Outcomes assessment in fracture healing trials: a primer

The methodology and interpretation of radiographic measures for malunion in proximal humerus fractures: a systematic review

BACKGROUND

Radiographic imaging is an essential tool for surgeons in classifying injury, guiding treatment decision-making, and assessing for adequate intraoperative reduction. However, the heterogeneity in radiographic outcome measures utilized in clinical studies evaluating proximal humerus fracture treatment has made it difficult for surgeons to interpret and analyze the available evidence, leading to continued controversy in the optimal management of these injuries. The aims of this systematic review are to 1) examine the literature to describe the methods for measuring and interpreting radiographic outcomes for malunion and 2) identify studies that have correlated functional outcome measures and radiographic outcome measures.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline, a systematic review of the literature was performed using EMBASE, MEDLINE, and the Cochrane Database of Systematic Reviews from inception to January 30, 2024. Outcomes of interest included radiographic outcome measures and functional outcome measures including pain assessment and range of motion measurements.

RESULTS

A total of 36 studies that used radiographic measures of alignment following treatment and union of proximal humerus fractures were identified. The most common measure was the head-shaft angle, utilized in 33 studies (92%). Tuberosity position was reported in 22 studies (61%). Only 21 studies (58%) provided a clear and reproducible technique for obtaining radiographic measures. The interpretation for radiographic malunion varied between studies. Varus malunion, using head-shaft angle measures, was defined as under 105° to under 130° in different studies. Although there is known variation between patients, only 3 studies utilized the imaging from the contralateral shoulder to define patient specific measures for malunion. Twenty-two studies assessed for an association between head-shaft angle malunion and patient functional outcome measures.

DISCUSSION AND CONCLUSION

Given the broad and inconsistent definition of malunion used between the included studies, there remains a lack of clear threshold for radiographic measures of alignment that surgeons can use in their clinical decision-making for proximal humerus fractures. Based on the evidence available, we propose a consistent definition of head-shaft angle measurement drawn from specified radiographic views, with varus malunion defined as <125° and valgus malunion >140°. To optimize the management and outcome of these fractures, radiographic outcomes must be standardized and correlated with function.

Extra-capsular proximal femoral fractures: a cohort comparison of union and complication rates after ballistic versus blunt trauma

PURPOSE

This study seeks to (1) describe the management of civilian ballistic extra-capsular proximal femur fractures (2) assess the rate of nonunion and complications and (3) compare the time to union of ballistic and blunt pertrochanteric femur fractures. Given the enhanced and widened extensive inflammatory response with ballistic trauma, we hypothesized that hip fractures from ballistic mechanisms would have faster times to union.

METHODS

Patients were included if they were skeletally mature with extra-capsular pertrochanteric femur fractures and radiographic and clinical follow-up of at least 6 months. Additional exclusion criteria included prior femur fractures and pathologic fractures. Orthopedic Trauma Association classification of all fractures was included. Union rate, time to union and complications were measured. Clinical union was defined as absence of pain with ambulation at the fracture site. Radiographic union was defined as mRUST ≥ 11. mRUST was measured at 6 weeks, 3 months and 6 months. Patients were included if they met study end points of a minimum of 6 months of follow-up, achieved union, or underwent revision surgery for nonunion.

RESULTS

52 fractures (23 ballistic, 29 blunt fractures) matched by age, BMI, sex, diabetes, and current smoking status were included in the study. 95.7% of the ballistic (22/23) and 100% of the blunt (29/29) fractures united. Average time to union was 90.5 days for the ballistic cohort and 114.9 days for the blunt cohort (p = 0.03). There were six additional complications: three broken interlocks, one varus malalignment, one superficial infection, and one infection requiring an antibiotic spacer.

CONCLUSION

In our series, we found the average time to union for ballistic pertrochanteric femur fractures was significantly less than that for blunt pertrochanteric femur fractures. There was no significant difference in complications or total nonunion. Overall, our study shows both subgroups achieved union in 3 months, which is less than previously reported. The time to union may be increased in the ballistic fractures by the enhanced and widened extensive inflammatory response or the blast effect may inoculate osteogenic material in to the soft tissues that enhances the healing process. This study demonstrates unique characteristics of ballistic fracture healing.

Low-Intensity Pulsed Ultrasound Versus Sham in the Treatment of Operatively Managed Scaphoid Nonunions: The SNAPU Randomized Controlled Trial

UPDATE

This article was updated on September 4, 2024 because of a previous error, which was discovered after the preliminary version of the article was posted online. In the Note listing the members of the Wrist and Elbow Research Group of Canada, the text that had read "Thomas T. Goetz, MD, FRCSC" now reads "Thomas J. Goetz, MD, FRCSC".

BACKGROUND

The primary goal after open reduction and internal fixation of an established scaphoid nonunion is to achieve union. Low-intensity pulsed ultrasound (LIPUS) has been reported to increase the rate of union and to decrease the time to union for multiple fractures and nonunions in clinical and animal models. The evidence for LIPUS in the treatment of scaphoid nonunion, however, is sparse. The aim of this study was to assess whether active LIPUS (relative to sham LIPUS) accelerates the time to union following surgery for scaphoid nonunion.

METHODS

Adults with a scaphoid nonunion indicated for surgery were recruited for a multicenter, prospective, double-blinded randomized controlled trial. After surgery, patients self-administered activated or sham LIPUS units beginning at their first postoperative visit. The primary outcome was the time to union on serial computed tomography (CT) scans starting 6 to 8 weeks postoperatively. Secondary outcomes included patient-reported outcome measures, range of motion, and grip strength.

RESULTS

A total of 142 subjects completed the study (69 in the active LIPUS group and 73 in the sham group). The average age was 27 years, and the cohort was 88% male. There was no difference in time to union (p = 0.854; hazard ratio, 0.965; 95% confidence interval, 0.663 to 1.405). Likewise, there were no differences between the active LIPUS and sham groups with respect to any of the secondary outcomes, except for wrist flexion at baseline (p = 0.008) and at final follow-up (p = 0.043).

CONCLUSIONS

Treatment with LIPUS had no effect on reducing time to union in patients who underwent surgical fixation of established scaphoid nonunions.

LEVEL OF EVIDENCE

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

Radiographic Union Assessment in Surgically Treated Distal Femur Fractures: A Systematic Review

BACKGROUND

Distal femur fractures are known to have challenging nonunion rates. Despite various available treatment methods aimed to improve union, optimal interventions are yet to be determined. Importantly, there remains no standard agreement on what defines radiographic union. Although various proposed criteria of defining radiographic union exist in the literature, there is no clear consensus on which criteria provide the most precise measurement. The use of inconsistent measures of fracture healing between studies can be problematic and limits their generalizability. Therefore, this systematic review aims to identify how fracture union is defined based on radiographic parameters for surgically treated distal femur fractures in current literature.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, Medline, EMBASE, Cochrane Central Register of Controlled Trials, and Web of Science Core Collection databases were searched from inception to October 2022. Studies that addressed surgically treated distal femur fractures with reported radiographic union assessment were included. Outcomes extracted included radiographic definition of union; any testing of validity, reliability, or responsiveness; reported union rate; reported time to fracture union; and any functional outcomes correlated with radiographic union.

