have the tail of the arrow connecting the outcome of interest, whereas indirect predictors are defined as variables that have the tail of the arrow connecting either direct predictors or other indirect predictors that have the tail of the arrow connecting direct predictors. Sevenfold cross validation and receiver-operating characteristic (ROC) curve analyses were performed to evaluate the accuracy and robustness of the Bayesian network models.

RESULTS

Both of our Bayesian network models showed that weaker muscle power before surgery (pretibialis anterior ≤ 1) and longer duration of neurologic injury before treatment (> 30 days) were associated with a decreased likelihood of return of function by 2 years. The models for posttibialis anterior muscle strength of 3 or greater and posttibialis anterior muscle strength of 4 or greater were the same in terms of the graphs, showing that the two direct predictors were pretibialis anterior muscle strength (score ≤ 1 or ≥ 2) and duration (≤ 30 days or > 30 days). Age, herniated soft disc, and leg pain were identified as indirect predictors. We developed a decision-support tool in which the clinician can enter pretibialis anterior muscle strength and duration, and from this obtain the probability estimates of posttibialis anterior muscle strength. The probability estimates of posttibialis anterior muscle strength of 3 or greater and posttibialis anterior muscle strength of 4 or greater were 94% and 85%, respectively, in the most-favorable conditions (pretibialis anterior ≥ 2; duration ≤ 30 days) and 18% and 14%, respectively, in the least-favorable conditions (pretibialis anterior ≤ 1; duration > 30 days). On the sevenfold cross validation, the area under the ROC curve yielded means of 0.78 (95% CI, 0.68-0.87) and 0.74 (95% CI, 0.64-0.84) for posttibialis anterior muscle strength of 3 or greater and posttibialis anterior muscle strength of 4 or greater, respectively.

CONCLUSIONS

The results of this study suggest that the clinician can understand intuitively the layered correlation among predictors by Bayesian network models. Based on the models, the decision-support tool successfully provided the probability estimates of posttibialis anterior muscle strength to treat drop foot attributable to lumbar degenerative diseases. These models were shown to be robust on the internal validation but should be externally validated in other populations.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Extracorporeal shockwave therapy (ESWT)--First choice treatment of fracture non-unions?

Fracture non-unions are still a challenging problem in orthopedics. The treatment of non-unions remains highly individualized, complex, and demanding. In most countries the surgical approach with debridement of the non-union gap, anatomical reduction and appropriate osteosynthesis along with autologous bone grafting is considered as the standard of care. One of the very first non-urologic applications of extracorporeal shockwave treatment (ESWT) concerned non-healing fractures. Since the early 1990ties the knowledge of the working mechanism has increased enormously. The purpose of this review article is to demonstrate by peer-reviewed literature in conjunction with our own experiences that ESWT can be an efficient, non-invasive, almost complication-free and cost effective alternative to surgical treatment of non-healing fractures.

Fracture healing: an appraisal of the effects of frequently prescribed medications

BACKGROUND

Recognizing the existence of adverse drug effects of frequently prescribed drugs can empower a clinician with knowledge to avoid dangerous adverse effects that may result in hazardous, negative patient outcomes on either fracture healing or bone health. Pharmacovigilance reports have described the influence of medications, allowing for bone health to be quite unpredictable.

METHODS

First, mechanisms found in the medical literature of potential drug adverse effects regarding fracture healing are presented. Second, the 100 most frequently prescribed medications in 2010 are reviewed regarding adverse effects on fracture healing. These reported adverse effects are evaluated for medical causation. Last, a data table describing the 100 reviewed medications and their reported effects on fracture healing is provided.

RESULTS

The actual number of different medications in the review was 72. Reported drug adverse effects on bone and fracture healing occurred with 59 of the 72 drugs (81.9%). These adverse effects are either described as a definitive statement or represented by postmarketing case reports. Thirteen of the 72 review drugs (18.1%) did not have any description of the possible effects on bone health. A total of 301 cases reports describing delayed union, malunion, and nonunion of fractures represent 31 of the 72 medications reviewed (43.1%).

CONCLUSIONS

This review offers the health-care provider information regarding potential adverse drug effects on bone health. Empowered with this information, clinicians may assist their patients in maximizing pharmacologic outcomes by avoiding these reported harmful adverse effects.

Extracorporeal shock wave therapy in musculoskeletal disorders: a review

Regenerative therapy is one of the most challenging and intriguing branches of modern medicine. Basic research has demonstrated the effectiveness of extracorporeal shockwaves (ESWT) in stimulating biological activities that involve intra-cell and cell-matrix interactions. These interactions are at the basis of the current clinical applications, and open the horizons to new applications in tissue regeneration. It is also feasible that shock waves could be used to treat various orthopaedic pathologies, removing the need for surgery. However, suitable translational studies need to be performed before ESWT can become a valid alternative to surgery.

Clinical application of extracorporeal shock wave therapy in orthopedics: focused versus unfocused shock waves

For the past decade extracorporeal shock wave therapy has been applied to a wide range of musculoskeletal disorders. The many promising results and the introduction of shock wave generators that are less expensive and easier to handle has added to the growing interest. Based on their nature of propagation, shock waves can be divided into two types: focused and unfocused. Although several physical differences between these different types of shock waves have been described, very little is known about the clinical outcome using these different modalities. The aim of the present review is to investigate differences in outcome in select orthopaedic applications using focused and unfocused shock waves.