RESULTS

Sixty articles with 3,050 operatively treated distal femur fractures were included. Operative interventions included lateral locked plate (42 studies), intramedullary nail (15 studies), dynamic condylar screw or blade plate (7 studies), dual plate or plate and nail construct (5 studies), distal anterior-posterior/posterior-anterior screws (1 study), and external fixation with a circular frame (1 study). The range of mean follow-up time reported was 4.3 to 44 months. The most common definitions of fracture union included "bridging or callus formation across 3 of 4 cortices" in 26 (43%) studies, "bony bridging of cortices" in 21 (35%) studies, and "complete bridging of cortices" in 9 (15%) studies. Two studies included additional assessment of radiographic union using the Radiographic Union Scale in Tibial fracture (RUST) or modified Radiographic Union Scale in Tibial fracture (mRUST) scores. One study included description of validity, and the other study included reliability testing. The reported mean union rate of distal femur fractures was 89% (range 58%-100%). The mean time to fracture union was documented in 49 studies and found to be 18 weeks (range 12-36 weeks) in 2,441 cases. No studies reported correlations between functional outcomes and radiographic parameters.

CONCLUSION

The current literature evaluating surgically treated distal femur fractures lacks consistent definition of radiographic fracture union, and the appropriate time point to make this judgement is unclear. To advance surgical optimization, it is necessary that future research uses validated, reliable, and continuous measures of radiographic bone healing and correlation with functional outcomes.

LEVEL OF EVIDENCE

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

The orthopaedic surgeon's clinical and experimental experience affect methods used for the fracture healing assessment (FHA) - An International Survey

Detection of fracture healing (FH), which depends on assessment methods, is a crucial factor affecting treatment. The study aimed to examine orthopedic surgeons in terms of practical methods of fracture healing (FHA) assessment (physical, imaging, measurement, and laboratory) and to check whether surgeons participating in clinical and laboratory experiments or only clinical practitioners prefer different FHA methods. An International Survey on Fracture Healing Assessment Methods was developed and distributed through the Web-based survey portal. Ninety-three orthopedic surgeons, on average age 41.46 years, from 24 countries participated in the study. Thirty-one respondents (33.3%) reported dealing with fractures both in the clinic and in experimental studies, six (6.5%) reported dealing with fractures only in laboratory research work, and fifty-six (60.2%) indicated that they dealt with fractures only clinically. The survey's internal consistency was significantly high (Cronbach's alpha coefficients ranged from 0.84 to 0.96). The majority of respondents (80.83%) use specific clinical criteria to define a fracture union. The FHA was mainly based on the physical examination and plain radiograms. Laboratory findings, patient-oriented outcomes scores, and quantitative methods are rarely used. Orthopaedic surgeons dealing with fractures both in the clinic and in laboratory fracture research studies are more likely to use more quantitative FHA methods. Future research is needed to improve the international standard of the FHA methods for use in research, clinical trials, and clinical practice. Using a quantitative, reliable, and standardized approach, including online support, can be valuable for increasing compliance in the orthopedic surgeon population, effectively improving the adherence of fracture healing assessment in clinical conditions, and improving early detection of fracture healing disorders, improving fracture efficiency treatment.

MSC-Derived Extracellular Vesicles in Preclinical Animal Models of Bone Injury: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVE

Mesenchymal stromal cell-derived extracellular vesicles (MSC-EVs) are a promising treatment for bone injuries, although studies remain preclinical. A systematic review and meta-analysis can assess the efficacy of MSC-EVs and identify treatment aspects associated with enhanced bone repair.

METHODS

English language, preclinical, controlled, in vivo studies identified in our systematic search (up to May 8, 2020) examining the use of MSC-EVs in bone healing were included. Risk of bias (ROB) was assessed using the SYRCLE tool. Aggregate Data Meta-Analysis was performed to determine the effect of MSC-EVs on Bone Volume/Total Volume (BV/TV) and New Bone Formation (NBF).

RESULTS

Thirteen studies were included. Twelve reported either BV/TV or NBF and were included in meta-analysis. ROB was unclear in all studies. Overall, MSC-EVs displayed benefit in terms of bone healing for both BV/TV (22.2% mean difference (MD); 95% CI: 15.8-28.5%, p < 0.001) and NBF (26.1% MD; 10.3-41.8%, p = 0.001) versus controls. Substantial heterogeneity, however, was observed between studies. MSC-EVs were reported to activate multiple signaling pathways including mTOR/AKT, AMPK and BMP2. Subgroup analysis indicated no significant difference in the improvement of BV/TV when using modified EVs isolated after gene transfection, preconditioning (p = 0.61), or using EVs in combination with a tissue scaffold and/or hydrogel versus other delivery methods (p = 0.20).

CONCLUSION

Use of MSC-EVs to promote healing of bone injury appears promising, however, heterogeneity between studies and the potential for reporting bias limits confidence in the extent of benefit. Reducing bias between studies and addressing aspects of potential reporting bias should augment confidence in future meta-analyses and propel the field towards clinical studies. Forest Plot analysis assessing the percentage change in bone volume (BV) / total volume (TV) in the presence (experimental) or absence (control) of MSC-EVs.

Comparison of the Kirschner Wire Tension Band with a Novel Nickel-Titanium Arched Shape-Memory Alloy Connector in Transverse Patellar Fractures: A Retrospective Study

This study aims to compare the clinical outcomes of the nickel-titanium arched shape-memory alloy connector (hereafter referred to as the ASC) and tension band fixation for the treatment of transverse patellar fractures. We retrospectively analyzed a total of 257 patients with transverse patellar fractures who were treated at our emergency orthopaedics department from March 2010 to March 2017. Either an ASC or the Kirschner wire (K-wire) tension band had been used to treat these fractures according to surgeons' experience and preference. We compared operative details, postoperative recovery, and postoperative knee function at 6 months. In terms of surgical duration, blood loss, incision length, length of hospital stay, and postoperative complications, patients in the ASC group showed significantly better results than patients in the K-wire group (p < 0.05). There were no significant differences between the two groups in terms of fracture healing time, knee mobility, and the Boström score at the postoperative 6-month evaluation (p > 0.05). Though, there were similar functional outcomes between two groups whose transverse patellar fractures were different methods, we found that the ASC method was a more reliable, more minimally invasive, and safer treatment option than the tension band wiring method using K-wires, resulting in less tissue damage, shorter surgical duration, shorter length of hospital stay, and fewer complications.

The use of bone turnover markers for monitoring the treatment of osteoporosis in postmenopausal females undergoing total knee arthroplasty: a prospective randomized study

BACKGROUND

Osteoporosis (OP) and osteoarthritis (OA) commonly coexist in postmenopausal females. The decrease in bone density and increase in bone resorption in postmenopausal females with OP may consequently affect the surgical outcome of total knee arthroplasty (TKA). However, clinicians often ignore monitoring the treatment of OP in the perioperative management of TKA. Bone turnover marker (BTM) can timely and accurately reflect bone metabolism to monitor the treatment of OP. The purpose of this study was to investigate the effect of BTM monitoring to guide the treatment of OP in postmenopausal females undergoing TKA.

METHODS

Postmenopausal females with OP who underwent primary unilateral TKA were randomly divided into two groups (monitoring group and control group), given oral medication (alendronate, calcitriol, and calcium), and followed for 1 year. In the monitoring group, serum BTMs (C-telopeptide of type I collagen (CTX-I), N-terminal propeptide of type I procollagen (PINP), and 25(OH)D) were assessed preoperatively and repeated postoperatively; alendronate was withdrawn when CTX-I and PINP reached the reference interval; and calcitriol and calcium were withdrawn when 25(OH)D reached the reference interval. In the control group, oral medication was implemented for a uniform duration of 3 months. During the 1-year follow-up, the mean maximum total point motion (MTPM) of the tibial component, bone mineral density (BMD), visual analog scale (VAS) score, range of motion, and Oxford Knee Score (OKS) score were obtained.

RESULTS

In the monitoring group, BTM monitoring prolonged the medication duration, but did not cause more adverse reactions than in the control group. The mean MTPM values at 6 m and 12 m in the monitoring group were lower than those in the control group, and the BMD at 12 m in the monitoring group was significantly higher than that in the control group. Patients in the monitoring group had lower VAS scores at 6 m and higher OKS scores at 6 m and 12 m than those in the control group.

CONCLUSION

In postmenopausal females with osteoporosis undergoing primary TKA, the application of BTM monitoring to guide the treatment of osteoporosis can enhance bone density, maintain prosthesis stability, and improve surgical outcome.

TRIAL REGISTRATION

ChiCTR ChiCTR-INR-17010495 . Registered on 22 January 2017.

The comparative efficacies of intravenous administration and intra-articular injection of tranexamic acid during anterior cruciate ligament reconstruction for reducing postoperative hemarthrosis: a prospective randomized study

Background

Hemarthrosis after anterior cruciate ligament (ACL) reconstruction can create many adverse joint effects. Tranexamic acid (TXA) can be used to minimize hemarthrosis and associated pain after ACL reconstruction. We aimed to compare the efficacies of intravenous (IV) administration and intra-articular (IA) injection of TXA during ACL reconstruction for reducing postoperative hemarthrosis.

Methods

A total of 120 patients who underwent arthroscopic ACL reconstruction were included in this prospective and randomized study. All patients were randomized into three groups: IV group, IA group and placebo group. Patients in the IV group received intravenously administered TXA (15 mg/kg in 100 mL of saline solution) 10 min before tourniquet release; patients in the IA group received intra-articular TXA (15 mg/kg in 100 mL of saline solution) injected via the drainage tube; and patients in the placebo group received an equivalent volume of normal saline administered into the knee joint cavity and intravenously. Drainage tubes were removed 24 h after surgery, and all enrolled patients experienced a 4-week follow-up period. The drain output volume, visual analogue scale (VAS) score, patellar circumference, hemarthrosis grade and Lysholm score of all patients were recorded.

Results

Both the IV group and the IA group had significantly lower drain output volumes at day 1, lower VAS scores at weeks 1 and 2, smaller patellar circumferences at weeks 1 and 2, and lower hemarthrosis grades at weeks 1 and 2 than the placebo group (p < 0.05). There were no significant differences in drain output volume, VAS score, patellar circumference or hemarthrosis grade between the IV group and the IA group at any time point (p > 0.05). No obvious differences in Lysholm score were observed between any pair of groups at week 4 (p > 0.05)). Neither infection nor deep vein thrombosis occurred in any group.

Conclusions

Both intravenous administration and intra-articular injection can reduce intra-articular hemarthrosis, joint pain and swelling during ACL reconstruction. No significant difference in the efficacies of reducing hemarthrosis, joint pain and swelling was found between intravenous administration and intra-articular injection.

Trial registration

The study was registered by the Chinese Clinical Trial Registry (The comparative efficacies of intravenous administration and intra-articular injection of tranexamic acid during anterior cruciate ligament reconstruction; ChiCTR-INR-17012217; August 1, 2017).

Reliability of radiographic union scale in tibial fractures and modified radiographic union scale in tibial fractures scores in the evaluation of pediatric forearm fracture union

Objectives

This study aims to evaluate the reliability of the radiographic union scale in tibial (RUST) fractures and modified RUST (mRUST) fractures in pediatric forearm fractures treated with elastic stable intramedullary nail (ESIN) and to investigate the effect of the experience of surgeon, thresholds for union, and delayed union decisions.

Patients and methods

In this retrospective study, radiographic images of 20 patients (10 males, 10 females; mean age 8.6±4.3; range, 4 to 11 years) with forearm fractures treated using ESIN between January 2013 and December 2018 were scored by 20 observers based on the RUST and mRUST scores. The observers scored the radiographs at immediate postoperative period, and at 4-, 8-, and 12-week follow-up. Intra- and interobserver agreement for each cortex, RUST, and mRUST were evaluated using intraclass correlation coefficient (ICC). The Fleiss’ kappa (k) coefficient was used in the agreement between evaluators regarding union decision. Receiver operating curves were created to determine the thresholds for radiographic union and delayed union.

Results

Intra- and interobserver reliability of the mRUST score (ICC: 0.84 and 0.79) were slightly higher than that of the RUST score (ICC: 0.80 and 0.72). Pediatric orthopedic and trauma surgeons had slightly higher agreement than the residents and general orthopedists for the total mRUST and RUST scores of the eight-week radiographs. Mean RUST and mRUST scores at the union for all fractures were 10.2±3.4 and 13.0±2.1, respectively. Kappa value for union was moderate (0.74). The total mRUST score had a higher predictive value for union than the total RUST score (area under the curve: 0.986 vs. 0.889). A mRUST score of ≥12 and RUST score of ≥9 were considered as the predictors of union. In addition, a mRUST score of ≤7 and RUST score of <9 were considered as the predictors of delayed union.

Conclusion

A moderate agreement for both RUST and mRUST scores was found. However, the agreement for mRUST was found to be slightly higher. Healing and union of forearm fractures treated with ESIN can be reliably assessed using RUST and mRUST.

Measuring Lateral Screw Protuberance Is a Clinically Accurate Method for Quantifying Femoral Neck Shortening

OBJECTIVES

The purpose of this study is to compare the reliability and accuracy of the screw protuberance method (SPM) and overlay method (OM) for measuring femoral neck shortening on anterior-posterior (AP) radiographs. The secondary aim is to investigate the changes in reliability and accuracy with varying femoral rotation.

METHODS

Radio-opaque femur sawbone models were fitted with either 3 cancellous screws or a sliding hip screw implant. Anterior-posterior radiographs were obtained using C-arm fluoroscopy with femoral neck shortening up to 15 mm and with the femoral shaft in 30 degrees of internal rotation to 30 degrees of external rotation (ER). Four observers measured femoral neck shortening at 2 time points. Intraobserver and interobserver reliability were calculated using the intraclass coefficient. Accuracy was analyzed through a Bland-Altman agreement statistic stratified by femoral rotation.

RESULTS

Both measurement techniques displayed excellent reliability, regardless of femoral rotation or implant. There was a significant difference in femoral neck shortening measurements with rotation for both the OM (P < 0.001) and SPM (P < 0.001). Both methods are accurate within 1 mm of the actual magnitude of shortening from 30-degree internal rotation to 15-degree ER. At 30-degree ER, shortening was underestimated by -2.10 mm using the OM (95% confidence interval, -2.43 to -1.76; P < 0.01) and by -1.64 mm using the SPM (95% confidence interval, -1.83 to -1.45; P < 0.01).

CONCLUSION

This study demonstrates that both the OM and SPM are accurate and reliable assessments for femoral neck shortening; however, both methods are sensitive to extreme ER. Given the simplicity of the SPM technique, it may have increased utility for pragmatic research studies.

Reliability of RUST and Modified RUST Scores for the Evaluation of Union in Humeral Shaft Fractures Treated with Different Techniques

BACKGROUND

The study aimed to evaluate the agreement between the radiographic union scale (RUST) and modified RUST (mRUST) in humeral shaft fractures treated with different techniques, and the effect of surgeons' experience and thresholds for determining bone union.

MATERIALS AND METHODS

A total of 20 orthopedic surgeons reviewed and scored radiographs of 30 patients with humeral shaft fractures treated by external fixation, intramedullary nailing, and plating using the RUST and mRUST on the 0 day, 6 weeks, 12 weeks and 24 weeks follow-up radiographs. Bone healing, interrater agreement between RUST and mRUST scores, and the threshold for radiographic union were evaluated.

RESULTS

The intraclass correlation coefficient (ICC) was slightly higher for the mRUST score than the RUST score (0.71 versus [vs.] 0.67). There was substantial agreement between the mRUST and RUST scores for external fixation (0.75 and 0.69, respectively) and intramedullary nailing (0.79 and 0.71); there was moderate agreement between them for plating (0.59 and 0.55). Surgeons with varying experience had a similar agreement for both scores and scores for each humeral cortex. The external fixation and intramedullary nailing group had higher RUST and mRUST scores than the plating group. The ICC for union was substantial (0.64; external fixation: 0.68, intramedullary nailing: 0.64, and plating: 0.61). More than 90% of the reviewers recorded scores of 10/12 for RUST and 13/16 for mRUST at the time of union.

CONCLUSIONS

RUST and mRUST scores can be used reliably for the evaluation of bony union in humeral fractures treated with an external fixator and intramedullary nailing. In cases of humeral plating, a more sensitive tool for evaluation of fracture union is needed.

Validation of a long bone fracture non-union healing score after treatment with mesenchymal stromal cells combined to biomaterials

The available scores to clinically evaluate fracture consolidation encounter difficulties to interpret progression towards consolidation in long-bone non-union, particularly when incorporating biomaterials in the surgical treatment. The aims of this study were to validate the REBORNE bone healing scale in tibia, humerus and femur non-unions treated by a combination of mesenchymal stromal cells (MSCs) and biomaterials, through the interclass correlation (ICC) among raters, and to define reliability and concordance in anteroposterior and lateral radiographs, compared to computed tomography (CT).

METHODS

Twenty-six cases from the EudraCT 2011-005441-13 clinical trial underwent bone healing evaluation, if at least 3 out of 4 cortical views clearly identified. Three senior orthopaedic surgeons evaluated radiographs and CTs at 3 and 6 months FU. All cases included preoperative imaging and radiographs at 12 months. The 4-stage scale score was obtained from each cortical view in orthogonal radiographs or CTs. A score of 0.6875 (11/16) was set as a threshold for bone healing. Statistically, ICC evaluated agreement among raters. Cronbach's alpha coefficient tested reliability. Lin's concordance correlation coefficients (CCC) were estimated between mean CT scores and mean radiographic scores. Bland and Altman graphs provided the limits of agreement between both imaging techniques. Sensitivity and specificity were assessed in radiographs (against CT), and the Area Under the Receiver Operating Characteristics (ROC) Curve was estimated. The probability to predict bone consolidation with REBORNE scores obtained from radiographs was modelled.

RESULTS

An ICC of 0.88 and 0.91 (CT and radiographs) confirmed agreement in the REBORNE score for non-union bone healing, with an inter-rater reliability of 0.92 and 0.95. Scores through the radiographic evaluation were found equivalent to the CTs at 6 months FU. A CCC of 0.79 was detected against CT. The radiographic scores in the REBORNE bone healing scale correctly classified bone consolidation in 77%, with an accuracy of 83% based on ROC curves.

CONCLUSIONS

The REBORNE score measured with CT or radiographic images was reliable among raters at a follow-up time above 6 months for long bone non-union fractures. The REBORNE scale measured with radiographs proved valid to assess consolidation against CT measurements.

Does bone marrow aspirate help enhance the integration of gamma irradiated allograft bone?

Bone allografts donated by other individuals offer a viable alternative to autograft. Risks of disease transmission are overcome by sterilizing the bone; unfortunately sterilization methods generally affect bone functional properties including osteogenic potential and biomechanical integrity. This study aimed to determine any enhancement effect when gamma sterilised allografts was impregnated with autologous bone marrow in improving the rate and quality of integration in metaphyseal-tibial defects of rabbits. Almost all subjects showed 50% of the defect being covered by new bones by the third week and smaller residual defect size in the treated group at the fifth week. Hounsfield units at the defect site showed increasing healing in all samples, with the treated group having an apparent advantage although insignificant (p > 0.05). In the histopathological score evaluating healing over cortical and cancellous bone at the fracture site showed only slight variations between the groups (p > 0.05). Therefore no enhanced healing by the autologous bone marrow was observed when added to the bone allografts in treating the unicortical defects.

Inter-Rater Reliability of the Modified Radiographic Union Score for Diaphyseal Tibial Fractures With Bone Defects

OBJECTIVES

To evaluate inter-rater reliability of the modified Radiographic Union Score for Tibial (mRUST) fractures among patients with open, diaphyseal tibia fractures with a bone defect treated with intramedullary nails (IMNs), plates, or definitive external fixation (ex-fix).

DESIGN

Retrospective cohort study.

SETTING

Fifteen-level one civilian trauma centers; 2 military treatment facilities.

PATIENTS/PARTICIPANTS

Patients ≥18 years old with open, diaphyseal tibia fractures with a bone defect ≥1 cm surgically treated between 2007 and 2012.

INTERVENTION

Three of 6 orthopedic traumatologists reviewed and applied mRUST scoring criteria to radiographs from the last clinical visit within 13 months of injury.

MAIN OUTCOME MEASUREMENTS

Inter-rater reliability was assessed using Krippendorff's alpha (KA) statistic; intraclass correlation coefficient (ICC) is presented for comparison with previous publications.

RESULTS

Two hundred thirteen patients met inclusion criteria including 115 IMNs, 24 plates, 29 ex-fixes, and 45 cases that no longer had instrumentation at evaluation. All reviewers agreed on the pattern of scoreable cortices for 90.4% of IMNs, 88.9% of those without instrumentation, 44.8% of rings, and 20.8% of plates. Thirty-one (15%) cases, primarily plates and ex-fixes, did not contribute to KA and ICC estimates because <2 raters scored all cortices. The overall KA for the 85% that could be analyzed was 0.64 (ICC 0.71). For IMNs, plates, ex-fixes, and no instrumentation, KA (ICC) was 0.65 (0.75), 0.88 (0.90), 0.47 (0.62), and 0.48 (0.57), respectively.

CONCLUSIONS

In tibia fractures with bone defects, the mRUST seems similarly reliable to previous work in patients treated with IMN but is less reliable in those with plates or ex-fixes, or after removal of instrumentation.

Radiographic Healing of Far Cortical Locking Constructs in Distal Femur Fractures: A Comparative Study With Standard Locking Plates

OBJECTIVES

To investigate the radiographic healing of far cortical locking (FCL) construct fixation in distal femur fractures compared with traditional locking plate (LP) constructs.

DESIGN

A retrospective cohort of 143 consecutive patients with 146 distal femur fractures.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

After excluding patients with OTA/AO type B fractures, referred nonunion cases, patients younger than 16 years, and patients with less than 24 weeks of follow-up, 69 patients with 70 total fractures were included for analysis.

INTERVENTION

AP and lateral knee radiographs were blinded to type of screws and individually reviewed by 3 orthopaedic trauma surgeons.

OUTCOME MEASUREMENTS

The modified RUST (mRUST) score was our primary outcome measure. mRUST scores were assigned at 6, 12, and 24 weeks and final follow-up based on AP and lateral radiographs and compared between FCL and LP groups as a tool for evaluating fracture healing. Secondary outcomes compared between FCL and LP included union rate and postoperative complications.

RESULTS

Statistically significant differences in mRUST scores were noted between FCL and LP groups at 6 weeks (P = 0.040), 12 weeks (P = 0.034), 24 weeks (0.044), and final follow-up (P = 0.048). There was no significant difference in union or specific complication rates between the 2 groups. The union rate was 90.5% and 82.1% for the FCL and LP groups, respectively, at final follow-up.

CONCLUSIONS

To our knowledge, this is the first comparative study between FCL and LP constructs. The FCL group was noted to have significantly higher mRUST scores at all periods indicating increased callus formation, but the differences seen were small and there were no differences in healing rates or complications between the 2 groups, thus bringing the clinical benefit of FCL into question. Further prospective study designs are needed to compare FCL with LP constructs and to investigate the role of interfragmentary motion on callus formation in distal femur fractures.

LEVEL OF EVIDENCE

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

Image Analysis Software as a Strategy to Improve the Radiographic Determination of Fracture Healing

OBJECTIVES

To develop and validate an unbiased, accurate, convenient, and inexpensive means of determining when an osseous defect has healed and recovered sufficient strength to allow weight bearing.

METHODS

A novel image processing software algorithm was created to analyze the radiographic images and produce a metric designed to reflect the bone strength. We used a rat femoral segmental defect model that provides a range of healing responses from complete union to nonunion. Femora were examined by x-ray, micro-computed tomography and mechanical testing. Accurate simulated radiographic images at different incident x-ray beam angles were produced from the micro-computed tomography data files.

RESULTS

The software-generated metric (SC) showed high levels of correlation with both the mechanical strength (τMech) and the polar moment of inertia (pMOI), with the mechanical testing data having the highest association. The optimization analysis yielded optimal oblique angles θB of 125 degrees for τMech and 50 degrees for pMOI. The Pearson R values for the optimized model were 0.71 and 0.64 for τMech and pMOI, respectively. Further validation using true radiographs also demonstrated that the metric was accurate and that the simulations were realistic.

CONCLUSIONS

The preliminary findings suggest a very promising methodology to assess bone fracture healing using conventional radiography. With radiographs acquired at appropriate incident angles, it proved possible to accurately calculate the degree of healing and the mechanical strength of the bone. Further research is necessary to refine this approach and determine whether it translates to the human clinical setting.

Research methodology for orthopaedic surgeons, with a focus on outcome

Since improving the patient's condition is the ultimate goal of clinical care and research, this review of research methodology focuses on outcomes in the musculoskeletal field.This paper provides an overview of conceptual models, different types of outcomes and commonly assessed outcomes in orthopaedics as well as epidemiological and statistical aspects of outcomes determination, measurement and interpretation.Clinicians should determine the outcome(s) most important to patients and/or public health in collaboration with the patients, epidemiologists/statisticians and other stakeholders.Key points in outcome choice are to evaluate both the benefit and harm of a health intervention, and to consider short- and longer-term outcomes including patient-reported outcomes.Outcome estimation should aim at identifying a clinically important difference (not the same as a statistically significant difference), at presenting measures of effects with confidence intervals and at taking the necessary steps to minimize bias. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170064.

The Non-Union Scoring System: an interobserver reliability study

PURPOSE

The Non-Union Scoring System (NUSS) aims to classify non-unions according to their severity and relate them to four treatment categories. The main purpose of this study was to evaluate the reliability of the NUSS. In addition we assessed its clinical validity.

METHODS

Forty-four Patients with a tibia non-union between 2005 and 2015 were included in this study. Data from all included patients were scored independently by three observers according to the NUSS criteria. The interobserver agreement was evaluated using the intraclass correlation coefficient (ICC). The interobserver agreement of the Weber-Cech system was assessed using Fleiss' kappa. Finally, the clinical validity of the NUSS was analysed by comparing outcomes of the actual treatment groups to the proposed treatment groups following from the NUSS scores.

RESULTS

Forty-four patients were included. The comparison of NUSS scores between observers showed substantial agreement [ICC; 0.78 (0.67-0.86)]. The comparison of the Weber-Cech classification between observers showed only fair agreement [Fleiss κ; 0.30 (0.17-0.42)]. The χ² test for the treatment groups according to the NUSS and the treatments at index procedure showed an independent relation (χ² = 5.794, 6 degrees of freedom, p: 0.447). In contrast, the proposed treatment strategy corresponds well to the definitive treatment (χ² = 29.963, 9 degrees of freedom, p < 0.001).

CONCLUSION

We conclude that the NUSS is both a reliable and valid system to classify non-unions.

Fracture healing: a consensus report from the International Osteoporosis Foundation Fracture Working Group

We used the RAND UCLA appropriateness method to decide appropriateness of use of osteoporosis medication after incident fracture and potential for fracture healing and make suggestions for trial design for clinical and preclinical research.

PURPOSE

To develop appropriateness criteria to assist in the use and study of osteoporosis medications in patients with recent fracture and in the potential use of osteoporosis medications to enhance delayed fracture healing. To promote further research by suggesting preclinical and clinical trial design for studies where fracture healing is the endpoint.

DESIGN

RAND/UCLA appropriateness method (RUAM).

PARTICIPANTS

A panel of experts, both members and non-members of the International Osteoporosis Foundation Fracture Working Group, were identified consisting of geriatricians, rheumatologists, orthopedists, endocrinologists, and internists. This resulted in a round 1 panel of 15 panelists, round 2 panel of 15 members, and a round 3 panel of 14 members.

MAIN OUTCOME MEASURE

Agreement on statements and scenarios using RUAM. Three rounds of voting by panelists took place. Agreement in a third round was reached for 111 statements and scenarios, measured by median panel ratings and the amount of dispersion of panel ratings, based on the interpercentile range.

RESULTS

An expert panel validated a set of statements and scenarios about the use of osteoporosis medications after incident fracture and use of these medications to enhance delayed fracture healing and made recommendations for study designs to investigate the effect of osteoporosis medications on fracture healing.

CONCLUSIONS

The result of this exercise is intended to assist in improving patient care by identifying the appropriateness of use of osteoporosis medications after fracture and in fracture healing and to make suggestions for further preclinical and clinical research.

Current Opinions on Fracture Follow-up: A Survey of OTA Members Regarding Standards of Care and Implications for Clinical Research

OBJECTIVES

To determine current practice standards among Orthopaedic Trauma Association surgeons for postoperative fracture follow-up and to investigate the implications of these standards on clinical research.

DESIGN

Survey.

SETTING

Web-based survey.

PARTICIPANTS

One hundred eighty-four orthopaedic trauma surgeons.

METHODS

A web-based questionnaire was distributed to Orthopaedic Trauma Association members to identify standard postoperative radiographic and clinical follow-up duration. Assuming uneventful, complete fracture healing at 3 months, data were collected for 3 generic fracture types (diaphyseal, extra-articular metaphyseal, and intra-articular) and 3 specific fractures (femoral shaft, intertrochanteric, and tibial plateau). Suggested follow-up for clinical research was also investigated.

RESULTS

For extra-articular fractures, standard radiographic and clinical follow-up were considered to be 6 months or less by greater than 70% of respondents. For intra-articular fractures, standard radiographic and clinical follow-up was considered to be 6 months or less by greater than 39% of respondents. The most common responses for radiographic follow-up were 3 months for extra-articular fractures (33%) and 12 months for intra-articular fractures (34%). The most common responses for clinical follow-up were 6 months for extra-articular fractures (37%) and 12 months for intra-articular fractures (35%). The majority (55%) indicated that follow-up to clinical and radiographic healing or the establishment of a nonunion should be the minimum follow-up for clinical fracture studies and 66% recommended follow-up to at least 1 year for functional outcome studies.

CONCLUSIONS

Most surgeons follow-up patients with lower extremity extra-articular fractures (with uneventful healing) radiographically for 3-6 months and clinically for 6 months and slightly longer for intra-articular fractures. Many surgeons cease radiographic and clinical follow-up by 6 months. Therefore, retrospective fracture healing studies can only reasonably expect follow-up for 6 months. Publication requirements for longer follow-up of fracture-related studies would likely eliminated retrospective studies from consideration. Most surgeons support obtaining at least 1-year follow-up for clinical studies that include functional outcome.

LEVEL OF EVIDENCE

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

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

OBJECTIVE

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

DESIGN

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

INTERVENTION

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

MAIN OUTCOME MEASURES

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

RESULTS

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

UNION

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

CONCLUSIONS

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

Use of screw locking elements improves radiological and biomechanical results of femoral osteotomies

BACKGROUND

Dynamic compression plate (DCP) constructs provide inadequate fixation in cases of poor bone quality and early weight-bearing. Screw locking elements (SLE) are flat locking nuts placed at the end of the screw to prevent screw stripping from the bone, improving fixation stability. The purpose of this work was to compare biomechanical and radiological evaluations of femoral ovine osteotomies fixed using DCP constructs with and without SLE.

METHOD

A dyaphyseal femoral osteotomy was performed in sixteen adult sheep and fixed with a DCP and cortical screws. Half of the animals were operated on with a SLE on each side of the osteotomy and the rest without the addition of SLE. Four animals of each group were euthanized after 8 weeks, and the remaining after 16 weeks. Both femora of each animal were radiographed and mechanically tested in torsion.

RESULTS

Radiologically femoral malalignment or screw loosening was observed in six out of the eight animals operated on without SLE. In contrast, all animals subjected to the operation with SLE showed complete radiological consolidation of the osteotomy. Seven of these eight animals showed normal femoral alignment and no osteosynthesis failure. Stiffness of the bones fixed with SLE was among 145% and 177% the value of their contralateral non-operated femurs (all animals of this group showed greater stiffness on the operated bone than its contralateral non-operated femur). However, stiffness of the bones operated on without SLE was among 58% and 87% the value of the stiffness of their contralateral non-operated bone (all animals of this group showed greater stiffness on the non-operated bone than the osteotomized ones).

CONCLUSIONS

Use of SLE avoided loosening of the system and stimulated stronger osteotomy consolidation. Clinical application of this improved system may thus be a feasible and cost-effective alternative to other more rigid and expensive bone fixation techniques.

Exuberant sprouting of sensory and sympathetic nerve fibers in nonhealed bone fractures and the generation and maintenance of chronic skeletal pain

Skeletal injury is a leading cause of chronic pain and long-term disability worldwide. While most acute skeletal pain can be effectively managed with nonsteroidal anti-inflammatory drugs and opiates, chronic skeletal pain is more difficult to control using these same therapy regimens. One possibility as to why chronic skeletal pain is more difficult to manage over time is that there may be nerve sprouting in nonhealed areas of the skeleton that normally receive little (mineralized bone) to no (articular cartilage) innervation. If such ectopic sprouting did occur, it could result in normally nonnoxious loading of the skeleton being perceived as noxious and/or the generation of a neuropathic pain state. To explore this possibility, a mouse model of skeletal pain was generated by inducing a closed fracture of the femur. Examined animals had comminuted fractures and did not fully heal even at 90+days post fracture. In all mice with nonhealed fractures, exuberant sensory and sympathetic nerve sprouting, an increase in the density of nerve fibers, and the formation of neuroma-like structures near the fracture site were observed. Additionally, all of these animals exhibited significant pain behaviors upon palpation of the nonhealed fracture site. In contrast, sprouting of sensory and sympathetic nerve fibers or significant palpation-induced pain behaviors was never observed in naïve animals. Understanding what drives this ectopic nerve sprouting and the role it plays in skeletal pain may allow a better understanding and treatment of this currently difficult-to-control pain state.

Patient-important outcome for the assessment of fracture repair

Current evidence indicates that fracture healing assessment is limited to the use of one or two domains (such as pain, range of motion or mobility) in any single study. Functional outcome measures, which include physician-rated or observer-based impairment ratings and patient self-reported or observer-based activity limitation measures, better position the effectiveness of a given intervention towards patient-important outcomes. Health status measures, for example, cover a wide-range of physical, emotional, and social health dimensions. In this paper, we will examine the utility of metrics to assess fracture healing that are important to both the patient and provider, with selected examples from the recent literature. We recommend outcome measures with established and verified reliability and validity. Policy-makers and other stakeholders need to have an accurate assessment of treatment outcome that includes changes in function over time-adequate measures, should be re-applied at periodic intervals.

Radiographic displacement in pelvic ring disruption: reliability of 3 previously described measurement techniques

BACKGROUND

The literature on pelvic ring disruptions is based largely on nonstandardized and nonvalidated radiographic outcomes. A thorough review of the literature revealed only 3 described methods for measuring radiographic displacement and 1 frequently used grading system for displacement. We aimed to test the reliability of these previously published radiographic measurement methods and grading system.

METHODS

Five separate observers measured radiographic displacement on the standardized pre- and postoperative anteroposterior, inlet, and outlet views of 25 patients with surgically treated Tile B and C pelvic fractures. The readers measured their initial impression based on the Tornetta and Matta grading system (excellent, good, fair, and poor). Next, they measured displacement using the inlet and outlet ratio as described by Sagi, the cross measurement technique as described by Keshishyan, and the absolute displacement method (ADM) as described by Lefaivre. The millimeter measurement obtained by the ADM was converted using the Tornetta and Matta grading system. Each continuous measure was compared for interobserver reliability using intraclass correlations (ICCs), and the categorical outcomes were compared using a kappa statistic. Finally, the relationship of the initial impression to the grade as determined by the ADM was compared using kappa agreement.

RESULTS

The agreement among observers based on initial impression was poor (kappa statistic, 0.306) but was fair among those reductions that were excellent (κ = 0.495). Using the Sagi method, the reliability ICC was moderate for the postoperative inlet [0.515, 95% confidence interval (CI), 0.338-0.702] and outlet ratio (0.594, 95% CI, 0.423-0.760) but almost perfect in preoperative radiographs (inlet: 0.814, 95% CI, 0.703-0.901; outlet: 0.863, 95% CI, 0.775-0.929). The ICCs for all interpretations of the Keshishyan technique were excellent but were highest when considered as a ratio (preoperative: 0.938, 95% CI, 0.894-0.969; postoperative: 0.912, 95% CI, 0.850-0.955). Using the ADM, the location and film used for measurement had poor agreement, and the ICC for the measurement in millimeters was moderate (preoperative: 0.522, 95% CI, 0.342-0.708; postoperative: 0.432, 95% CI, 0.255-0.634) and the kappa agreement poor when converted using the Tornetta and Matta scale (κ = 0.2190). The agreement between the impression and the converted grade from the ADM was poor (κ = 0.2520).

CONCLUSIONS

Radiographic measurement in pelvic x-rays to date has been nonvalidated, and we found the interobserver reliability on common methods, including overall impression and absolute displacement in millimeters, to be poor. The inlet/outlet ratio as described by Sagi was reliable only with wide displacement. The cross measurement technique allows least observer choice and had excellent reliability but does not give a measurement that we can easily interpret based on convention in pelvic fracture description.

Development and preliminary validation of a Function IndeX for Trauma (FIX-IT)

BACKGROUND

Assessing fracture healing in clinical trials is subjective. The new Function IndeX for Trauma (FIX-IT) score provides a simple, standardized approach to assess weight-bearing and pain in patients with lower extremity fractures. We conducted an initial validation of the FIX-IT score.

METHODS

We conducted a cross-sectional study involving 50 patients with lower extremity fractures across different stages of healing to evaluate the reliability and preliminary validity of the FIX-IT score. Patients were independently examined by 2 orthopedic surgeons, 1 orthopedic fellow, 2 orthopedic residents and 2 research coordinators. Patients also completed the Short Form-36 version 2 (SF-36v2) questionnaire, and convergent validity was tested with the SF-36v2.

RESULTS

For interrater reliability, the intraclass correlation coefficients ranged from 0.637 to 0.915. The overall interrater reliability for the total FIX-IT score was 0.879 (95% confidence interval 0.828-0.921). The correlations between the FIX-IT score and the SF-36 ranged from 0.682 to 0.770 for the physical component summary score, from 0.681 to 0.758 for the physical function subscale, and from 0.677 to 0.786 for the role-physical subscale.

CONCLUSION

The FIX-IT score had high interrater agreement across multiple examiners. Moreover, FIX-IT scores correlate with the physical scores of the SF-36. Although additional research is needed to fully validate FIX-IT, our results suggest the potential for FIX-IT to be a reliable adjunctive clinician measure to evaluate healing in lower extremity fractures.

LEVEL OF EVIDENCE

Diagnostic Study Level I.

The Radiographic Union Score for Hip (RUSH): the use of a checklist to evaluate hip fracture healing improves agreement between radiologists and orthopedic surgeons

OBJECTIVE

The assessment of fracture healing following intertrochanteric fracture fixation is highly variable with no validated standards. Agreement with respect to fracture healing following surgery is important for optimal patient management. The purpose of this study was to (1) assess reliability of intertrochanteric fracture healing assessment and (2) determine if a novel radiographic scoring system for hip fractures improves agreement between radiologists and orthopedic surgeons.

MATERIALS AND METHODS

A panel of three radiologists and three orthopedic surgeons assessed fracture healing in 150 cases of intertrochanteric fractures at two separate time points to determine inter-rater and intra-rater agreement. Reviewers, blinded to the time after injury, first subjectively assessed overall healing using frontal and lateral radiographs for each patient at a single time point. Reviewers then scored each fracture using a Radiographic Union Score for Hip (RUSH) form to determine whether this improves agreement regarding hip fracture healing.

RESULTS

Inter-rater agreement for the overall subjective impression of fracture healing between reviewer groups was only fair (intraclass coefficient [ICC] = 0.34, 95 % CI: 0.11-0.52. Use of the RUSH score improved overall agreement between groups to substantial (ICC = 0.66, 95 % CI: 0.53-0.75). Across reviewers, healing of the medial cortex and overall RUSH score itself demonstrated high correlations with overall perceptions of healing (r = 0.53 and r = 0.72, respectively).

CONCLUSIONS

The RUSH score improves agreement of fracture healing assessment between orthopedic surgeons and radiologists, offers a systematic approach to evaluating intertrochanteric hip fracture radiographs, and may ultimately provide prognostic information that could predict healing outcomes in patients with femoral neck fractures.

Effect of initial postoperative visit radiographs on treatment plans

BACKGROUND

It is a common practice among orthopaedic surgeons to make radiographs at the first outpatient postoperative visit after surgical repair of acute fractures. There is not much literature that investigates the benefits and necessity of such a practice. We hypothesized that the practice of routine postoperative radiographs is unnecessary and increases cost to the patients and the health-care system, increases radiation exposure, and provides no change in patient management.

METHODS

A retrospective review of patients sustaining acute fractures requiring operative fixation was done with the goal of determining how often a radiograph made at the first postoperative visit in the surgeon's office resulted in a change in patient management.

RESULTS

Fifteen (7.5%) of 200 fractures in 171 patients had a clinical indication for a radiograph because of an abnormal physical examination finding or history of additional trauma. Three (1.5%) of these fractures had a deviation from standard postoperative care; this deviation was a change in postoperative care on the basis of the patient history and physical examination rather than radiographs. One fracture (0.5%) had a radiographic change from the immediate postoperative radiograph to the clinic radiograph, yet did not have a change in treatment. The estimated average radiation exposure per radiograph was 0.164 mSv, and the average charge to the patient per radiograph was $335.13.

CONCLUSIONS

The majority of radiographs made at the first postoperative visit in the surgeon's office after acute fracture fixation did not result in a change in patient management and added substantial cost to the health-care system.

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

Background

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

Methods

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

Results

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

Conclusions

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

Significance of circulating endothelial progenitor cells in patients with fracture healing process

Fracture healing is a complex bone formation process, and neovascularization may contribute to new bone regeneration. The circulating endothelial progenitor cell (EPC) mobilization and homing could involve in neovascularization and vasculogenesis. In this study, we investigate the changes of circulating EPC during bone fracture healing, and the possible contribution of EPCs to increased neovascularization and fracture healing. The number of circulating EPCs was monitored in twenty-four patients with long bone traumatic fracture within the first 48 h and at 3, 5, 10, and 14 days post-fracture. The mononuclear cells which isolated from peripheral blood were analyzed by flow cytometry. Peripheral blood counts of leukocytes and platelets were measured by hematology analyzer. The amount of peripheral EPCs significantly increased in patients with fracture compared to age-matched healthy control subjects within the first 48 h after injury, and peaked at 3 days post-fracture. There was no significant difference in the change trend of early EPCs between male and female, but the number of early EPCs was significantly greater in younger patients compared to older patients. A comparison of the EPCs levels between patients with severe injury (ISS > 16) and patients with mild injury (ISS ≤ 16) revealed no statistically significant difference. The level of early EPCs was inverse correlation with the level of plate after fracture, but no correlation with the level of peripheral leucocytes. These findings suggest traumatic fracture may induce the mobilization of EPCs into the peripheral circulation. The increased EPCs may contribute to neovascularization and involve in fracture healing.

Methodology and interpretation of radiographic outcomes in surgically treated pelvic fractures: a systematic review

OBJECTIVE

To identify and evaluate previously described methods for the measurement, and interpretation, of radiographic outcomes of operatively treated pelvic fractures.

DATA SOURCES

A systematic review of the available literature was performed using all major databases (MEDLINE, EMBASE, MEDLINE IN-PROGRESS, and Cochrane Central) in August 2009.

STUDY SELECTION

Inclusion criteria were case series, cohort studies, or clinical trials regarding orthopaedic treatment of acute traumatic pelvic ring fractures treated surgically in adults, with at least 12 weeks of radiographic follow-up. Exclusion criteria were case reports or case series of <10 patients, review articles, foreign language articles, and series where time frame of outcome measurement was not stated were excluded.

DATA EXTRACTION

Modality, and timeline, of the radiographic assessment was recorded. Next, the description of the method of radiographic measurement technique used was scrutinized for standardization. The interpretation of the radiographic measurement was evaluated, and any grading scale used was recorded. The interpretation of the quality of the radiographic result as described by each author was recorded. Finally, a qualitative methodological analysis was performed.

DATA SYNTHESIS

Number of standardized radiographic assessment techniques used (3 of 31) and interpretation scales used (13 of 31) were calculated. Nonweighted mean follow-up time (30.6 months) and overall positive radiographic outcomes were calculated (78.6% good or excellent).

CONCLUSIONS

Reporting of radiographic outcomes in pelvic fractures has been done using largely unstandardized and universally untested measurement techniques. The interpretations of these measurements are also inconsistent and untested. Substantive future research is needed in this area.

Subjective results after surgical treatment for displaced intra-articular calcaneal fractures

We present a retrospective study investigating the results of the subjective assessment of displaced intra-articular calcaneal fractures in a selected cohort of 42 patients treated operatively, with a follow-up duration of at least 3 years. The adjusted American Orthopaedic Foot and Ankle Society questionnaire, Foot Function Index, and visual analog scale were used to quantify the subjective evaluations. Our hypothesis was that good subjective results could be predicted and obtained in patients with specific characteristics if anatomic reduction of the fracture was achieved. The results of the study confirmed our hypothesis. A number of specific subgroup analyses were undertaken. The study confirmed that Böhler angle restoration and the quality of reduction of the subtalar joint facet are important prognostic factors related to the outcome. In contrast, gender and Sanders type had less influence at the intermediate-term follow-up results. The main weaknesses of the present study included its retrospective nature, the lack of a control group managed nonoperatively for comparison, and the small sample size. Moreover, the operating surgeon performed the radiographic measurement and categorized the quality of the surgical reconstruction.

Guidelines for fracture healing assessments in clinical trials. Part I: definitions and endpoint committees

Patients sustaining long bone fractures experience a significant socioeconomic burden. Investigational products are in developmental phases in an attempt to significantly reduce the time to fracture healing, however, high quality clinical trials need to be conducted in order to evaluate the efficacy of these interventions. The assessment of fracture healing is not a standardised process as it involves a degree of subjectivity. The use of endpoint Adjudication Committees to adjudicate fracture healing in clinical trials has the potential to help to resolve this issue. This manuscript outlines the current definitions used in the assessment of fracture healing and highlights the need for endpoint Adjudication Committees in fracture healing trials.

Guidelines for fracture healing assessments in clinical trials. Part II: electronic data capture and image management systems--Global Adjudicator™ system

Adjudication of outcomes helps to reduce variation in outcome assessment when clinical judgement is used. Adjudication is extremely important when the outcome being measured is subjective, as in the assessment of fracture healing. Adjudication Committees have the potential to provide a systematic, independent, and unbiased method of determining fracture healing. In order to make the adjudication process less time consuming and more efficient, Global Research Solutions™, a Contract Research Organization which specialises in orthopaedic and surgical clinical trials, developed the Global Adjudicator™, a web-based system, to serve as both an image management system and electronic data capture system. This manuscript highlights the features of the Global Adjudicator™ and demonstrates the benefits of using a web-based adjudication system.

Recent aspects on outcomes in geriatric fracture patients

As the population ages, the number of fragility fractures is expected to increase dramatically. These injuries are frequently associated with less than satisfactory outcomes. Many of the patients experience adverse events or death, and few regain their pre-injury functional status. Many also lose their independence as a result of their fracture. This manuscript will explore problems and some potential solutions to evaluate the outcomes of geriatric fracture care. Specific, system-wide, and societal concerns will be discussed. Limited suggestions will be made for future steps to improve outcomes assessments.

The radiographic union scale in tibial fractures: reliability and validity

Radiographic assessment of tibial fracture healing continues to pose significant challenges to both routine fracture care and clinical research. Orthopaedic surgeons fail to achieve sufficient agreement on fracture healing when using conventional radiographic measures such as their general impression or the number of cortices bridged by callus. Moreover, the extent to which radiographic assessment of healing corresponds to patient-important outcomes is largely unknown. In an attempt to improve the former (ie, reliability) and inform the latter (ie, validity), recent studies have explored a novel radiographic assessment for tibial shaft fractures, the Radiographic Union Scale for Tibial fractures (RUST). The RUST score assesses the presence of bridging callus and that of a fracture line on each of 4 cortices seen on 2 orthogonal radiographic views. A recent study has found that RUST scores have greater inter-rater reliability when compared with surgeon's general impression or the number of cortices bridged by callus. This may increase the utility of radiographs as a standardized measure of treatment efficacy in the follow-up of tibial fractures.